What is the recommended management for internal hemorrhoids?

Management of Internal Hemorrhoids

All internal hemorrhoids should begin with conservative management including increased fiber (25-30 grams daily), adequate water intake, and avoidance of straining, regardless of grade or severity. 1, 2, 3

Initial Conservative Management (First-Line for All Grades)

Dietary and lifestyle modifications form the foundation of treatment:

• Increase dietary fiber to 25-30 grams daily using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1, 2
• Ensure adequate water intake to prevent constipation 1, 2, 3
• Take regular sitz baths with warm water to reduce inflammation and discomfort 2, 3
• Avoid prolonged sitting and straining during defecation 2

Pharmacological adjuncts for symptom relief:

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though 80% of patients experience symptom recurrence within 3-6 months after cessation 1, 2
• Topical analgesics (lidocaine 1.5-2%) provide symptomatic relief of local pain and itching 1, 2
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 3

Office-Based Procedures (When Conservative Management Fails)

Rubber band ligation is the preferred first-line procedural treatment for persistent Grade I-III internal hemorrhoids:

• Success rates range from 70.5-89% depending on hemorrhoid grade, with approximately 90% of patients remaining asymptomatic at 1-year follow-up 2, 4
• Long-term follow-up (10-17 years) shows 69% of patients remain asymptomatic 2
• The band must be placed ≥2 cm proximal to the dentate line to avoid severe pain 2
• Can be performed in an office setting without anesthesia using suction devices 2
• Up to 3 hemorrhoidal columns may be banded in a single session, though many practitioners prefer 1-2 columns at a time 2
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 2, 5

Common complications of rubber band ligation:

• Pain occurs in 5-60% of patients but is typically minor and manageable with sitz baths and over-the-counter analgesics 2
• Other complications include abscess, urinary retention, band slippage, and prolapse/thrombosis of adjacent hemorrhoids (approximately 5% of patients) 2
• Severe bleeding may occur when the eschar sloughs, typically 1-2 weeks after treatment 2
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 2

Alternative office-based procedures:

• Injection sclerotherapy is suitable for Grade I-II hemorrhoids, achieving 89.9% improvement or cure rate, but has no proven superiority over conservative management alone 2
• Infrared photocoagulation has 67-96% success rates for Grade I-II hemorrhoids but requires more repeat treatments than rubber band ligation 2
• Bipolar diathermy achieves 88-100% success rates for bleeding control in Grade II hemorrhoids 2

Surgical Management (For Failed Conservative/Office-Based Treatment or Advanced Disease)

Conventional excisional hemorrhoidectomy is indicated for:

• Failure of medical and office-based therapy 2
• Symptomatic Grade III-IV hemorrhoids 2, 3
• Mixed internal and external hemorrhoids 2
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 2
• Anemia from hemorrhoidal bleeding 2

Surgical outcomes:

• Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) is the most effective treatment overall, particularly for Grade III-IV hemorrhoids, with recurrence rates of only 2-10% 2, 5
• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 2
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 2
• Complications include urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 2

Procedures to avoid:

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 2, 5
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 2, 5

Critical Diagnostic Considerations

Before attributing symptoms to hemorrhoids:

• Perform anoscopy when feasible and well-tolerated to visualize hemorrhoids and rule out other anorectal pathology 1, 3
• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 2
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population)—colonoscopy is required to rule out inflammatory bowel disease or colorectal cancer 2, 3
• Anal pain is generally not associated with uncomplicated internal hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids), abscess, or thrombosis 2
• Colonoscopy should be performed in patients over 50 years or with risk factors for colorectal cancer before treating hemorrhoids 3

Management Algorithm by Grade

Grade I (bleeding without prolapse):

• Conservative management with fiber, fluids, lifestyle modifications 2
• If persistent bleeding: rubber band ligation or sclerotherapy 2

Grade II (prolapse with spontaneous reduction):

• Conservative management initially 2
• If persistent symptoms: rubber band ligation (70.5-89% success rate) 2, 4

Grade III (prolapse requiring manual reduction):

• Conservative management initially 2
• If persistent symptoms: rubber band ligation as first procedural intervention 2
• If rubber band ligation fails: conventional excisional hemorrhoidectomy 2

Grade IV (irreducible prolapse):

• Conventional excisional hemorrhoidectomy is the treatment of choice 2

Common Pitfalls to Avoid

• Never use topical corticosteroids for more than 7 days—prolonged use causes thinning of perianal and anal mucosa 1, 2, 3
• Never attribute anemia or chronic bleeding to hemorrhoids without colonoscopy, especially in patients over 50 years 2, 3
• Never assume all anorectal symptoms are due to hemorrhoids—other conditions like anal fissures, abscesses, or fistulas may coexist or be the primary cause 2
• Do not perform rubber band ligation in immunocompromised patients due to increased risk of necrotizing pelvic infection 2