Some hemorrhoids can’t be managed with conservative treatments alone, either because symptoms persist or because an internal hemorrhoid has prolapsed. Fortunately, a number of minimally invasive treatments are available that are less painful than traditional hemorrhoid removal (hemorrhoidectomy) and allow a quicker recovery. These procedures are generally performed in a surgeon’s office or as outpatient surgery in a hospital.
Procedures for hemorrhoids treatment
Band it. The most commonly used hemorrhoid procedure in the United States is rubber band ligation, in which a small elastic band is placed around the base of a hemorrhoid (see bow above). The band causes the hemorrhoid to shrink and the surrounding tissue to scar as it heals, holding the hemorrhoid in place. It takes two to four procedures, done six to eight weeks apart, to completely eliminate the hemorrhoid. Complications, which are rare, include mild pain or tightness (usually relieved with a sitz bath), bleeding, and infection. Other office procedures include laser or infrared coagulation, sclerotherapy, and cryosurgery. They all work on the same principle as rubber band ligation but are not quite as effective in preventing recurrence. Side effects and recurrence vary with the procedure, so consult your physician about what’s best for your situation.
Hemorrhoidectomy. You may need surgery if you have large protruding hemorrhoids, persistently symptomatic external hemorrhoids, or internal hemorrhoids that return despite rubber band ligation. In a traditional hemorrhoidectomy, a narrow incision is made around both external and internal hemorrhoid tissue and the offending blood vessels are removed. This procedure cures 95% of cases and has a low complication rate — plus a well-deserved reputation for being painful. The procedure requires general anesthesia, but patients can go home the same day. Patients can usually return to work after 7–10 days. Despite the drawbacks, many people are pleased to have a definitive solution to their hemorrhoids.
Staples. An alternative to traditional hemorrhoidectomy is called stapled hemorrhoidopexy. This procedure treats bleeding or prolapsed internal hemorrhoids. The surgeon uses a stapling device to anchor the hemorrhoids in their normal position. Like traditional hemorrhoid removal, stapled hemorrhoidopexy is performed under general anesthesia as day surgery, but it’s less painful and recovery is quicker.
Treat hemorrhoids only when the patient complains of them. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient.
Treatment of hemorrhoids is divided by the cause of symptoms, into internal and external treatments. Accurately classifying a patient’s symptoms and the relation of the symptoms to internal and external hemorrhoids is important.
Treatment guidelines are available from the American Gastroenterological Association, the American Society of Colon and Rectal Surgeons, and the American College of Gastroenterology (ACG).
The ACG guidelines, for example, recommend that patients with symptomatic hemorrhoids initially be treated with increased fiber and adequate fluid intake. The guidelines also recommend that if dietary modifications do not eliminate symptoms in patients with first- to third-degree hemorrhoids, various office procedures, including banding, sclerotherapy, and infrared coagulation, should be considered, with ligation probably being the most effective treatment. The ACG further states that patients should be referred for surgery if they are refractory to or unable to tolerate office procedures, if their hemorrhoids are accompanied by large symptomatic external tags, or if they have either fourth-degree or large third-degree hemorrhoids.
Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic, and the treatment may be surgical or nonsurgical. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting.
The following is a quick summary of treatment for internal hemorrhoids by grade:
- Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods
- Grade II or III hemorrhoids are initially treated with nonsurgical procedures
- Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy
- Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation
Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), is an excellent alternative for treating internal hemorrhoids that have not been amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with procedure for prolapsing hemorrhoids and skin tag excision.
In a meta-analysis of randomized, controlled trials, however, Chen et al concluded that the recurrence rate of prolapsing hemorrhoids was higher with stapled hemorrhoidectomy than with LigaSure hemorrhoidectomy. Operative resection is sometimes required to control the symptoms of internal hemorrhoids.
External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), whereas operative resection is reserved for the latter. Remember that therapy is directed solely at the symptoms, not at aesthetics.
When performed well, operative hemorrhoidectomy should have a 2-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually be addressed with further nonoperative treatments. Long-term results from procedure for prolapsing hemorrhoids are unavailable at this time.
The major controversies regarding the treatment of hemorrhoids center on the indications for treatment and the choice of operative versus nonoperative therapy. Most experienced surgeons are using office-based nonoperative therapies and are relying less on operative hemorrhoidectomy than they previously were. In the United States, rubber band ligation (compared with injection sclerotherapy) is the mainstay of conservative treatment. Procedure for prolapsing hemorrhoids (PPH), which has been gaining increasing favor in the United States, provides an excellent alternative to operative hemorrhoidectomy for patients with minimal external disease and large internal hemorrhoids.
How to Treat Hemorrhoids at Home
You don’t need to see a doctor for quick ways to ease your itching and pain, or for ongoing fixes to keep the discomfort from getting worse. The best treatments for hemorrhoids are often things you can do at home.
Many of these tips will help you avoid constipation and make it easier to go. That can stop hemorrhoids before they form, too.
Dramaric relief for most hemorrhoid symptoms can be found with simple, home remedies for hemorrhoids. To avoid occasional flare-ups, try the following.
