Internal hemorrhoids are swollen veins located inside the rectum, above the dentate line. They often cause painless bleeding but can also lead to discomfort, itching, or prolapse. When over-the-counter treatments fail to manage persistent symptoms like significant bleeding or severe pain, prescription medicine or a procedure may be necessary. The “best” treatment depends on the hemorrhoid’s severity, which is typically graded from I (no prolapse) to IV (permanently prolapsed). Consulting a healthcare provider is the first step to accurately diagnose the condition and establish a targeted treatment plan.
Prescription Topical Treatments for Acute Symptoms
Prescription-strength topical medications are frequently employed to manage the inflammation and pain associated with acute flare-ups of Grade I and Grade II internal hemorrhoids. These treatments typically come as creams, ointments, or suppositories applied directly to the affected area. The primary agents are high-potency corticosteroids, such as hydrocortisone acetate, which are significantly stronger than non-prescription versions. These steroids suppress the localized immune response, effectively reducing severe swelling and inflammation of the hemorrhoidal tissue.
A combination of a corticosteroid with a local anesthetic is a common prescription strategy for addressing intense discomfort. Products containing both hydrocortisone and a strong local anesthetic, like lidocaine, provide dual action. The steroid reduces swelling, while the anesthetic quickly numbs nerve endings to relieve pain and itching. Due to the potency of the corticosteroid, these formulations are intended for short-term use, often limited to one to two weeks, to prevent potential side effects like skin thinning or mucosal atrophy.
Prescription suppositories are particularly useful for internal hemorrhoids as they allow the active ingredients to be delivered directly inside the rectum, closer to the inflamed tissue. Some combination products may also contain protectants or astringents that form a physical barrier over the irritated mucous membrane. These topical treatments are highly effective for mitigating acute symptoms, offering rapid relief from pain, swelling, and itching during a flare-up of milder hemorrhoidal disease. They function as a bridge to comfort while conservative measures, such as dietary changes, take effect, but they do not provide a permanent cure.
Oral Medications and Supportive Therapies
Oral medications provide a systemic approach to managing the symptoms and underlying vascular issues of internal hemorrhoids. A prominent class of systemic treatment is phlebotonics (also known as venotonics), which are compounds taken by mouth to improve the health and tone of blood vessels. One of the most studied phlebotonics is micronized purified flavonoid fraction (MPFF), a blend containing diosmin and other flavonoids. MPFF works by enhancing venous tone, increasing lymphatic drainage, and reducing capillary permeability, which helps decrease bleeding and inflammation.
MPFF and similar oral flavonoids are often prescribed for managing acute hemorrhoidal crises, as they can significantly improve symptoms like bleeding and overall discomfort. These compounds address the underlying pathology of weakened vein walls, offering a benefit that topical treatments cannot provide. For severe discomfort, a physician may prescribe oral pain relievers, such as stronger nonsteroidal anti-inflammatory drugs (NSAIDs), or, in rare cases, a short course of muscle relaxants if anal sphincter spasm is present.
Supportive oral therapies are a routine part of the prescription plan, focusing on preventing the straining that aggravates hemorrhoids. To ensure soft, easy-to-pass stools, a doctor may prescribe high-strength bulk-forming agents, such as psyllium, or prescription-level stool softeners like docusate sodium. These treatments minimize mechanical trauma during bowel movements, creating an optimal environment for the inflamed tissue to heal.
Non-Surgical Office Procedures When Medicine Fails
When prescription medications fail to provide adequate long-term relief, or if hemorrhoids have progressed to Grade III or early Grade IV, the definitive treatment shifts to minimally invasive office procedures. These interventions are designed to physically shrink or remove the problematic tissue, offering a more lasting solution than medication alone. Rubber Band Ligation (RBL) is the most common and highly effective office procedure, especially for Grade I, II, and III internal hemorrhoids.
The RBL procedure involves placing a small rubber band around the base of the internal hemorrhoid, typically performed using an anoscope without general anesthesia. This cuts off the blood supply, causing the hemorrhoid to wither, die, and eventually fall off within a few days or a week. RBL has a high success rate in resolving bleeding and prolapse for Grade III hemorrhoids, with improvement noted in over 75% of patients.
Another common non-surgical option is Infrared Coagulation (IRC), which is particularly suitable for smaller Grade I and Grade II hemorrhoids. IRC uses a focused beam of infrared light to generate heat, which causes the hemorrhoidal tissue to coagulate and scar. This scar tissue then fixes the hemorrhoid to the rectal wall, preventing further prolapse and shrinking the blood vessels.
Both RBL and IRC are outpatient procedures that minimize downtime compared to surgery. They require consultation with a specialist, such as a gastroenterologist or proctologist, who can accurately assess the hemorrhoid grade. These procedures become the preferred treatment strategy when persistent symptoms persist, and they are considered the next logical step before considering more invasive surgical options for advanced disease.