Consider the following when making your decision:

• Home treatment is usually the first step in treating hemorrhoids. Home treatment includes adjusting your diet to avoid constipation, drinking more fluids, using a stool softener, and using ointments to relieve symptoms.
• Fixative procedures, which cut off the blood flow to the hemorrhoids using rubber bands, lasers, heat, or chemical injections, are an option if you have internal hemorrhoids that bulge from the anus during bowel movements.
• You might consider surgery to remove hemorrhoids (hemorrhoidectomy) for internal hemorrhoids that bulge from the anus or external hemorrhoids that are causing symptoms and have not improved with home treatment.

What types of hemorrhoids are there?

Hemorrhoids may occur either near the opening of the anus (external hemorrhoids) or inside the anal canal (internal hemorrhoids).

• External hemorrhoids may be painful but usually do not need medical treatment unless a clot develops.
• Internal hemorrhoids usually do not cause pain. However, they can itch, cause a pressure sensation, and make it difficult to clean the anal area. They may also bleed or stick out from the anus. Internal hemorrhoids are assessed and treated according to how bad they are.
  • First-degree hemorrhoids do not bulge from the anus.
  • Second-degree hemorrhoids bulge from the anus during bowel movements but go back into the anus afterward on their own.
  • Third-degree hemorrhoids bulge from the anus during bowel movements, but they can be pushed back into the anus.
  • Fourth-degree hemorrhoids bulge outside the anus all the time.

What are the methods of treatment for hemorrhoids?

Hemorrhoids are treated with home treatment, fixative (nonsurgical) procedures, and/or surgery.

Home treatment

Home treatment methods for hemorrhoids mainly involve having healthier bowel habits.

You can avoid making hemorrhoids worse by blotting the anus gently after bowel movements with white toilet paper moistened with water or a cleansing agent such as Balneol or with moistened, medicated pads such as Tucks. Also, avoid rubbing the anal area, and avoid soaps with perfumes or dyes. To relieve symptoms, apply ice several times a day. Also, try applying moist heat, such as warm, damp towels, several times daily, or sitting in warm water (sitz bath).

Other measures you can take at home include increasing the amount of fiber and water in your diet and taking stool softeners. This will help prevent constipation and make stools easier to pass. Changing some of your habits so that you do not strain while having bowel movements will often relieve symptoms caused by both types of hemorrhoids. This also may keep hemorrhoids from becoming bigger. However, although hemorrhoids may shrink, they will not go away.

Fixative procedures

The goal of fixative procedures is to reduce the blood supply to the hemorrhoid, causing the hemorrhoid to shrink or go away. These nonsurgical treatments cure most smaller and some larger internal hemorrhoids. Fixative procedures include tying off hemorrhoids with rubber bands (rubber band ligation); scarring the tissue around the hemorrhoids (coagulation therapy) with devices that use heat, a laser, or an electrical current; and injecting hemorrhoids with chemicals that cause them to shrink (injection sclerotherapy). These are called fixative procedures because the scar that results keeps nearby veins from bulging into the anal canal.

Hemorrhoidectomy

Surgical removal of hemorrhoids (hemorrhoidectomy) is the most successful way to treat large internal hemorrhoids. Small internal hemorrhoids are sometimes treated surgically when several hemorrhoids are present, bleeding cannot be controlled with other treatments, or both internal and external hemorrhoids are present.

How effective are the different hemorrhoid treatments?

Most internal hemorrhoids become smaller and cause less pain with either home treatment or fixative procedures, which cut off blood flow to the hemorrhoids.

• Hemorrhoid surgery may give better long-term results than fixative procedures.
• Compared with fixative procedures, surgery costs more, is more risky, and has a longer recovery period.
• Fixative procedures are less risky and less painful than surgery and require less time off from work and other activities.
• Of the fixative procedures, rubber band ligation seems to give the best results but also appears to have a higher risk of complications, especially pain.

Fixative procedures, especially rubber band ligation, may successfully treat hemorrhoid symptoms.

