Most hemorrhoids respond well to simple measures you can start at home today, and only a small fraction ever require surgery. The treatment ladder runs from dietary changes and warm baths at the mild end, through quick office procedures like rubber band ligation in the middle, to formal surgical removal for severe or recurring cases. Which rung you land on depends largely on the grade of your hemorrhoids, how long you have had them, and whether they are internal, external, or a painful thrombosed lump. Understanding the full range of options helps you have a more productive conversation with a doctor and avoid both under-treating a problem that needs attention and over-treating one that does not.
What Hemorrhoids Actually Are and Why They Flare
Hemorrhoids are not varicose veins, although they are often described that way. They are the symptomatic enlargement and displacement of the normal cushions of tissue that line the anal canal.1PubMed Central. Hemorrhoids: from basic pathophysiology to clinical management Everyone has these cushions; they help with fine control of continence. Problems start when pressure, straining, or other factors cause the cushions to swell, slide downward, and bleed or protrude.
The usual suspects behind that process include constipation, straining during bowel movements, low fiber intake, a higher body mass index, pregnancy, and prolonged sitting.2PubMed Central. Lifestyle and Risk Factors in Hemorrhoidal Disease A large screening-colonoscopy study found that people who strained during bowel movements were roughly 60 percent more likely to have hemorrhoids than those who did not, and those who reported hard stools were about 30 percent more likely.3PLOS ONE. Risk Factors for Hemorrhoids on Screening Colonoscopy More recently, smartphone use on the toilet has drawn attention: one study found that scrolling while sitting on the toilet was tied to a 46 percent increased risk of hemorrhoids after adjusting for other factors, likely because phones encourage people to sit longer than they otherwise would.4PLoS One. Smartphone use on the toilet and the risk of hemorrhoids
Fiber, Fluids, and Other Home Measures
Adding fiber is the single most recommended first step for internal hemorrhoids that bleed. Fiber softens stool and adds bulk, which reduces the straining that aggravates swollen cushions. A study of fiber supplements for bleeding internal hemorrhoids found that symptoms improved over time, though the effect was not immediate.5PubMed. Effect of fiber supplements on internal bleeding hemorrhoids The researchers noted fiber was especially useful for people waiting for a more definitive procedure or who had reasons to avoid invasive treatment. Psyllium husk is the most studied supplement, but ground flaxseed and methylcellulose work on the same principle. Whatever you choose, increase the dose gradually and drink plenty of water; fiber without fluid can make constipation worse.
Beyond fiber, basic habit changes matter. Limiting toilet time to the business at hand, avoiding straining and bearing down, and going when you first feel the urge rather than delaying all help keep pressure off the anal cushions. Research on toilet posture shows that squatting opens the anorectal angle more than standard sitting, reducing the abdominal pressure needed to defecate.6PubMed. Influence of Body Position on Defecation in Humans You do not need to install a squat toilet; a small footstool that raises your knees above your hips mimics much of the effect. Studies have also found a direct link between time spent sitting on the toilet and hemorrhoid severity.7PubMed Central. Sitting vs. squatting: a scoping review of toilet postures and associated health outcomes
Sitz Baths and Topical Relief
A sitz bath is simply sitting in a few inches of warm water for 10 to 15 minutes, usually two or three times a day and after bowel movements. It sounds old-fashioned, but it works. A comparative study in pregnant women with hemorrhoids found that all patients in the sitz bath group achieved complete healing, compared with about 85 percent in a group using an anorectal cream.8PubMed. Hemorrhoids during pregnancy: Sitz bath vs. ano-rectal cream: A comparative prospective study of two conservative treatment protocols Warm water increases blood flow to the area, relaxes the internal sphincter, and eases pain without medication.
