Internal hemorrhoids can be removed through several methods, ranging from quick office procedures to surgery, depending on how severe they are. Most cases respond to non-surgical treatments. The approach your doctor recommends will depend on the grade of your hemorrhoid, your symptoms, and whether you’ve already tried conservative measures.
How Hemorrhoid Grade Determines Treatment
Internal hemorrhoids are classified on a four-point scale based on how much they protrude from the anal canal. Grade I hemorrhoids are visible but stay inside. Grade II hemorrhoids bulge out during straining but slide back in on their own. Grade III hemorrhoids push out and need to be manually pushed back in. Grade IV hemorrhoids are permanently prolapsed and can’t be pushed back at all.
This grading system directly shapes your treatment path. Grades I and II almost always start with dietary changes and office-based procedures. Grade III may respond to office procedures or may need surgery. Grade IV nearly always requires surgical removal. Regardless of severity, treatment starts with high-fiber eating and changes to bowel habits before anything more invasive is considered.
Dietary and Lifestyle Changes
Fiber is the foundation of hemorrhoid management at every grade. The recommended intake is 14 grams per 1,000 calories you eat, which works out to about 28 grams per day on a standard 2,000-calorie diet. Focus on whole grains, green leafy vegetables, and fruits. Fiber softens stool and reduces the straining that worsens hemorrhoids, and it can shrink mild cases on its own over several weeks.
Drink at least eight large glasses of water a day to help the fiber work properly. Limit dairy products, red meat, processed foods, and sugary baked goods, all of which contribute to constipation. Avoid sitting on the toilet for extended periods or straining during bowel movements. Warm sitz baths (sitting in a few inches of warm water for 10 to 15 minutes) can relieve swelling and discomfort while you wait for dietary changes to take effect.
Rubber Band Ligation
Rubber band ligation is the most widely recommended office procedure for Grade I, II, and some Grade III internal hemorrhoids. During the procedure, a doctor places a small rubber band around the base of the hemorrhoid, cutting off its blood supply. The tissue shrivels and falls off on its own, usually within one week.
Success rates range from 70% to 80%. At two-year follow-up, about 15.5% of patients report symptoms coming back. Of those who do recur, roughly two-thirds are treated with repeat banding rather than surgery. Compared to other office-based options, rubber band ligation has the best long-term results and the lowest chance of needing additional treatment. The trade-off is that it causes more post-procedure pain than alternatives like infrared coagulation or injection therapy. Most people describe a dull aching or pressure for one to three days afterward.
Infrared Coagulation and Sclerotherapy
Two other office-based options work well for lower-grade hemorrhoids, particularly when pain tolerance is a concern.
Infrared coagulation uses a burst of infrared light to create scar tissue at the base of the hemorrhoid, shrinking its blood supply. It causes fewer and less severe complications than banding, making it a good choice for patients who want the gentlest procedure. Originally intended for Grade I and II hemorrhoids, newer reports show acceptable results for Grade III and even some Grade IV cases. However, patients treated with infrared coagulation are more likely to need retreatment down the line compared to those who get banding.
Sclerotherapy involves injecting a chemical solution into the hemorrhoid tissue, causing it to scar and shrink. It works best for Grade I hemorrhoids, with success rates dropping for Grades II and III. Like infrared coagulation, it’s less painful than banding but more likely to require repeat treatment. At the 12-month mark, similar numbers of patients are symptom-free regardless of which office procedure they chose initially.
Doppler-Guided Artery Ligation
This procedure uses an ultrasound probe to locate the arteries feeding the hemorrhoid, then ties them off with a stitch. It’s suitable for Grade I, II, and III hemorrhoids and works especially well for Grade II. Current guidelines suggest it can be considered as an alternative to full surgical removal. Because no tissue is cut away, recovery tends to be more comfortable than traditional surgery, though it’s a more involved procedure than simple banding.
Surgical Removal for Advanced Cases
When office procedures haven’t worked, or when you’re dealing with Grade III or IV hemorrhoids, surgery becomes the most effective option. Two main surgical approaches exist, and the choice between them matters for both recovery and long-term outcomes.
Excisional Hemorrhoidectomy
This is the traditional approach: the surgeon cuts away the hemorrhoid tissue entirely. It’s the gold standard for Grade III and IV hemorrhoids and carries the lowest recurrence rate of any treatment. At 24 months, patients who undergo excisional hemorrhoidectomy report significantly fewer returning symptoms, less urgency, and a higher quality of life compared to those who have stapled procedures.
The downside is a more painful recovery. In one study of open hemorrhoidectomy patients, 22% experienced temporary difficulty urinating on the first day after surgery, 7% had some post-operative bleeding, and 4% developed a wound infection. Bleeding can increase around the seventh day as the surgical site heals. Most of these complications resolve within the first two weeks.
Stapled Hemorrhoidopexy
Instead of cutting out the hemorrhoid, this procedure uses a circular stapling device to pull prolapsed tissue back into its normal position and reduce blood flow to the area. It’s less painful in the early days after surgery and allows a faster return to work. However, current guidelines do not recommend it as a first-line surgical option. A Cochrane review of 12 trials found that patients who had stapled procedures were more than three times as likely to have hemorrhoids recur compared to those who had traditional excision. It’s generally reserved for prolapsing internal hemorrhoids when other methods have failed.
What Recovery Looks Like
Recovery differs dramatically depending on the procedure. After rubber band ligation or infrared coagulation, most people return to normal activities the same day, with mild discomfort for a few days. After surgical removal, the timeline is longer and more structured.
On the day of surgery, you’ll stick to clear liquids like broth, gelatin, and juices to avoid nausea and constipation. By the next day, you can return to a regular diet heavy on whole grains, vegetables, and fruit. Rest for the first 24 hours, then gradually resume normal activities as you feel up to it. Avoid heavy lifting or straining for at least five to seven days. Nothing should be inserted into the rectum for at least five days, including suppositories or enemas.
Pain after excisional hemorrhoidectomy is often the most intense during the first bowel movement and tends to improve steadily over one to two weeks. Keeping stools soft with fiber and plenty of water makes a significant difference in comfort during this period. Most people are back to their regular routine within two to three weeks, though full healing of the surgical site can take longer.
Recurrence and Long-Term Outlook
No procedure guarantees hemorrhoids won’t return. Rubber band ligation sees about a 15.5% recurrence rate within two years. Excisional hemorrhoidectomy has the lowest long-term recurrence of any option, while stapled hemorrhoidopexy has the highest. Regardless of which procedure you have, maintaining a high-fiber diet, staying hydrated, and avoiding prolonged straining are the most effective ways to prevent new hemorrhoids from developing. The underlying factors that caused hemorrhoids in the first place, like chronic constipation, prolonged sitting, or low fiber intake, will cause them again if left unaddressed.