Most internal hemorrhoids can be fixed without surgery. Grade I and II hemorrhoids, which make up the majority of cases, typically respond well to dietary changes, symptom relief at home, and office-based procedures if needed. More advanced hemorrhoids that prolapse outside the anal canal may require a procedural or surgical fix, but even those treatments have become less invasive over the past decade.
The right approach depends on how severe your hemorrhoids are, which is classified on a four-point grading scale based on whether the tissue stays inside, slides out and goes back on its own, needs to be pushed back in, or can’t be pushed back at all.
Understanding the Four Grades
Internal hemorrhoids sit inside the anal canal where you can’t see or feel them directly. They’re graded I through IV based on how much they prolapse, meaning how far they bulge downward:
- Grade I: Swollen tissue that stays inside the canal. The main symptom is painless bleeding during bowel movements.
- Grade II: Tissue that bulges out during straining but slides back in on its own afterward.
- Grade III: Tissue that bulges out and must be pushed back in manually. Often causes itching and mucus leakage.
- Grade IV: Tissue that stays permanently prolapsed and cannot be pushed back in. Chronic irritation and inflammation are common at this stage.
Grades I and II are almost always managed with conservative treatments. Grade III can go either way, sometimes responding to office procedures, sometimes requiring surgery. Grade IV nearly always needs a surgical fix.
Fiber, Fluids, and Bowel Habits
The single most effective home treatment for internal hemorrhoids is increasing your fiber intake. Fiber softens stool and adds bulk, which reduces the straining that engorges hemorrhoidal tissue in the first place. The recommended target is 14 grams of fiber per 1,000 calories you eat. On a standard 2,000-calorie diet, that works out to about 28 grams per day. Most people fall well short of this.
Good sources include beans, lentils, whole grains, berries, pears, broccoli, and psyllium husk supplements. If you’re adding fiber quickly, start gradually to avoid bloating and gas. Pair increased fiber with plenty of water and other clear liquids like fruit juice or broth, since fiber needs fluid to do its job properly.
Beyond diet, changing your bathroom habits matters. Avoid sitting on the toilet longer than necessary, don’t strain or bear down forcefully, and go when you feel the urge rather than delaying. These simple changes reduce pressure on the veins inside the anal canal and can resolve mild hemorrhoids entirely over a few weeks.
Sitz Baths and Topical Relief
A sitz bath is a shallow warm soak that relaxes the muscles around the anus and improves blood flow to the area, which helps reduce swelling and discomfort. Fill a basin or bathtub with a few inches of warm water at around 104°F (40°C) and soak for 15 to 20 minutes. Doing this two to three times a day, especially after bowel movements, can noticeably ease symptoms within a few days.
Over-the-counter creams and suppositories containing ingredients like witch hazel, hydrocortisone, or lidocaine can temporarily relieve itching, burning, and minor pain. These products treat symptoms, not the underlying hemorrhoid, so they work best alongside the dietary and habit changes described above. Hydrocortisone products shouldn’t be used for more than a week at a time, since prolonged use can thin the skin.
Venotonic Supplements
A class of plant-based supplements can help strengthen vein walls and reduce inflammation in hemorrhoidal tissue. The most studied of these contains a combination of two citrus-derived compounds (diosmin and hesperidin) in a micronized form that the body absorbs more easily. Clinical data shows these supplements reduce swelling and pain at dosages between 1,800 and 2,700 milligrams per day during flare-ups. They’re used across all four grades of internal hemorrhoids and are sometimes prescribed after hemorrhoid procedures to speed recovery. These supplements are available without a prescription in many countries and are generally well tolerated.
Office-Based Procedures
When home measures aren’t enough, several procedures can be done in a doctor’s office without general anesthesia. These are typically used for grade I through III hemorrhoids.
Rubber Band Ligation
This is the most common and effective office procedure. A small rubber band is placed around the base of the hemorrhoid, cutting off its blood supply. The tissue shrinks and falls off within a few days, usually without you noticing. The procedure takes only a few minutes and causes a dull aching or pressure sensation for a day or two.
Rubber band ligation works well in the short term, but recurrence is its main limitation. For grade II and III hemorrhoids, roughly half of patients see symptoms return within a year. About one in four of those patients will need a repeat banding, and some eventually move on to surgery. Despite this, banding remains a reasonable first step because it’s quick, inexpensive, and avoids the recovery time of surgery. Many people get lasting relief after one or two sessions.
Infrared Coagulation
This technique uses a burst of infrared light to create a small scar at the base of the hemorrhoid, reducing blood flow to the tissue. It causes fewer and less severe complications than rubber band ligation and is essentially painless for most patients. The trade-off is that it’s less effective for larger hemorrhoids and may require multiple treatment sessions. It’s best suited for grade I and small grade II hemorrhoids.
Sclerotherapy
A chemical solution is injected into the hemorrhoidal tissue, causing it to shrink and scar over several weeks. Like infrared coagulation, sclerotherapy is better for smaller hemorrhoids and tends to be less effective than banding for more advanced grades. It’s a reasonable option when bleeding is the primary symptom.
Surgical Options for Severe Hemorrhoids
Surgery is typically reserved for grade III hemorrhoids that haven’t responded to office procedures and for grade IV hemorrhoids. The two most established surgical approaches offer different trade-offs between recovery pain and long-term durability.
Traditional Hemorrhoidectomy
This is the gold standard for permanently removing hemorrhoidal tissue. The surgeon cuts out the swollen tissue under anesthesia. It’s the most effective long-term fix, with recurrence rates around 6% at one year, dramatically lower than any office-based procedure. The downside is recovery. Post-operative pain is significant, often lasting two to three weeks, and most people need time off work. Possible complications include bleeding, urinary retention, and, rarely, narrowing of the anal canal.
Stapled Hemorrhoidopexy
Instead of removing tissue, this procedure uses a circular stapling device to pull prolapsed hemorrhoidal tissue back up into its normal position and cut off part of its blood supply. Recovery pain is generally less than with a traditional hemorrhoidectomy, which made this technique popular when it was introduced. However, large clinical trials have shown that recurrence rates are higher with stapling compared to excision. Some patients also develop residual skin tags, difficulty with bowel movements, or ongoing itching after the procedure. For this reason, many surgeons now reserve stapling for select cases rather than using it as a first-line surgical option.
Hemorrhoidal Artery Ligation
This newer technique uses a specialized scope with a built-in Doppler ultrasound probe to locate the specific arteries feeding the hemorrhoidal tissue. The surgeon then stitches those arteries closed, starving the hemorrhoid of blood flow. If the tissue is prolapsing, the same stitches can be used to lift it back into place. Because no tissue is cut out, post-operative pain is typically less than with a traditional hemorrhoidectomy. It’s most commonly used for grade II and III hemorrhoids and offers a middle ground between office procedures and full excision.
What to Watch For With Bleeding
Bright red blood on toilet paper or in the bowl during a bowel movement is the hallmark symptom of internal hemorrhoids, but rectal bleeding can also signal other conditions. If bleeding is heavy, doesn’t stop, or comes with abdominal pain, unexplained weight loss, fatigue, dizziness, or a change in the size or shape of your stools, those symptoms warrant prompt evaluation. Even mild rectal bleeding that persists despite treatment deserves a medical assessment to rule out other causes, particularly for anyone over 45 or with a family history of colorectal problems.