Hemorrhoids are a common condition involving swollen, enlarged veins that develop either inside the lower rectum or under the skin around the anus. Also called piles, these masses can cause symptoms like bleeding, discomfort, and itching, prompting people to seek medical guidance. Consulting a doctor is necessary because these symptoms can overlap with more serious conditions, such as anal fissures or colorectal cancer. The type of medical professional seen depends on the severity of symptoms and response to initial care.
The First Step: Primary Care Physicians and Initial Diagnosis
For most people, the Primary Care Physician (PCP) is the starting point for hemorrhoid concerns. The PCP begins with a thorough medical history and physical examination, including a visual inspection and often a digital rectal exam. This initial assessment confirms the presence of hemorrhoids and rules out other causes of rectal bleeding or pain.
Initial management focuses on conservative, at-home treatments designed to reduce symptoms and prevent further irritation. This approach includes dietary and lifestyle modifications, such as increasing daily fiber intake to 25 to 35 grams and drinking more water to soften stool consistency. The doctor may also recommend over-the-counter topical creams, ointments, or suppositories for temporary relief, or suggest warm sitz baths to reduce inflammation and discomfort. These conservative measures are often sufficient for treating Grade I hemorrhoids, which are internal and do not prolapse, and often Grade II hemorrhoids.
If symptoms fail to improve significantly after one or two weeks of consistent conservative treatment, or if the initial presentation includes severe or persistent bleeding, the PCP typically recommends a referral. A referral is also standard practice if symptoms suggest a higher-grade internal hemorrhoid or if a more extensive examination is needed to exclude other gastrointestinal diseases.
Specialized Care: The Role of Gastroenterologists
If conservative care is insufficient, a Gastroenterologist (GI) is often the next specialist involved. GIs specialize in the entire digestive tract and perform office-based, minimally invasive procedures for symptomatic internal hemorrhoids, typically Grades I, II, and sometimes Grade III. These procedures are performed in an outpatient setting and do not require general anesthesia.
One common procedure GIs perform is rubber band ligation (RBL). During RBL, a small, tight rubber band is placed around the base of the internal hemorrhoid, cutting off its blood supply. This lack of circulation causes the hemorrhoid tissue to wither and fall off within about a week.
Gastroenterologists also employ sclerotherapy, which involves injecting a chemical solution directly into the hemorrhoid tissue. This injection causes the hemorrhoid to scar and shrink, and it is often used for early internal hemorrhoids that primarily cause bleeding. Another method is infrared coagulation (IRC), which uses light or heat to coagulate and shrink the hemorrhoid by cutting off blood flow. These non-surgical interventions resolve persistent symptoms without the recovery time associated with traditional surgery.
Advanced Treatment: Colorectal Surgeons and Surgical Options
A Colorectal Surgeon specializes in diseases of the colon, rectum, and anus, and is the appropriate referral for the most severe or complex cases. Referral is necessary when minimally invasive GI procedures have failed, or when the hemorrhoidal disease is advanced. This includes Grade IV internal hemorrhoids that are permanently prolapsed and cannot be manually reduced, large external hemorrhoids, or cases involving thrombosis.
The primary surgical treatment offered is a hemorrhoidectomy, which is the surgical removal of the hemorrhoidal tissue. This procedure is highly effective for severe or recurrent hemorrhoids, offering the lowest risk of recurrence. A hemorrhoidectomy typically involves a longer and more painful recovery period compared to office-based procedures.
Another surgical option is the stapled hemorrhoidopexy, also known as Procedure for Prolapse and Hemorrhoids (PPH), which is reserved for internal hemorrhoids. This technique uses a circular stapling device to remove excess tissue, lifting the hemorrhoids back into position and disrupting their blood supply. Stapling generally results in less immediate postoperative pain than a full hemorrhoidectomy but has been associated with a slightly higher risk of recurrence. For an acutely thrombosed external hemorrhoid, the surgeon may perform a thrombectomy to excise the clot, providing immediate pain relief if performed within the first 72 hours of symptom onset.