Managing Internal Hemorrhoids: When to Consider Treatment Options

Internal hemorrhoid bleeding

Hello Doctor,
I have had hemorrhoids since my school days, but after turning 30, they started to prolapse without bleeding.
This year, however, I began to experience bleeding.
Earlier this year, I consulted a doctor who prescribed a hemorrhoid ointment and enteric-coated tablets, along with warm sitz baths, dietary control, and timing for bathroom visits.
By around February, my condition improved significantly; there was no bleeding and no prolapse, so I stopped the medication and sitz baths, although I continued to manage my bathroom timing and diet.
However, around mid-August, after eating guava for a week, my stools became hard, and I had to strain during bowel movements, which led to bleeding again.
There was no prolapse and no pain, just bleeding.
Even with sitz baths, medication, anal exercises, and eating fruits and vegetables, I still experience occasional bleeding, not every time (about 1-2 times a week on average).
On August 27, I visited a colorectal clinic, and the doctor noted that I have one larger internal hemorrhoid, several smaller ones, and one external hemorrhoid.
The doctor suggested rubber band ligation for the larger hemorrhoid, but I am afraid of invasive treatment, so I opted for oral medication and ointment instead.
During the medication period, I did not experience any bleeding, but once the prescribed medication ran out, I switched back to the enteric-coated tablets.
A few days ago, I noticed small traces of blood again, and today, after having harder stools, I experienced painless bleeding.
I would like to ask if this means that the medication is ineffective and that I must undergo ligation to resolve the issue.
I am really scared of invasive treatments around my rectal area, fearing that if the ligation site is not properly cared for, it could lead to more severe infections.
Is there any way to coexist with this condition to prevent further bleeding? I have completely eliminated spicy foods, take daily sitz baths, maintain a regular sleep schedule, and eat more fruits and vegetables, yet I still experience bleeding, which feels very helpless.
I apologize for the lengthy message, and I appreciate your time in reading it.
Thank you, Doctor.

Yu Tu, 30~39 year old female. Ask Date: 2023/09/07

Dr. Chen Shidian reply Gastroenterology and Hepatology

Internal hemorrhoids will not resolve without active management.
If there is frequent bleeding, it is advisable to discuss invasive treatment options with a surgeon, as the general risks are low.

Reply Date: 2023/09/07

More Info

Managing internal hemorrhoids can be a challenging experience, especially when symptoms such as bleeding and discomfort persist despite conservative treatments. It sounds like you've been proactive in managing your condition, but the recurrence of bleeding indicates that further evaluation and possibly more aggressive treatment may be necessary.

Internal hemorrhoids are swollen veins in the rectum that can cause symptoms like bleeding, discomfort, and prolapse. The fact that you have experienced bleeding after periods of constipation or hard stools suggests that your hemorrhoids may be aggravated by straining during bowel movements. This is a common issue, and managing your bowel habits is crucial in preventing further complications.

From your description, it seems that you have already tried several conservative measures, including dietary changes, sitz baths, and topical medications. While these methods can be effective for many patients, they may not be sufficient for everyone, especially if the hemorrhoids are larger or more symptomatic. The recommendation from your doctor to consider rubber band ligation is a common approach for larger internal hemorrhoids that do not respond to conservative treatment. This procedure involves placing a small rubber band around the base of the hemorrhoid, cutting off its blood supply, and causing it to shrink and eventually fall off.
Your concerns about the invasiveness of the procedure and the potential for complications, such as infection, are valid. However, rubber band ligation is generally considered a safe and effective outpatient procedure with a low risk of complications. Most patients experience minimal discomfort, and serious complications are rare. It is important to follow post-procedure care instructions to minimize any risks.

If you are hesitant about undergoing rubber band ligation, it may be worthwhile to discuss alternative treatments with your healthcare provider. Options such as sclerotherapy (injection of a solution to shrink the hemorrhoid) or infrared coagulation may be less invasive alternatives. However, the effectiveness of these treatments can vary, and they may not be suitable for all cases.

In addition to procedural options, continuing to manage your bowel habits is essential. Ensure you are consuming a high-fiber diet, staying well-hydrated, and using stool softeners if necessary to prevent straining during bowel movements. Regular exercise can also help promote healthy bowel function.

If you find that your symptoms persist or worsen, it may be time to reconsider the option of rubber band ligation or another procedural intervention. It is crucial to communicate openly with your healthcare provider about your fears and concerns, as they can help address these issues and guide you toward the best treatment plan for your situation.

In summary, while conservative measures can be effective for some individuals with internal hemorrhoids, persistent symptoms like bleeding may warrant further evaluation and treatment. Rubber band ligation is a common and effective option, but discussing your concerns with your doctor can help you make an informed decision about your care. Remember, managing hemorrhoids often requires a combination of lifestyle changes and medical interventions, and finding the right balance is key to achieving relief.

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