What are the appropriate treatment options for internal hemorrhoids?

Treatment of Internal Hemorrhoids

Begin with conservative management for all grades of internal hemorrhoids, escalate to rubber band ligation for persistent grade I-III disease, and reserve surgical hemorrhoidectomy for grade III-IV hemorrhoids that fail office procedures or present with complications such as anemia. 1

Initial Conservative Management (First-Line for All Grades)

All patients with internal hemorrhoids must start with dietary and lifestyle modifications before any procedural intervention 1:

• Increase dietary fiber to 25-30 grams daily using psyllium husk (5-6 teaspoons mixed with 600 mL water daily) to soften stool and reduce straining 1, 2
• Adequate fluid intake to prevent constipation and maintain soft stools 1
• Avoid prolonged sitting and straining during defecation 2
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1

Pharmacological Adjuncts for Symptom Relief

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

Critical Diagnostic Requirements Before Treatment

Never attribute rectal bleeding or anemia to hemorrhoids without proper evaluation 1:

• Anoscopy should be performed when feasible to visualize internal hemorrhoids and exclude other anorectal pathology 1, 2
• Colonoscopy is mandatory if fecal occult blood is positive, anemia is present, or the patient is ≥50 years old or has colorectal cancer risk factors 1
• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood must not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anemia from hemorrhoids is rare (0.5 cases per 100,000 population); colonoscopy is required to exclude inflammatory bowel disease or colorectal cancer 1
• Persistent anal pain is not typical of uncomplicated internal hemorrhoids and suggests alternative diagnoses such as anal fissure (present in up to 20% of hemorrhoid patients), abscess, or thrombosis 1

Office-Based Procedures (Second-Line for Persistent Grade I-III Disease)

Rubber Band Ligation (Preferred Office Procedure)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails 1:

• Success rates: 70.5-89% depending on hemorrhoid grade, with approximately 90% of patients asymptomatic at 1-year follow-up 1
• Long-term outcomes: 69% remain asymptomatic at 10-17 years 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1, 3

Technique and Safety

• Place bands ≥2 cm proximal to the dentate line to avoid severe pain (somatic sensory nerves are absent above the anal transition zone) 1
• Can be performed in office without anesthesia using commercially available suction devices 1
• Up to 3 hemorrhoidal columns may be banded per session, though many practitioners prefer 1-2 columns at a time 1

Complications

• Pain (5-60% of patients): typically minor, manageable with sitz baths and over-the-counter analgesics 1
• Other complications (≈5%): abscess, urinary retention, band slippage, prolapse/thrombosis of adjacent hemorrhoids 1
• Severe bleeding: may occur when eschar sloughs, typically 1-2 weeks post-treatment 1
• Necrotizing pelvic sepsis (rare but serious): increased risk in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) 1

Alternative Office Procedures (Less Preferred)

• Injection sclerotherapy: suitable for grade I-II hemorrhoids, with 89.9% improvement rate, but no proven superiority over conservative management alone 1
• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, but requires more repeat treatments than rubber band ligation 1, 4
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management (Reserved for Grade III-IV or Failed Conservative/Office Therapy)

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for 1:

• Failure of medical and office-based therapy
• Symptomatic grade III-IV hemorrhoids
• Mixed internal and external hemorrhoids
• Hemorrhoids with anemia from chronic bleeding
• Concomitant anorectal conditions (fissure, fistula) requiring surgery

Surgical Technique

Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) is the most effective treatment overall, particularly for grade III-IV hemorrhoids 1, 2:

• Recurrence rate: 2-10% (lowest of all treatment modalities) 1, 2
• Success rate: 90-98% 1
• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 1

Postoperative Expectations

• Postoperative pain requires narcotic analgesics 1
• Most patients do not return to work for 2-4 weeks 1
• Complications: urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), incontinence (2-12%), sphincter defects (up to 12%) 1

Procedures to Avoid

• Anal dilatation should be abandoned: 52% incontinence rate at 17-year follow-up and causes sphincter injuries 1
• Cryotherapy is rarely used: prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Stapled hemorrhoidopexy: promising results but lacks long-term follow-up data; complications include rectal perforation, retroperitoneal sepsis, and pelvic sepsis 1

Management of Thrombosed External Hemorrhoids (Distinct from Internal Hemorrhoids)

Early Presentation (≤72 Hours)

Complete surgical excision under local anesthesia within 72 hours provides faster pain relief and lower recurrence rates compared to conservative management 1, 2:

• Excision should be complete—simple incision and drainage is contraindicated due to persistent bleeding and higher recurrence rates 1, 2
• Can be performed as an outpatient procedure under local anesthesia 1

Late Presentation (>72 Hours)

Conservative management is preferred after 72 hours, as natural resolution has typically begun 1:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks achieves 92% resolution rate (vs. 45.8% with lidocaine alone), with no systemic side effects 1, 2
• Topical nitrates show good results but are limited by high incidence of headache 1
• Topical heparin significantly improves healing, though evidence is limited 1
• Stool softeners, oral analgesics, and sitz baths for symptomatic relief 1

Common Pitfalls to Avoid

• Never use topical corticosteroids for >7 days—prolonged use causes perianal and anal mucosal thinning 1, 2
• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy 1
• Never perform simple incision and drainage of thrombosed hemorrhoids—complete excision is required 1, 2
• Avoid rubber band ligation in immunocompromised patients due to increased risk of necrotizing pelvic infection 1
• Do not assume all anorectal symptoms are hemorrhoids—up to 20% have concomitant anal fissures 1