Hemorrhoids are swollen veins located in the rectum and anus, causing common symptoms like discomfort, itching, and sometimes bleeding. While many cases resolve with simple home care, persistent or recurring symptoms signal that underlying factors are preventing healing or that the condition has progressed. The failure to find relief indicates a need to look beyond over-the-counter remedies and explore behavioral changes, advanced medical procedures, or the possibility of a different diagnosis.
Daily Habits That Prevent Healing
The failure of hemorrhoids to resolve often stems from daily habits that place excessive mechanical stress on the anal cushion tissues. Chronic straining during a bowel movement significantly increases intra-abdominal pressure, which engorges the hemorrhoidal veins and prevents them from shrinking. This frequent exertion tears down the connective tissue anchoring the hemorrhoids, leading to their eventual prolapse.
Prolonged sitting on the toilet is another common obstacle to healing. The seated position allows gravity to pull blood into the hemorrhoidal veins while the toilet rim restricts blood flow out of the area, causing pooling. Reducing time spent on the toilet to only what is necessary for evacuation helps alleviate this pressure. Adopting a posture that mimics squatting, often achieved by placing a small step stool under the feet, can straighten the anorectal angle and minimize the need to strain.
Dietary insufficiency, particularly a lack of fiber and water, plays a major role in persistent symptoms. Fiber adds bulk to the stool and helps retain water, creating a soft, easy-to-pass consistency that requires minimal effort. Health guidelines suggest consuming between 25 and 35 grams of fiber per day. Without adequate hydration, however, fiber supplements can worsen constipation, perpetuating the cycle of straining and irritation. Ignoring the urge to defecate also allows stool to dry and harden in the colon, guaranteeing a painful experience later.
Understanding Advanced Non-Surgical Treatments
When conservative changes fail to resolve internal hemorrhoids, a physician may recommend minimally invasive, office-based procedures. These treatments are designed for symptomatic internal hemorrhoids (typically Grade I, II, or III) and target the tissue to reduce its size or cut off its blood supply. Rubber band ligation (RBL) is considered the standard for internal hemorrhoids that have not responded to initial treatment. During RBL, a small rubber band is placed around the base of the hemorrhoid above the dentate line.
The band works by cutting off the blood flow (ischemia), causing the hemorrhoid to wither and fall off within several days to a week. Sclerotherapy is another technique where a chemical solution is injected directly into the hemorrhoid tissue. This injection creates an inflammatory reaction that leads to scarring (fibrosis), which fixes the hemorrhoid in place and reduces its vascularity.
Infrared coagulation (IRC) uses a probe to direct infrared light at the base of the hemorrhoid. The heat energy coagulates the tissue and causes the blood within the vein to clot. This controlled thermal damage results in the hemorrhoid shrinking and scarring to the rectal wall, preventing prolapse. These procedures offer effective relief with minimal downtime before considering more involved surgical options.
When Symptoms Indicate a Different Diagnosis
Persistent anal discomfort and bleeding should always prompt a thorough evaluation because not all anorectal symptoms are caused by hemorrhoids. Severe pain is often characteristic of an anal fissure, which is a small tear in the lining of the anal canal, typically caused by passing hard stool. The sharp, stinging pain associated with a fissure is distinct from the dull ache of a hemorrhoid.
Other conditions that may mimic hemorrhoids include anal abscesses and fistulas. An anal abscess is a collection of pus from an infection of the anal glands, presenting as a painful, swollen lump. An anal fistula is an abnormal tunnel connecting the anal canal to the skin, often resulting from a previously drained abscess. Fistulas may cause persistent drainage and irritation that can be mistaken for a prolapsed hemorrhoid.
Internal hemorrhoids are classified by degree of prolapse. Grade III requires manual pushing back inside, and Grade IV is permanently prolapsed and irreducible. A Grade IV condition suggests the structural support is compromised and is unlikely to resolve without medical intervention. Rectal bleeding, while common with hemorrhoids, can also be a sign of more serious conditions such as colorectal cancer, making professional medical confirmation necessary.
Considering Surgical Intervention
When Grade III or Grade IV hemorrhoids fail to respond to non-surgical treatments, surgical intervention becomes the definitive solution. The most traditional and reliably effective method is the excisional hemorrhoidectomy, where the hemorrhoidal tissue is surgically cut away. This method provides a permanent resolution with the lowest rate of recurrence, but it is associated with a higher level of postoperative pain and a longer recovery period, often requiring two to four weeks before returning to normal activity.
An alternative is stapled hemorrhoidopexy (PPH), used primarily for prolapsing internal hemorrhoids. This method uses a circular stapling device to remove a ring of tissue higher up in the anal canal rather than excising the cushions. The stapling interrupts the blood flow to the hemorrhoids and simultaneously pulls the prolapsed tissue back into its correct anatomical position.
Stapled hemorrhoidopexy typically results in less postoperative pain and a faster return to work, sometimes within a week, compared to the traditional excisional procedure. The trade-off is a slightly higher risk of recurrence of the prolapse or symptoms over the long term. The choice depends on the severity of the disease, the patient’s pain tolerance, and the priority placed on minimizing recovery time versus ensuring the lowest chance of recurrence.