Get more fiber. Add more fiber to your diet from food, a fiber supplement (such as Metamucil, Citrucel, or Fiber Con), or both. Along with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids. High-fiber foods include broccoli, beans, wheat and oat bran, whole-grain foods, and fresh fruit. Fiber supplements help decrease hemorrhoidal bleeding, inflammation, and enlargement. They may also reduce irritation from small bits of stool that are trapped around the blood vessels. Some women find that boosting fiber causes bloating or gas. Start slowly, and gradually increase your intake to 25–30 grams of fiber per day. Also, increase your fluid intake.
Exercise. Moderate aerobic exercise, such as brisk walking 20–30 minutes a day, can help stimulate bowel function.
Take time. When you feel the urge to defecate, go to the bathroom immediately; don’t wait until a more convenient time. Stool can back up, leading to increased pressure and straining. Also, schedule a set time each day, such as after a meal, to sit on the toilet for a few minutes. This can help you establish a regular bowel habit.
Sitz. A sitz bath is a warm water bath for the buttocks and hips (the name comes from the German “sitzen,” meaning “to sit”). It can relieve itching, irritation, and spasms of the sphincter muscle. Pharmacies sell small plastic tubs that fit over a toilet seat, or you can sit in a regular bathtub with a few inches of warm water. Most experts recommend a 20-minute sitz bath after each bowel movement and two or three times a day in addition. Take care to gently pat the anal area dry afterward; do not rub or wipe hard. You can also use a hair dryer to dry the area.
Seek topical relief for hemorrhoids. Over-the-counter hemorrhoid creams containing a local anesthetic can temporarily soothe pain. Creams and suppositories containing hydrocortisone are also effective, but don’t use them for more than a week at a time, because they can cause the skin to atrophy. Witch hazel wipes (Tucks) are soothing and have no harmful effects. A small ice pack placed against the anal area for a few minutes can also help reduce pain and swelling. Finally, sitting on a cushion rather than a hard surface helps reduce the swelling of existing hemorrhoids and prevents the formation of new ones.
Treat the clot. When an external hemorrhoid forms a blood clot, the pain can be excruciating. If the clot has been present for longer than two days, apply home treatments for the symptoms while waiting for it to go away on its own. If the clot is more recent, the hemorrhoid can be surgically removed or the clot withdrawn from the vein in a minor office procedure performed by a surgeon.
To perform a rubber band ligation, the clinician places a ligator over the hemorrhoid to position a rubber band around its base.
Ease Pain and Itching
Take warm baths. Soak in a bathtub filled with a few inches of warm water for about 15 minutes at a time. Do it two or three times a day and after every bowel movement. If you want to wash the area, too, use unscented soap and don’t scrub.
Pat gently afterward to dry. You can even use a blow dryer on a cool setting if that feels better.
There are also special “sitz baths” you can put directly on your toilet seat to make soaking easier.
Rub on relief. Over-the-counter wipes or creams with witch hazel can soothe pain and itch with no side effects. Don’t use one with hydrocortisone for more than a week unless your doctor says it’s OK.
Ice it. Put a small cold pack on the trouble spot several times a day. It can dull pain and bring down the swelling for a little while.
Consider painkillers. An over-the-counter medicine, like acetaminophen, aspirin, or ibuprofen, could help with soreness.
Don’t scratch. You could damage the skin and make the irritation — and the itching — worse.
Choose cotton. Wear loose, soft underwear. It keeps the area aired out and stops moisture from building up, which can bother your hemorrhoids.
Good Bathroom Habits
Limit your time on the throne. If you don’t go after a few minutes, don’t wait or force something to happen. Try to get into a routine where you go at the same time every day.
Be gentle. If toilet paper is irritating, try dampening it first. Or use pre-moistened wipes, cotton balls, or alcohol-free baby wipes.
Don’t hold it in. When you feel like you have to go, do it. Don’t wait for a better time or place. Stool can back up. And that can lead to straining and more pressure. Go as soon as you can when you feel the urge.
Try a squat position. Put a short bench or a stack of phone books under your feet when you go to the bathroom. Raising your knees as you sit on the toilet changes the position of your inner workings and could make bowel movements easier.
Don’t Make Things Worse
Bump up the fiber. It softens your stools and makes them move through your body more easily. You’ll find it in beans, whole-grain breads and cereals, and fresh fruits and veggies. You may also want to try a supplement if you can’t get enough from foods. Add fiber slowly to help avoid gas and bloating.
Drink lots of fluids. Stay well hydrated to keep stools soft so they’re easier to pass. Water is the best choice. Drink plenty throughout the day. Prune juice is a natural laxative and can help you go.
Exercise regularly. Even brisk walking 20-30 minutes every day can help keep you from getting stopped up.
Breathe! Keep the air moving in and out when you’re working hard. It’s common to hold your breath as you’re pushing, pulling, or making an effort (you probably don’t realize you’re doing it) — and that can lead to hemorrhoid pain and bleeding.
Use a pillow. Sit on a cushion instead of a hard surface. It will ease swelling for any hemorrhoids you have. It may also help prevent new ones from forming.
Take breaks. If you must sit for a long time, get up every hour and move around for at least 5 minutes.
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