Internal hemorrhoids are swollen blood vessels inside the lower rectum, and most cases improve with straightforward changes to diet, bathroom habits, and symptom relief at home. Treatment depends on severity: mild hemorrhoids typically respond to fiber, hydration, and topical remedies, while more advanced cases may need an in-office procedure or surgery.
How Internal Hemorrhoids Are Graded
Internal hemorrhoids are classified into four grades, and knowing where yours fall helps determine the right treatment approach. Grade I hemorrhoids bleed but don’t protrude. Grade II hemorrhoids bulge out during a bowel movement but slide back in on their own. Grade III hemorrhoids protrude and need to be pushed back in manually. Grade IV hemorrhoids are permanently prolapsed and can’t be pushed back at all.
Most people dealing with grade I or II hemorrhoids can manage symptoms effectively at home. Grade III and IV hemorrhoids are more likely to need a procedure.
Start With Fiber and Hydration
The single most effective first step is increasing fiber intake. Fiber softens stool and adds bulk, which reduces the straining that worsens hemorrhoids. The current dietary guidelines recommend about 14 grams of fiber per 1,000 calories you eat, which works out to roughly 28 grams a day on a standard 2,000-calorie diet. Most people fall well short of that number.
Good sources include beans, lentils, whole grains, broccoli, pears, and berries. If you struggle to get enough through food alone, a fiber supplement (like psyllium husk) can fill the gap. Increase your intake gradually over a week or two to avoid bloating and gas. Drink plenty of water alongside the fiber, since fiber works by absorbing fluid. Without adequate hydration, extra fiber can actually make constipation worse.
The American Society of Colon and Rectal Surgeons strongly recommends increasing fiber and fluid intake as the foundation of hemorrhoid treatment, noting it improves both prolapse and bleeding.
Sitz Baths for Symptom Relief
A sitz bath is a shallow warm soak that targets your anal area. Fill a bathtub with a few inches of warm water (around 104°F or 40°C) or use a small basin that fits over your toilet seat. Soak for 15 to 20 minutes, up to three or four times a day during a flare-up. The warmth relaxes the muscles around the anus, boosts blood flow, and can noticeably reduce pain and itching. Pat dry gently afterward rather than rubbing.
Over-the-Counter Treatments
Several topical products can help with pain, itching, and swelling. Hydrocortisone creams reduce inflammation. Phenylephrine-based products temporarily shrink swollen tissue. Pramoxine is a local anesthetic that numbs the area. These are all available without a prescription and can be applied directly to the affected area.
Oral flavonoid supplements (containing compounds like diosmin and hesperidin) are another option worth considering. These plant-based supplements strengthen blood vessel walls and reduce inflammation. Clinical studies show they can significantly reduce anal pain, with bleeding improving in roughly half of patients within a week. They appear to be most helpful during an acute flare-up rather than as a long-term maintenance strategy.
Bathroom Habits That Matter
How you use the toilet has a direct impact on hemorrhoid symptoms. Try to spend no more than 5 to 10 minutes on the toilet per visit. Sitting longer than that increases pressure on the veins in your rectum, even if you’re not actively straining. That means leaving your phone outside the bathroom.
Go when you feel the urge rather than waiting. Delaying bowel movements allows stool to harden, which leads to more straining. When you do sit down, avoid bearing down forcefully. Let gravity and your body’s natural reflexes do most of the work. Some people find that placing a small footstool under their feet while sitting on the toilet puts the body in a more natural squatting position, which can make it easier to pass stool without straining.
When Home Treatment Isn’t Enough
If you’ve been consistent with fiber, hydration, sitz baths, and better bathroom habits for several weeks without adequate relief, the next step is an in-office procedure. Rubber band ligation is the most commonly recommended option. A doctor places a tiny rubber band around the base of the hemorrhoid, cutting off its blood supply. The tissue shrinks and falls off within about a week. The procedure takes just a few minutes and doesn’t require anesthesia.
Rubber band ligation works well for grade I and II hemorrhoids, though results are less durable for grade III. A large randomized trial found that nearly half of patients with grade III hemorrhoids experienced recurrence within a year of banding, and about a quarter needed additional treatment. For grade I and II hemorrhoids, success rates are considerably better. Repeat banding sessions are common and considered part of the normal treatment process.
Infrared coagulation is another office-based option, typically used for small to medium internal hemorrhoids. A device delivers a burst of infrared light to the hemorrhoid, creating scar tissue that cuts off blood flow. The hemorrhoid shrinks and detaches within 7 to 10 days. The scar tissue also anchors nearby veins in place, helping prevent new hemorrhoids from bulging into the anal canal.
Surgical Options for Severe Cases
Surgery is generally reserved for grade III and IV hemorrhoids that haven’t responded to less invasive approaches. The two main options are traditional excisional surgery (hemorrhoidectomy) and stapled hemorrhoidopexy.
A hemorrhoidectomy physically removes the hemorrhoid tissue. It’s the most effective long-term solution, with recurrence rates as low as 6% at one year. The tradeoff is a more painful recovery. A large clinical trial published in The Lancet found that stapled hemorrhoidopexy causes less pain in the first three weeks, but both procedures result in similar recovery timelines by six weeks. Complication rates were comparable between the two approaches (7% for stapled versus 9% for traditional surgery).
The stapled procedure repositions the hemorrhoid tissue rather than removing it, which is why the early recovery tends to be more comfortable. However, the traditional approach showed better long-term outcomes for bowel control and fewer issues with the persistent feeling of needing to go. Your surgeon can help determine which approach makes more sense based on the size and location of your hemorrhoids.
Bleeding That Warrants Attention
Bright red blood on toilet paper or in the bowl after a bowel movement is the hallmark of internal hemorrhoids. This bleeding is typically painless, intermittent, and tied to specific triggers like straining or constipation. It usually stops on its own or with basic treatment.
Certain patterns should prompt a closer look. Blood that’s darker in color, bleeding that persists despite treatment, or bleeding accompanied by changes in bowel habits, unexplained weight loss, persistent abdominal cramping, or unusual fatigue could signal something other than hemorrhoids. These symptoms overlap with colorectal conditions that need diagnostic evaluation, typically through a colonoscopy. This is especially important if you’re over 45 or have a family history of colorectal cancer.