Treatment of Piles (Hemorrhoids)

Classification — Internal Hemorrhoids

1. Conservative / Medical Management

• Dietary fibre: 20–30 g daily; fibre supplementation reduces persistent hemorrhoid symptoms by ~53%
• Fluid intake: 6–8 glasses of non-alcoholic, non-caffeinated fluid daily
• Bowel habit modification: avoid straining and prolonged sitting on the toilet
• Stool softeners: docusate sodium; polyethylene glycol 3350 if fibre alone is insufficient
• Topical agents: phenylephrine/mineral oil/petrolatum or glucocorticoid-based creams for pain and itching (caution: glucocorticoids predispose to candidiasis); glycerin suppositories have little role
• Sitz baths: warm soaks for symptomatic relief, especially after procedures or for thrombosed external hemorrhoids
• Phlebotonics (e.g., flavonoids/diosmin): improve venous tone, stabilise capillary permeability, reduce bleeding; excellent safety profile; useful adjunct for Grades II–III

2. Office-Based / Procedural Treatments

Rubber Band Ligation (RBL) — Most Common Office Procedure

• Grades: II and III (most effective); Grade I may be too small
• Success rate: 65–75%
• Bands applied just proximal to the hemorrhoid above the dentate line — placement below the dentate line causes severe pain (must be removed immediately)
• Creates ischaemic necrosis → tissue sloughs over days
• Most patients managed with ≤3 procedures
• Complications: post-procedure pain, bleeding (1% risk of severe haemorrhage when band sloughs), rare life-threatening sepsis/pelvic cellulitis

Sclerotherapy

• Grades: I–IV (favoured in patients with AIDS, even for Grades III–IV)
• Sclerosant: 5% phenol or saline injected at hemorrhoid base via anoscope (1–2 mL)
• Success rate: ~75%
• More late complications than banding

Infrared Photocoagulation (IRC)

• Grades: I and II
• Infrared light fired 3–5 times at hemorrhoid base for 1.5 seconds per session; multiple sessions may be needed
• Efficacy slightly less than RBL; complications are rare

Radiofrequency / Bipolar Coagulation

• Bicap probe applied to hemorrhoid base above dentate line, activated 4–6 times for 2 seconds each

Cryotherapy

• No longer recommended due to prolonged healing

3. Surgical Treatment

Excisional Hemorrhoidectomy

• Grades: III and IV
• Success rate: >85% at 10-year follow-up
• External tags may be excised simultaneously
• Drawback: pronounced postoperative pain

Procedure for Prolapsing Hemorrhoids (PPH) / Stapled Hemorrhoidopexy

• Grades: III and IV
• Success rate: >75%; however, long-term recurrence rates are higher than with excisional hemorrhoidectomy
• Significantly less postoperative pain overall, but some patients experience severe, persistent pain or defecation urgency
• Rare but serious: pelvic sepsis and death reported

Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL)

• Doppler probe guides suture placement to interrupt blood supply to the anal canal
• Recurrence rate: ~9% for prolapse, ~7.8% for bleeding at 1 year

4. Treatment of External Hemorrhoids

• Non-thrombosed: no treatment required unless symptomatic; conservative excision if conservative measures fail
• Thrombosed external hemorrhoids: acute onset of perianal pain with a purplish nodule
  • Conservative: sitz baths, ice, analgesics, stool softeners
  • Surgical excision (not incision) within 48–72 hours of onset for best results: elliptic radial incision, all thrombus removed — lower recurrence rate than simple incision

Summary Table — Internal Hemorrhoids