When is Surgery Necessary for Internal Hemorrhoids?

Medically reviewed by: Gary H. Hoffman, MD

Bright, red smears on the toilet paper after a bowel movement, or drops into the toilet bowl. Itching. Tissue prolapsing from the anus, sometimes so prominently that it cannot be pushed back in even with a finger. While external hemorrhoids are known as the more annoying of the two types of hemorrhoids, internal hemorrhoids are no walk-in-the-park, either.

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Your colon and rectal surgeon, also known as a proctologist, will be able to educate you about the different types of hemorrhoids.

What are Internal Hemorrhoids?

While external hemorrhoids occur just outside the anus, internal hemorrhoids are swollen areas of tissue just inside the rectum. Although they typically lack the pain often associated with their external counterparts, they are more likely to bleed. In fact, blood on the toilet paper during a bowel movement is sometimes the only symptom of internal hemorrhoids.

Unfortunately, though, they can also become so inflamed that they prolapse out through the anus causing more serious symptoms. When protrusion occurs, an intense itching often follows, thanks to a condition known as pruritus ani. Scratching, scrubbing, or wiping to relieve the itching usually just leads to further irritation, making the situation worse.

Should I See a Doctor for Internal Hemorrhoid Symptoms?

Symptoms of internal hemorrhoids require a visit to the doctor to rule out more serious causes and to get the fastest relief possible. While hemorrhoid symptoms typically aren’t an emergency medical situation, the symptoms should be concerning enough to encourage you to schedule an appointment sooner rather than later. Hemorrhoid symptoms are similar to the early symptoms of a number of more serious conditions, including colon cancer and inflammatory bowel disease.

It is important to note that some internal hemorrhoid symptoms do call for an immediate trip to see your doctor or a visit to the emergency room. These include acute or excessive bleeding, and prolapsed hemorrhoids that cannot be pushed back inside manually.

When is More Invasive Treatment Necessary?

Usually, hemorrhoids can be managed with conservative treatment. In some cases, however, more invasive treatment may be necessary. The most common reason internal hemorrhoids call for more invasive treatment is because symptoms persist despite conservative treatment.

Some patients also have severe enough symptoms to require medical intervention at the time of diagnosis. This includes patients with:

  • Excessive bleeding, especially bleeding that leads to anemia
  • Prolapsed hemorrhoids that cannot be manually reduced
  • Strangulated hemorrhoids
  • Extreme pain
  • Signs of gangrene due to reduced or absent blood supply to the tissue

How are Internal Hemorrhoids Treated?

Even if you require medical treatment for your symptomatic internal hemorrhoids, there are often other treatments to try before resorting to surgery. The most common of these methods is known as rubber band ligation.

Most colon and rectal specialists perform this procedure in the office, and it only takes a few minutes. The doctor places a tiny band at the base of the hemorrhoid, reducing blood flow. This will shrink the inflamed tissue, stopping symptoms. Some patients require as many as four band placements to completely eliminate symptoms. This process causes only mild pain, requires no anesthesia, and you can return to work immediately.

Some doctors may prefer other procedures that work in a similar way, including sclerotherapy (painless hemorrhoidal shots), infrared or laser coagulation, and cryosurgery.

What if I Need a Hemorrhoidectomy?

If rubber band ligation or another similar in-office procedure does not help – or if you have large protruding hemorrhoids that make you a poor candidate for this type of treatment, you may require a hemorrhoidectomy.

A traditional hemorrhoidectomy is an invasive surgery that takes a week or more of recovery before you can return to work and your regular activities. It also requires general anesthesia. Still, it is the most effective method for getting rid of problematic hemorrhoids.

The surgeon completes this procedure by making an incision around the inflamed tissue and removing the involved blood vessels. Hemorrhoidectomies are typically performed as day surgeries, and patients return home the same day. Complications or reactions to anesthesia may call for overnight hospitalization.

While traditional hemorrhoidectomies are very effective and most patients are pleased despite the long recovery time, a newer alternative is being used by some doctors to treat prolapsed internal hemorrhoids. Known as a stapled hemorrhoidopexy or PPH, this procedure utilizes a special stapler to tack the inflamed tissue back into its natural position. Over the following days, the inflamed tissue returns to its original size, eliminating symptoms.

A stapled hemorrhoidopexy also requires general anesthesia, and it may not be a suitable alternative to a traditional procedure for all patients. The benefits, however, include a much faster recovery and the ability to return to work in a matter of days. Patients also report much less pain than after a traditional hemorrhoidectomy.

Another less invasive procedure is known as THD, or Transanal hemorrhoidal dearterialization. This procedure, which requires general anesthesia and can be performed at an outpatient surgical center, works by depriving the hemorrhoids of their blood supply. This allows the hemorrhoids to shrivel up and disappear.

Even when they are symptomatic, internal hemorrhoids can typically be managed at home using conservative treatments recommended by your doctor. However, it is paramount to see your doctor or a colon and rectal specialist to ensure there is not something more sinister causing your symptoms. If you experience heavy bleeding and prolapsed tissue, or if your hemorrhoids do not respond to other treatments, surgery may be necessary. Even when a traditional hemorrhoidectomy is indicated, most patients report that it was worth it thanks to the improvement in their quality of life after recovery.

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