Over-the-counter creams and suppositories containing hydrocortisone, lidocaine, or witch hazel can provide short-term itch and pain relief. They are fine for a flare lasting a few days, but extended unsupervised use carries risks. A case series documented 11 patients who developed perianal ulcers after using a hemorrhoidal ointment containing triamcinolone, lidocaine, and pentosan polysulfate sodium without medical follow-up; the ulcers healed only after the patients stopped using the product.9PubMed. Multiple Perianal Ulcers Related to Use of a Hemorrhoidal Ointment With the Active Ingredients Triamcinolone Acetonide, Lidocaine, and Pentosan Polysulfate Sodium: A Series of 11 Spanish Patients The takeaway: if you are reaching for the cream more than a week or two in a row, see a doctor rather than continuing to self-treat.
Oral Venoactive Drugs
In many countries outside the United States, doctors prescribe oral flavonoid-based supplements, sometimes called phlebotonics or venoactive drugs, as a first-line addition to fiber. The most studied is micronized purified flavonoid fraction, a combination of diosmin and hesperidin. Evidence shows it can reduce bleeding, pain, itching, and anal discharge during acute flares.10PubMed. Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease A randomized trial of a flavonoid mixture found that pain, bleeding, and swelling decreased significantly within 12 days of treatment compared to placebo.11PubMed. Flavonoids mixture (diosmin, troxerutin, hesperidin) in the treatment of acute hemorrhoidal disease: a prospective, randomized, triple-blind, controlled trial Another trial comparing Centella asiatica extract with flavonoids reported that bleeding stopped faster in the Centella group, with a median of two weeks to cessation versus three weeks for flavonoid groups.12Scientific Reports. Comparison of Centella with Flavonoids for Treatment of Symptoms in Hemorrhoidal Disease and After Surgical Intervention: A Randomized Clinical Trial
These drugs are generally well tolerated, with mild gastrointestinal upset being the main side effect. In the United States, flavonoid preparations are available over the counter as dietary supplements rather than prescription medications, so quality and dosing vary by brand. If you are interested in trying them, look for products that specify micronized diosmin content and discuss the option with your doctor.
Office Procedures for Internal Hemorrhoids
When home measures and medications are not enough, several quick procedures can be done in a clinic without general anesthesia. These are typically offered for grade I through III internal hemorrhoids (those that bleed, may prolapse during straining, or prolapse and need manual pushing back in).
Rubber Band Ligation
Rubber band ligation is the most commonly performed office procedure for hemorrhoids. A small rubber band is placed around the base of the internal hemorrhoid, cutting off its blood supply. The tissue shrinks and falls off within a week or so. A long-term follow-up study found a success rate of about 70 percent, with roughly 30 percent of patients eventually needing retreatment or surgery.13PubMed. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids Complications in that study included bleeding in about 3 percent of treatment sessions and thrombosed external hemorrhoids in roughly 1.5 percent. Patients on blood thinners or aspirin had higher bleeding rates.
Mild pain and a feeling of pressure for a day or two are common and expected. Serious complications are rare but worth knowing about: they include delayed heavy bleeding (usually 10 to 14 days later) and, in very rare cases, pelvic infection.14PubMed Central. Rubber band ligation of hemorrhoids: A guide for complications Fever, inability to urinate, or worsening pain after banding are red flags that warrant an immediate call to your doctor.
Sclerotherapy and Infrared Coagulation
Sclerotherapy involves injecting a chemical solution into the hemorrhoid, causing it to scar and shrink. Infrared coagulation (IRC) uses a burst of infrared light to coagulate the tissue. Both are quick, usually painless, and best suited for smaller, bleeding internal hemorrhoids. Head-to-head comparisons show similar effectiveness between the two, and both are comparable to rubber band ligation at 12 months in terms of the proportion of patients who remain symptom-free.15PubMed. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy A meta-analysis confirmed no significant difference in effectiveness between sclerotherapy and IRC.16Biomedical Journal of Scientific & Technical Research. Comparison of Three Treatment Methods of Ⅰ-Ⅲ Degree Hemorrhoids: A Meta Analysis IRC tends to cause less discomfort during the procedure itself and has been found safe and well accepted by patients in prospective trials.17PubMed. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids
The practical difference often comes down to what your doctor’s office has available. Rubber band ligation may have a slight edge for larger or prolapsing hemorrhoids, while IRC and sclerotherapy are popular choices for smaller, early-stage bleeding.
