A very common question that I am asked is whether everyone with hemorrhoids needs surgery. And the truth of the matter is that only a minority of patients need surgery for hemorrhoids. Many times, I am actually able to treat hemorrhoids more effectively in the office than in the operating room. So, who can be treated in the office and who needs surgery for hemorrhoids?
First, we should talk about the difference between external and internal hemorrhoids. I’ve talked about this difference in another post as well. External hemorrhoids have pain nerves and can’t be treated with hemorrhoid banding. Imagine if you put a rubber band on your finger – it would hurt; that’s why you can’t rubber band external hemorrhoids. But, internal hemorrhoids don’t have pain nerves. They have nerves known as autonomic nerves, which supply sensations similar to the intestinal tract (that’s why we can have cramps due to gas). Because internal hemorrhoids don’t have pain nerves, they can be treated with procedures in the office.
There’s a grading scale for hemorrhoids. It’s useful to understand this so we can talk about different types of hemorrhoids:
* First Degree – Bleed only, but do not prolapse
* Second Degree – Bleed, prolapse, but spontaneously reduce
* Third Degree – Bleed, prolapse, and require manual reduction
* Fourth Degree – Bleed, prolapse, and are irreducible
Most colon and rectal surgeons believe that the most effective office-based procedure to treat internal hemorrhoids is rubber band ligation. This is typically done for grades one, two, and three internal hemorrhoids. We use a small scope called an anoscope to view the hemorrhoid. A special device called (you guessed it) a bander is used to place a rubber band on the hemorrhoid. That sticks the hemorrhoid down to the wall. For patients who have prolapse of hemorrhoids (the hemorrhoid comes out when they move their bowels), the prolapse is stopped with the banding. The band will then fall off, along with the hemorrhoid, in about 10-14 days. Hemorrhoid banding is a very effective treatment for bleeding caused by hemorrhoids and prolapse.
Typically, hemorrhoids of grades 1-3 can be effectively treated in the office with hemorrhoid banding. Banding for grade 3 hemorrhoids is less successful than for grade 1 hemorrhoids, but it still is effective. And, let’s face it, not many people are excited about hemorrhoid surgery. So, it’s often worthwhile to try. I’m fairly effective in keeping patients with grades 1-3 hemorrhoids out of the operating room.
Grade 4 hemorrhoids are treated less often with rubber band ligation. But, I often see patients who have both external hemorrhoids and grade 3 internal hemorrhoids at the same time. So, the internal hemorrhoids can be treated with banding and the external hemorrhoids often don’t cause any problems afterward.
However, one thing that should be pointed out is about grade 1 hemorrhoids. Just because there is rectal bleeding doesn’t mean that it is caused by hemorrhoids. I’m not trying to scare anyone, but one of the more common scenarios is a patient with rectal cancer who thinks that bleeding that has been occurring is due to hemorrhoids. This can be differentiated by a colonoscopy.
Thanks for joining!
As you can see, there are a lot of subtleties in hemorrhoids. This is one of the more common things that I treat as a colon and rectal surgeon.
Remember, and if you’ve read my other posts you’ll already know this, make sure and get your daily fiber! That is the main over-the-counter treatment that is effective for hemorrhoids. Many of the over-the-counter creams just aren’t effective.