Hemorrhoids are swollen veins located in the rectum or around the anus. Internal hemorrhoids develop inside the rectum above the dentate line and are classified by the degree to which they prolapse outside the anal canal. Grade 2 internal hemorrhoids protrude outside the anus during a bowel movement or straining, but they retract back into their normal position spontaneously. This spontaneous reduction makes them highly treatable with conservative or minimally invasive methods, often avoiding traditional surgery. Treatment focuses on reducing swelling, alleviating symptoms, and preventing the prolapse from worsening.
First-Line Conservative Management
Conservative management is the initial tool for treating symptomatic Grade 2 internal hemorrhoids. The primary goal is to maintain soft, easily passable stools to eliminate the straining that causes prolapse. A daily dietary intake of 25 to 35 grams of fiber is recommended for this purpose.
Fiber intake should include both soluble and insoluble types to regulate bowel movements effectively. Insoluble fiber adds bulk to the stool, helping to speed its passage through the digestive system. Soluble fiber, found in foods like oats, beans, and psyllium husk, dissolves in water to form a gel-like substance that softens the stool. This combination prevents both constipation and diarrhea, both of which irritate hemorrhoids.
Adequate hydration is important, as fiber needs water to work properly and prevent the stool from becoming dry. Drinking at least 64 ounces of water daily helps the fiber absorb moisture, ensuring softer stools. Combining high fiber with sufficient fluid intake reduces the need to strain, which can decrease hemorrhoidal bleeding.
Proper toilet habits are essential to prevent the Grade 2 prolapse from worsening. Straining during defecation increases pressure on the hemorrhoidal veins and should be avoided. Limit the time spent sitting on the toilet to no more than five minutes, as prolonged sitting allows the anal cushions to engorge with blood. If a bowel movement does not occur quickly, it is better to get up and try again later.
Sitz baths involve sitting in a few inches of warm water for 10 to 15 minutes. This practice provides localized relief from pain and discomfort and can be performed two or three times a day. The warm water helps relax the anal sphincter muscles, which temporarily reduces pain and improves blood flow to the area.
Symptom Relief: Topical and Oral Medications
While lifestyle changes are implemented, over-the-counter (OTC) medications can manage pain, itching, and swelling. Topical protectants, such as those containing zinc oxide or witch hazel, form a physical barrier over the irritated skin. Witch hazel also acts as a mild astringent, temporarily relieving itching and irritation.
For acute pain, topical local anesthetics like lidocaine or pramoxine can be applied to numb the area. These creams and ointments temporarily block nerve signals, providing rapid relief from discomfort. Since these products are generally intended for external use, their application for internal symptoms should be discussed with a healthcare provider.
Topical corticosteroids, such as hydrocortisone, reduce inflammation and swelling, helping with persistent itching. These medications should only be used for a short duration, typically no more than a week, as prolonged use can thin the skin. Oral pain relievers like acetaminophen or ibuprofen can manage general discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen should be used cautiously if hemorrhoids are actively bleeding, as they can increase the risk of bleeding.
Definitive Treatment: Minimally Invasive Procedures
If conservative management fails to control symptoms after a month, a physician may recommend a definitive, office-based procedure. These procedures are low-risk and are the preferred next step for symptomatic Grade 2 internal hemorrhoids. They aim to reduce the size of the hemorrhoidal tissue and prevent prolapse.
Rubber Band Ligation (RBL)
Rubber Band Ligation is a highly effective method for treating Grade 2 hemorrhoids. The procedure involves placing a small, tight rubber band around the base of the internal hemorrhoid. This action cuts off the blood supply to the tissue, a process known as ischemia.
The deprived tissue then withers and falls off, typically within one week. The hemorrhoid and the band pass naturally during a bowel movement, often unnoticed. A small scar forms where the hemorrhoid was, which secures the remaining tissue and prevents future prolapse in that area.
Patients may experience mild pain or a feeling of fullness for a few days, manageable with over-the-counter medication. Mild bleeding may occur when the tissue detaches, usually seven to ten days post-procedure. To promote healing, patients should avoid heavy lifting and straining for two to three weeks.
Sclerotherapy
Sclerotherapy is a minimally invasive technique involving the injection of a chemical solution (sclerosant) into the submucosal tissue at the base of the hemorrhoid. The chemical agent, such as 5% phenol-in-oil, causes a localized inflammatory and scarring reaction called sclerosis. This process leads to the development of scar tissue that shrinks the hemorrhoid over time.
The injected solution fixes the tissue in place, preventing further prolapse and reducing bleeding. Since the injection is made above the dentate line where there are few nerve endings, the procedure is generally painless. Sclerotherapy is useful for smaller Grade 2 hemorrhoids and those prone to bleeding. The treatment usually takes less than ten minutes, and patients can often resume normal activities the following day, though repeat treatments may be necessary.