Hemorrhoidal Artery Ligation
A newer option uses a special Doppler ultrasound probe inserted into the anal canal to locate the arteries feeding each hemorrhoid. The surgeon then stitches those arteries shut, and sometimes lifts the prolapsing tissue back into place. A meta-analysis comparing this technique to rubber band ligation in nearly 1,000 patients found that short-term success was virtually identical (about 85-86 percent), but hemorrhoidal artery ligation had a lower recurrence rate: roughly 19 percent versus 28 percent for banding.18PubMed Central. Hemorrhoidal Artery Ligation (HAL) vs. Rubber Band Ligation (RBL) for Second- and Third-Degree Hemorrhoids: A Systematic Review and Meta-Analysis The trade-off is that artery ligation usually requires a trip to the operating room and light sedation rather than a quick office visit.
When Surgery Is Needed
Surgery is generally reserved for grade III hemorrhoids that have not responded to less invasive treatment and for grade IV hemorrhoids (those that are permanently prolapsed and cannot be pushed back in). It is also the go-to option for large external hemorrhoids causing persistent problems.
The two classic operations are the open (Milligan-Morgan) hemorrhoidectomy and the closed (Ferguson) hemorrhoidectomy. Both involve cutting out the hemorrhoidal tissue under anesthesia. A meta-analysis of 11 randomized trials found that the closed technique offered a modest but real reduction in postoperative pain compared to the open technique.19PubMed Central. Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review A separate evidence review concluded that either closed hemorrhoidectomy or open hemorrhoidectomy with electrocoagulation of the pedicle is a sound primary approach.20PubMed. Evidence-Based Management of Pain After Excisional Haemorrhoidectomy Surgery: A PROSPECT Review Update
Excisional hemorrhoidectomy is the most effective long-term solution, with the lowest recurrence rates of any treatment. The downside is that recovery is genuinely painful, often requiring two to four weeks off work and strong pain management in the first week. This is the main reason surgeons exhaust less invasive options first.
Stapled hemorrhoidopexy is an alternative that staples prolapsing tissue back into position rather than removing it. Compared with Doppler-guided artery ligation, stapling caused more postoperative pain but resulted in lower recurrence and higher patient satisfaction at one year.21PubMed. Outcome of stapled hemorrhoidopexy versus doppler-guided hemorrhoidal artery ligation for grade III hemorrhoids A broader review confirms that stapled hemorrhoidopexy allows faster recovery than traditional hemorrhoidectomy but carries higher recurrence rates and a small risk of serious complications.22PubMed Central. Still a Case of “No Pain, No Gain”? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020 Choosing between stapling and excision often comes down to how much you prioritize a faster return to normal life versus a lower chance of the problem coming back.
Thrombosed External Hemorrhoids
A thrombosed external hemorrhoid is a sudden, painful lump at the anal margin caused by a blood clot forming inside an external hemorrhoid. It is hard, purple-blue, and can make sitting miserable. Many people first try to wait it out, and the clot will eventually reabsorb on its own, but the timeline matters.
A study comparing conservative management with surgical excision found that symptoms took an average of 24 days to resolve without surgery versus about 4 days with excision. Recurrence was also far more common in the conservative group, at about 25 percent versus 6 percent, and when recurrence did happen, it came back sooner.23Diseases of the Colon and Rectum. Thrombosed external hemorrhoids: Outcome after conservative or surgical management A recent meta-analysis confirmed that operative management was associated with roughly half the recurrence risk compared to conservative treatment.24PubMed. Operative versus nonoperative treatment of thrombosed external hemorrhoids: a systematic review and meta-analysis
The practical advice: if you develop a thrombosed hemorrhoid and can see a doctor within the first 48 to 72 hours, excision under local anesthesia is a quick procedure that provides almost immediate relief and a much lower chance of the clot returning. If you wait past that window, the clot has often started to organize and the tissue is more inflamed, making excision less straightforward. At that point, conservative measures (sitz baths, pain relievers, stool softeners) while the body reabsorbs the clot are usually the better path.
