What are the treatment options for hemorrhoids?

Sclerotherapy is a treatment option for grade 1 or grade 2 hemorrhoids. In this procedure, a proctoscope is gently inserted into the anus. A proctoscope is a short tube with a light on it which the doctor can use to look at the membranes lining the anus. A drug (usually polidocanol) is then injected into the mucous membrane tissue under the enlarged hemorrhoids. The aim of this procedure is to shrink the hemorrhoids. It typically needs to be carried out several times in order to treat all of the enlarged hemorrhoids. The injections are typically given a few weeks apart. You can return to your normal daily activities after each procedure.

After sclerotherapy, some patients experience bleeding, mild pain, pressure, or the feeling that there is something in their anus. In rare cases, swelling or infections occur. Sometimes a painful blood clot (thrombus) forms in or near the anus. In many people, the hemorrhoids grow again after two to three years and further treatment is then needed.

This approach is mainly used in the treatment of grade 2 hemorrhoids. It is also used for grade 1 and grade 3 hemorrhoids, though. In rubber band ligation (also simply known as “banding”), the doctor first gently inserts a proctoscope into the anus. With the help of an instrument (a ligator), he or she then places a small rubber band – only a few millimeters wide – around the base of the enlarged hemorrhoid. The band cuts off the blood supply to the hemorrhoid, causing the tissue to die and fall off after a few days. The dead tissue and rubber band then leave the body when you go to the toilet, without you noticing it. This procedure generally has to be repeated after a few weeks in order to treat all of the enlarged hemorrhoids.

Studies suggest that rubber band ligation has some advantages over the surgical removal (hemorrhoidectomy) of grade 2 hemorrhoids. The patients have less pain after the procedure and can return to work sooner. Possible complications following the procedure include pain, bleeding, thrombosis or abscesses. Here, too, the hemorrhoids may grow bigger again after the procedure meaning that more treatment will be needed.

If someone has grade 3 or grade 4 hemorrhoids, doctors often recommend surgery. In this kind of operation, the enlarged hemorrhoids are removed (“ectomy” means “removal”) using instruments like scissors, a scalpel or a laser. In some approaches the wound is left open afterwards, in others it is partially or completely closed with stitches. These types of surgical techniques are referred to as "open," "partially open," or "closed." Different techniques can also be combined. The doctor will explain which approach is most suitable for you before the operation. Leaving the wound partially or completely open has the advantages of fewer stitch-related complications and fewer hematoma (bruising) problems. One disadvantage is that it takes longer for open wounds to heal.

Regardless of which operation they have, most patients experience pain in their anus for a few days afterwards. Bowel movements ("pooping") and sitting may hurt as a result. This can usually be treated with painkillers. Other problems that may arise include bleeding after the operation, wound infections, problems urinating ("peeing") and – rarely – abscesses, narrowing of the anus (anal stenosis) or fecal incontinence. Fecal incontinence is the inability to control bowel movements properly, causing stool ("poo") to accidentally leak.

Stapling is a more recently developed technique, typically used in the treatment of grade 3 hemorrhoids. This procedure involves first removing some of the enlarged hemorrhoid tissue, and then “stapling” the remaining tissue to the lining of the anus again.

Current research suggests that people who have this procedure experience less pain afterwards compared to people who have a hemorrhoidectomy. They were also able to return to everyday activities sooner. But stapling was found to have a disadvantage compared to conventional surgery too: The hemorrhoids were more likely to come back after stapling. They grew bigger again in

• 3 out of 100 people who had conventional surgery, and in
• 9 out of 100 people who had the stapling procedure.

So, compared to hemorrhoidectomy, the stapling procedure may need to be repeated more often. Side effects like itching or bleeding were just as common after stapling as they were after other kinds of surgery.