Hemorrhoids are a common condition involving swollen blood vessels in the rectum and anus, often causing discomfort, itching, or bleeding. People often try to self-diagnose, leading to confusion over appropriate treatment methods. The effectiveness of any procedure, such as banding, depends entirely on the precise location of the swollen tissue. Understanding the anatomical division in the anal canal clarifies which treatments are suitable for which type of hemorrhoid.
Distinguishing Internal and External Hemorrhoids
The difference between internal and external hemorrhoids centers on the dentate line, an anatomical landmark inside the anal canal. This boundary separates the upper, insensitive part of the canal from the lower, highly sensitive part. Internal hemorrhoids form above the dentate line, where the tissue lacks pain-sensing somatic nerves.
Because of this lack of nerve supply, internal hemorrhoids typically cause painless bleeding, often seen as bright red blood on toilet paper or in the bowl. External hemorrhoids are located below the dentate line, covered by anoderm, which is modified skin packed with somatic nerve endings. This rich nerve supply is why external hemorrhoids cause significant pain, itching, and discomfort.
Rubber Band Ligation: Purpose and Procedure
Rubber Band Ligation (RBL) is a minimally invasive technique designed for internal hemorrhoids that have not responded to conservative care. This procedure cuts off blood flow to the swollen tissue, causing it to wither and fall off naturally, usually within one week.
During the procedure, a physician uses an anoscope to view the internal hemorrhoid, then places a tight rubber band around its base using a ligator. Because the tissue above the dentate line does not transmit pain signals, the treatment is generally well-tolerated. RBL is a highly effective office-based treatment, typically done in one to three sessions spaced several weeks apart.
Why Banding Is Contraindicated for External Hemorrhoids
Applying Rubber Band Ligation (RBL) to an external hemorrhoid is strongly advised against because of the intense pain it would cause. The tissue below the dentate line is extremely sensitive due to its dense network of pain receptors. Placing a constricting band in this area would create immediate and severe, intolerable pain.
Banding external hemorrhoids also carries a high risk of complications, including swelling, infection, and thrombosis (blood clot formation). External hemorrhoids often present as acute thrombosed hemorrhoids, which require immediate management different from banding. Therefore, RBL is reserved only for the less-sensitive internal type of hemorrhoid.
Definitive Treatments for External Hemorrhoids
Since banding is not an option, treatment for external hemorrhoids focuses on managing pain and swelling. Initial treatment for mildly symptomatic or non-thrombosed external hemorrhoids begins with conservative management. This involves increasing dietary fiber and ensuring adequate hydration to soften stool and reduce straining.
Soaking the affected area in a warm sitz bath can help temporarily relieve pain and irritation. Over-the-counter topical creams and ointments containing hydrocortisone or witch hazel can also be used to reduce inflammation and itching. These measures aim to alleviate pressure and shrink the swollen blood vessels.
When an external hemorrhoid becomes acutely thrombosed (forming a hard, painful lump due to a blood clot), medical intervention is often necessary. The most effective treatment is an external thrombectomy, which involves a small incision to remove the clot. This procedure is typically performed under local anesthesia in a physician’s office and provides rapid relief if done within the first two to three days of symptom onset.
For chronic or very large external hemorrhoids that do not respond to less invasive methods, surgical removal, known as a conventional hemorrhoidectomy, may be recommended. While this option involves a longer recovery period and more post-operative pain, it is the most definitive treatment, offering the lowest rate of recurrence. A hemorrhoidectomy is reserved for the most severe cases or when conservative treatments have failed.