Rubber band ligation is used to treat small and medium-sized hemorrhoids that are too large to be treated by injection sclerotherapy and infrared photocoagulation. It is the most successful fixative procedure and the one most commonly used. More than 86% of the time, hemorrhoid symptoms do not return. If they do return, they can be treated again with rubber band ligation or other treatments.¹

Infrared photocoagulation is also used to treat small hemorrhoids. It has fewer risks than injection sclerotherapy and a similar success rate. It is generally more expensive than injection sclerotherapy.¹

Injection sclerotherapy is rarely performed; its success depends on the skill of the doctor, and it works well only for small hemorrhoids. About 77% to 86% of the time, the hemorrhoids do not return.¹

Improvements in symptoms after rubber band ligation appear to last longer than after other types of fixative procedures, but people reportedly have more pain after the procedure than after injection sclerotherapy or infrared photocoagulation.

Surgery usually cures a hemorrhoid, but the long-term success of hemorrhoid surgery depends largely on how well you are able to change your daily bowel habits to avoid constipation and straining.

What are the risks of the different treatments for hemorrhoids?

Most fixative procedures, such as rubber band ligation and infrared photocoagulation, usually have few risks. Possible problems may include:

• Pain or discomfort. For some people, the pain may be so bad that they will not be able to do their normal activities for a day or so.
• Bleeding, which may require another doctor visit to treat.
• Temporary difficulty urinating because of pain. If the person is completely unable to urinate, treatment will be needed.
• Infection or abscess. In rare cases, rubber band ligation may cause a bad infection that can be life-threatening and requires hospitalization for treatment.

Rubber band ligation appears to cause more pain than other types of fixative procedures. Infrared photocoagulation usually causes fewer side effects and does not have the rare, life-threatening complications.¹

Surgery (hemorrhoidectomy) is more likely than fixative procedures to cause side effects. These may include:

• Pain, which may last for weeks. Passing bowel movements, even if they are soft, can be quite painful.
• Bleeding, which may last for a few days. If the bleeding is severe, you may need treatment.
• Inability to urinate or pass stools. Inability to pass stools may cause stools to become stuck in the anal canal (fecal impaction).
• Infection.

In rare cases, a more serious problem may develop.

What are the risks of not treating hemorrhoids?

If you do not treat hemorrhoids, you may continue to have discomfort, pain, or bleeding. If bleeding is severe, it may cause anemia. You may have difficulty keeping the anal area clean.

If you change your daily habits so that your stools are soft and easy to pass, your hemorrhoids will probably get smaller, cause less pain, and may not cause any symptoms. If you have fixative procedures or surgery, you will still need to get enough fluid and fiber to keep your stools soft.

If you need more information, see the topic Hemorrhoids.

Your choices are:

• Use home treatments to control hemorrhoid symptoms.
• Have a fixative procedure that cuts off the blood flow to the hemorrhoids. Rubber band ligation and infrared photocoagulation are the most commonly performed fixative procedures.
• Have surgery to remove the hemorrhoid (hemorrhoidectomy).

The decision about what treatment to use for hemorrhoids takes into account your personal feelings and the medical facts. The method you choose will depend on:

• The location of the hemorrhoids, whether they are internal or external.
• The size of the hemorrhoids and how bad they are.
• The amount of pain or discomfort the hemorrhoids cause.
• The amount of bleeding from the hemorrhoids.
• Other conditions that may affect your choice.

