Nonoperative techniques? Consider rubber band ligation
A systematic review of 3 poor-quality trials comparing rubber band ligation with excisional hemorrhoidectomy in patients with grade III hemorrhoids found that excisional hemorrhoidectomy produced better long-term symptom control but more immediate postoperative complications of anal stenosis and hemorrhage.6 Rubber band ligation had the lowest recurrence rate at 12 months compared with the other nonoperative techniques of sclerotherapy and infrared coagulation.7
Fiber supplements help relieve symptoms
A Cochrane systematic review of 7 RCTs enrolling a total of 378 patients with grade I to III hemorrhoids evaluated the effect of fiber supplements on pain, itching, and bleeding. Persistent hemorrhoid symptoms decreased by 53% in the group receiving fiber.8
When surgical hemorrhoidectomy is recommended
The American Society of Colon and Rectal Surgeons recommends adequate fluid and fiber intake for all patients with symptomatic hemorrhoids. For grade I to III hemorrhoids, the society states that banding is usually most effective. When office treatments fail, the society recommends surgical hemorrhoidectomy (SOR: B).
The society recommends excision of thrombosed hemorrhoids less than 72 hours old and expectant treatment with analgesia and sitz baths for thrombosed hemorrhoids present for longer than 72 hours (SOR: B).9
The American Gastroenterological Association recommends excision of symptomatic thrombosed external hemorrhoids that present early. Surgical hemorrhoidectomy should be reserved for when conservative treatment fails and for patients with symptomatic grade III and IV hemorrhoids.10