Rubber Band Ligation (RBL)

Rubber band ligation is considered the most effective office-based treatment for internal hemorrhoids. It is commonly used for:

• Grade I and II internal hemorrhoids
• Selected Grade III hemorrhoids that do not respond to conservative measures

• Cuts off blood supply to the hemorrhoid
• Causes the tissue to slough off within 1–10 days
• Promotes fixation of mucosa to submucosa, improving prolapse

• Patients on blood thinners such as warfarin, heparin, or clopidogrel may not be candidates
• Typically 1–2 bands can be placed per session
• Multiple sessions may be required

• Most patients have no significant downtime
• A mild pressure or ache for 1–3 days is common and usually relieved by acetaminophen
• Symptom improvement is often long-lasting if dietary and lifestyle changes continue

Elastic Band Ligation

If symptoms recur, repeat RBL can be performed. Surgical hemorrhoidectomy remains an option for refractory cases. Safety & Complications RBL has been shown to have:

• Lower complication rates
• Lower cost
• Similar or improved outcomes compared to excisional hemorrhoidectomy or hemorrhoid artery ligation

• Pain
• Bleeding
• Infection

• Fever
• Severe anal pain
• Urinary difficulty
• Fecal incontinence
• Nausea/vomiting

Injection Sclerotherapy

Sclerotherapy involves injecting a sclerosing agent into the hemorrhoidal tissue to produce:

• Inflammation
• Fibrosis
• Scar fixation of mucosa to submucosa

• Quick and often painless
• May require multiple short sessions
• Can be considered in some patients on anticoagulants, depending on clinical judgment

• Post-procedure pain: 24%–49%
• Post-procedure bleeding: 0.9%–6%
• Recurrent bleeding: 1.5%–29%
• Recurrent prolapse: ~16%

Infrared Coagulation (IRC)

Infrared coagulation is another office-based option for:

• Grade I
• Grade II
• Selected Grade III internal hemorrhoids

• A small probe delivers infrared radiation
• The tissue heats, becomes inflamed, sloughs, and scars
• This reduces excess prolapsing tissue

• Quick and generally well tolerated
• Few complications
• Multiple treatments may be required

• Post-procedure pain: 16%–100%
• Post-procedure bleeding: 15%–44%

Excisional Hemorrhoidectomy

Excisional Hemorrhoidectomy (EH), or surgical removal of hemorrhoidal tissue, is typically offered to select patients with external hemorrhoids or symptomatic combined internal and external hemorrhoids (grades III–IV). It remains an effective option for patients who fail, cannot tolerate, or are not candidates for office-based procedures, or for those with significant external disease.

Both open and closed excisional hemorrhoidectomy techniques may be used, and surgery can be performed with a variety of surgical devices.

• Hemorrhoidectomy is performed in an operating room and may be done under sedation, general anesthesia, or spinal anesthesia (similar to an epidural during childbirth).
• Serious complications after surgical hemorrhoidectomy are rare. The most common complication is postoperative hemorrhage. Acute urinary retention occurs in approximately 1% to 15% of cases and is the most frequent cause of delayed discharge in ambulatory settings. Long-term complications may include anal stricture and fecal incontinence.

Stapled Hemorrhoidectomy

Stapled hemorrhoidopexy is not routinely recommended as a first-line surgical treatment for internal hemorrhoids due to its marginal efficacy and significant risk profile.

• SH employs a circular stapling device to excise a ring of submucosa proximal to the dentate line, creating a mucosa-to-mucosa anastomosis that elevates the anal cushions and interrupts feeding vessels. Although effective for prolapsing internal hemorrhoids, it does not address external hemorrhoids.
• SH is also associated with several unique complications, including rectovaginal fistulas, staple line bleeding, and staple line strictures.

Doppler-Guided Hemorrhoidal Artery Ligation (HAL)

Doppler-guided hemorrhoidal artery ligation may be used for patients with internal hemorrhoids. HAL uses an anoscope equipped with a Doppler probe to identify hemorrhoidal arteries, allowing for targeted suture ligation. Advantages include the absence of tissue excision and potentially less postoperative pain. It may also be combined with mucopexy for symptomatic hemorrhoidal prolapse.

• However, compared with rubber band ligation (RBL), patients typically experience more pain in the early postoperative period following HAL. HAL is also more expensive and has demonstrated reduced cost-effectiveness compared with RBL.

Postoperative Instructions After Hemorrhoidectomy

Pain Management: Some pain is expected after hemorrhoid surgery. The goal is to keep it manageable. Full activity may take 2–4 weeks to resume. Pain medication is usually a combination of narcotic and non-narcotic medicines. We aim to limit the use of stronger narcotics to reduce side effects.
Sitz Baths: Sitting in a warm bath (sitz bath) 2–3 times per day for 10–15 minutes can provide significant relief. Urination Issues: Occasionally, patients may have difficulty urinating after surgery. If this happens:
• Try urinating while sitting in a sitz bath.
• If unsuccessful, contact the surgeon’s office or go to the emergency department for bladder catheterization. Failure to address this can cause permanent bladder damage from over- stretching.
Bowel Movements: Having a bowel movement within the first 48 hours after surgery is important. To help:
• Follow a high-fiber diet.
• Take a fiber supplement.
• Drink plenty of liquids.