Deciding about treatment for hemorrhoids

Method	Reason to use method	Reason not to use method
Home treatment	Hemorrhoids cause pain and discomfort. Home treatment should be the first choice for hemorrhoids. Avoiding constipation by drinking more fluids, eating more fiber, or using a stool softener may provide sufficient relief. Ointments that relieve the itching, pain, and swelling may provide sufficient relief.	You have already tried home treatments with little or no success. A blood clot has developed in a hemorrhoid. The hemorrhoid causes significant bleeding or sticks out from the anus, making it difficult to keep the area clean. A large internal hemorrhoid bulges out of the anus, and the blood supply to the hemorrhoid is cut off (strangulated hemorrhoid). This is usually extremely painful, and urgent treatment is needed.
Fixative procedure	Hemorrhoids cause significant pain and discomfort. You have significant bleeding, and you are concerned about how much or how often the hemorrhoids bleed, or you are anemic from the bleeding. You have large hemorrhoids that may not hurt but may stick out from the anus and make it difficult to keep the anal area clean.	Home treatments provide sufficient relief from hemorrhoid symptoms. You have external hemorrhoids that are causing symptoms and have not improved with home treatment. Fixative procedures are not used for external hemorrhoids. You have internal hemorrhoids that are large and bulge out of the anus, are clotted (thrombosed), or come back after fixative treatment.
Surgery	A large internal hemorrhoid bulges out of the anus, and the blood supply to the hemorrhoid is cut off (strangulated hemorrhoid). This is usually extremely painful, and urgent treatment is needed. Surgery is the only option available for people who have only external hemorrhoids that are causing symptoms and have not improved with home treatment. Treating external hemorrhoids can be very painful and often requires medicine to control pain. Surgery may be done to treat internal hemorrhoids that are large and bulge out of the anus, are clotted (thrombosed), or come back after fixative treatment. Surgery may provide better long-term results than fixative procedures. However, surgery is more expensive and more painful, requires a longer recovery time, and has a greater risk of complications.	Surgery to remove external hemorrhoids that do not have clots in them is not usually considered unless: The hemorrhoids are large and uncomfortable and make it difficult to keep the anal area clean. You are having surgery on the anal area for other reasons, such as to treat internal hemorrhoids or to repair a tear in the lining of the anal canal (anal fissure). Health professionals recommend home treatment and nonsurgical medical treatment of hemorrhoids during pregnancy. Surgery is rarely done to treat hemorrhoids during pregnancy. However, it can be safely done if pain and bleeding persist after nonsurgical treatment.

People who have certain health conditions may not be able to have some fixative or surgical procedures. These conditions include:

• Bleeding disorders or taking medicine to prevent blood clots (blood thinners or anticoagulants).
• Human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS).
• Rectal prolapse.
• Anal tumors or narrowing (strictures) at the opening of the anal canal.
• A large tear in the lining of the anal canal (anal fissure) or infection around the anus.
• Crohn's disease or ulcerative colitis.
• Cirrhosis of the liver.
• Irritable bowel syndrome or other conditions that cause a person to have frequent diarrhea, severe constipation, or both.
• Heart failure.
• Portal hypertension.

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about the different methods of treating hemorrhoids. Discuss the worksheet with your health professional.

Circle the answer that best applies to you.

I have tried changing my habits to avoid constipation and straining during bowel movements.	Yes	No	NA*
I have tried home treatments, such as using stool softeners or ointments, with little or no success.	Yes	No	NA
I am concerned about the amount of pain or bleeding from my hemorrhoids.	Yes	No	Unsure
I am willing to accept the greater risks of surgery for permanent relief of my hemorrhoids.	Yes	No	Unsure
I have external hemorrhoids that are causing symptoms and have not improved with home treatment.	Yes	No	NA
My hemorrhoids are large and uncomfortable and make it difficult to keep the anal area clean.	Yes	No	Unsure
My hemorrhoids are very large and, although they don't hurt, they stick out from the anus.	Yes	No	Unsure
An internal hemorrhoid has returned, even though I previously had fixative treatment.	Yes	No	NA

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use a certain treatment for hemorrhoids.

Check the boxes below that represent your overall impression about your decision.

Leaning toward using home treatment

Leaning toward NOT using home treatment

Leaning toward having a fixative procedure

Leaning toward NOT having a fixative procedure

Leaning toward having surgery

Leaning toward NOT having surgery

Citations

1. Johanson JF, Rimm A (1992). Optimal nonsurgical treatment of hemorrhoids: A comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. American Journal of Gastroenterology, 87(11): 1601–1606.

Author	Monica Rhodes
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	Adam Husney, MD - Family Medicine
Specialist Medical Reviewer	Brent Shoji, MD - General Surgery
Last Updated	October 10, 2006