Hemorrhoids During Pregnancy
Pregnancy is one of the most common triggers for hemorrhoids, thanks to the combined effects of increased pelvic blood volume, hormonal changes that relax vein walls, and the physical pressure of the growing uterus. Most pregnancy-related hemorrhoids can be managed conservatively with increased fiber, stool softeners, adequate fluids, and good toilet habits.25PubMed Central. Hemorrhoids in pregnancy Sitz baths are particularly useful in this population, as noted above.
Topical treatments are generally considered low risk in the third trimester, though none have been formally evaluated for safety in pregnancy.25PubMed Central. Hemorrhoids in pregnancy One combination of tribenoside and lidocaine has been studied specifically in pregnant and postpartum women and found safe after the first trimester, with relief starting within minutes of application.26PubMed Central. Hemorrhoid management in women: the role of tribenoside + lidocaine A Cochrane review noted that while oral hydroxyethylrutosides looked promising for symptom relief, the evidence was insufficient to recommend them broadly in pregnancy, and the most commonly used conservative approaches had not been rigorously evaluated in this population.27Cochrane Database of Systematic Reviews. Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium In practice, doctors prefer to defer any procedure or surgery until after delivery unless there is a severe complication like significant bleeding or an incarcerated prolapse.
Recurrence and Long-Term Prevention
No matter how you treat hemorrhoids, they can come back. A systematic review of real-world evidence found recurrence rates ranging from 0 to over 50 percent depending on the treatment, though the majority of studies reported rates of 20 percent or less.28PubMed Central. Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review The risk factors for recurrence mirror the risk factors for developing hemorrhoids in the first place: low fiber intake, straining, and prolonged sitting. Traditional excisional hemorrhoidectomy has the lowest recurrence rates of any treatment, while rubber band ligation and stapled procedures trade some durability for less pain and faster recovery.22PubMed Central. Still a Case of “No Pain, No Gain”? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020
Prevention boils down to keeping stools soft and easy to pass. That means maintaining fiber intake (around 25 to 30 grams a day for most adults), drinking enough water, staying physically active, and not spending more time on the toilet than necessary. If you had a procedure or surgery, continuing these habits afterward is what keeps the problem from cycling back.
Why People Delay Getting Help
Hemorrhoids carry an outsized amount of embarrassment relative to how common and treatable they are. A cross-sectional study of people who did not seek medical care for their symptoms found the most common reason was the belief that symptoms would go away on their own, cited by about 28 percent. Other barriers included lack of time, shame (about 15 percent), fear of a serious diagnosis, and fear of surgery.29PubMed Central. Barriers to Seeking Medical Care for Hemorrhoidal Symptoms: A Cross-Sectional Observational Study Research on patient delay has also found that people who perceived their hemorrhoids as having a high social impact actually took longer to seek care, not less, suggesting that the very stigma that makes the condition distressing also keeps people away from treatment.30PubMed. Factors influencing patient delay in individuals with haemorrhoids: A study based on theory of planned behavior and common sense model
There is also a safety reason to get checked. Rectal bleeding is the hallmark symptom of hemorrhoids, but it is also a symptom of colorectal cancer and other conditions. A systematic review on the overlap between hemorrhoid symptoms and rectal cancer stressed that standardized evaluation and proper screening tools can meaningfully reduce the chance of a missed diagnosis.31PubMed Central. Hemorrhoids and Rectal Cancer: A Systematic Review of Clinical Overlap, Diagnostic Misclassification, and Early Detection Strategies for Primary Care This does not mean every person with a little blood on the toilet paper needs to panic, but new or changing rectal bleeding, especially in anyone over 45 or with a family history of colorectal cancer, warrants a conversation with a doctor rather than another tube of cream.