Internal hemorrhoids are treated with a combination of dietary changes, topical relief, and, when needed, in-office or surgical procedures. The right approach depends on severity. Most people with mild symptoms improve within a few weeks by increasing fiber, staying hydrated, and adjusting bathroom habits. More advanced cases may require a quick office procedure like rubber band ligation, which is 70% to 80% effective.
How Internal Hemorrhoids Are Graded
Internal hemorrhoids are classified into four grades, and your grade largely determines your treatment path. Grade I hemorrhoids don’t prolapse (push outside the anal opening) and are usually discovered only because of painless bleeding. Grade II hemorrhoids prolapse during a bowel movement but slide back in on their own. Grade III hemorrhoids prolapse and need to be pushed back in manually, often causing itching and moisture around the anus. Grade IV hemorrhoids are permanently prolapsed and can’t be pushed back in at all. Painless bleeding can occur at any grade.
Grades I and II almost always respond to conservative, at-home treatment. Grade III hemorrhoids often benefit from an office procedure. Grade IV hemorrhoids typically require surgery.
Dietary and Lifestyle Changes
Fiber is the single most important dietary change you can make. It softens stool and adds bulk, which reduces the straining that worsens hemorrhoids. The recommended intake is about 14 grams of fiber per 1,000 calories you eat, which works out to roughly 28 grams per day on a standard 2,000-calorie diet. Most people fall well short of that number. Good sources include beans, lentils, whole grains, berries, broccoli, and pears. If you can’t get enough through food alone, a fiber supplement like psyllium husk can close the gap.
Increase your fiber intake gradually over a week or two. A sudden jump can cause bloating and gas. Drink plenty of water and other clear fluids alongside the added fiber so it works properly.
Beyond fiber, a few bathroom habits make a real difference. Don’t sit on the toilet longer than necessary, and avoid straining or holding your breath during a bowel movement. Go when you feel the urge rather than delaying. These behavioral changes are considered the primary first-line therapy for symptomatic hemorrhoids, backed by strong clinical recommendations from the American Society of Colon and Rectal Surgeons.
Sitz Baths for Symptom Relief
A sitz bath is a shallow soak that reduces irritation and promotes blood flow to the anal area. Fill a basin or bathtub with a few inches of warm water, around 104°F (40°C), and sit in it for 15 to 20 minutes. You can do this two to three times a day, especially after bowel movements. Sitz baths won’t shrink a hemorrhoid, but they reliably ease discomfort and itching during flare-ups and after procedures.
Over-the-Counter Treatments
Topical creams, suppositories, and ointments can provide temporary relief from pain, itching, and swelling. Common active ingredients include phenylephrine, which constricts blood vessels to reduce swelling; pramoxine, a local anesthetic that numbs the area; and petrolatum or glycerin, which act as skin protectants. These products are available as suppositories for internal use or as external creams.
One important limitation: OTC hemorrhoid treatments are designed for short-term use. If your symptoms haven’t improved within seven days, stop using the product and see a doctor. Prolonged use of steroid-containing formulations (like those with hydrocortisone) can thin the skin and create new problems.
In-Office Procedures
When home treatment isn’t enough, several minimally invasive procedures can be done right in a doctor’s office without general anesthesia. These are most appropriate for Grade I through III internal hemorrhoids.
Rubber Band Ligation
This is the most widely used office procedure. Your 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 about a week. Studies find rubber band ligation to be 70% to 80% effective. Most people return to normal activities the same day, though some need a day or two to recover. You should avoid lifting heavy objects for at least two weeks afterward.
Rubber band ligation tends to cause fewer complications than other office-based options. You may feel a dull ache or a sensation of fullness in the rectum for a day or two, but significant pain is uncommon.
Infrared Coagulation
A device directs infrared light at the hemorrhoid, creating scar tissue that cuts off blood flow. It’s used for Grade I through III hemorrhoids and has effectiveness rates comparable to rubber band ligation. However, meta-analyses show that infrared coagulation carries a slightly higher rate of minor complications than banding.
Sclerotherapy
A chemical solution is injected directly into the hemorrhoid, causing it to shrink. The effectiveness and recurrence rates are similar to infrared coagulation. Sclerotherapy is sometimes preferred for smaller hemorrhoids or for patients on blood-thinning medications where banding might carry a higher bleeding risk.
Surgical Options for Severe Cases
Surgery is reserved for Grade III and IV hemorrhoids that haven’t responded to other treatments, or for very large hemorrhoids. Recovery is more involved, but the long-term results are significantly better.
Conventional Hemorrhoidectomy
This is the gold standard for advanced hemorrhoids. The surgeon removes the hemorrhoidal tissue entirely. It’s the most effective option with the lowest recurrence rate. In a large Cochrane review comparing it to stapled surgery, only 9 out of 476 patients in the conventional group experienced recurrence, compared to 37 out of 479 in the stapled group. The tradeoff is a more painful recovery, typically lasting two to four weeks before you’re back to full activity.
Stapled Hemorrhoidopexy
Rather than removing the hemorrhoid, this procedure uses a circular stapling device to reposition prolapsed tissue and cut off blood supply. Recovery is less painful and faster than a conventional hemorrhoidectomy. However, patients who undergo stapled surgery are roughly three times more likely to have hemorrhoids return over the long term. For that reason, it’s less commonly recommended as a first-line surgical option despite the easier recovery.
Transanal Hemorrhoidal Dearterialization (THD)
This newer technique uses ultrasound to locate the arteries feeding the hemorrhoid, then stitches them closed. It’s used for Grade II through IV hemorrhoids and is often combined with a procedure to lift prolapsed tissue back into place. In a study of 271 patients, only 1.5% experienced complications (bleeding, urinary retention, or constipation), and just 1.8% needed further intervention afterward. Postoperative pain was reported by fewer than 4% of patients, most of whom had additional procedures done at the same time.
Red Flags That Need Prompt Attention
Bleeding during bowel movements is the hallmark of internal hemorrhoids, but not all rectal bleeding comes from hemorrhoids. If you notice changes in bowel habits, stools that change in color or consistency, or abdominal symptoms like pain or new-onset constipation alongside bleeding, further evaluation is necessary to rule out other causes. Patients who continue to bleed after otherwise successful hemorrhoid treatment should also be investigated further.
Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness, or faintness. A thrombosed hemorrhoid, which causes severe pain, swelling, and a hard discolored lump, also warrants prompt medical attention. Chronic low-level blood loss from hemorrhoids can, in rare cases, lead to anemia.