Hemorrhoids are a common condition affecting the veins in the lower rectum and anus, causing symptoms like pain, itching, and bleeding. Seeking a professional diagnosis is important to rule out more serious causes of rectal bleeding, rather than relying solely on over-the-counter treatments. The healthcare provider a patient sees is determined by the severity, location, and complexity of the disease. Treatment typically progresses from conservative measures to office-based procedures and, finally, to more involved surgical options.
Starting with Primary Care Physicians
For most individuals experiencing new or mild hemorrhoid symptoms, the initial point of contact is a Primary Care Physician (PCP), such as a Family Medicine doctor or Internist. PCPs perform an initial physical examination and confirm the diagnosis, often classifying internal hemorrhoids by grade. Early-stage hemorrhoids, typically Grade I and Grade II, are primarily managed through conservative methods.
PCPs focus on modifying lifestyle factors to prevent straining during bowel movements. This includes recommending increased dietary fiber intake and fluid consumption to soften stool. They may also suggest using over-the-counter creams, ointments, or suppositories for temporary symptom relief, or taking warm sitz baths to reduce inflammation and discomfort.
When conservative treatments fail to relieve symptoms for Grade I or Grade II hemorrhoids, or if the hemorrhoids are more advanced (Grade III or IV), the PCP issues a referral. This directs the patient to a specialist who can offer more aggressive, procedural treatment. A referral is also necessary if the PCP suspects the symptoms may be caused by a different, underlying gastrointestinal issue.
Specialists for Minimally Invasive Treatments
When conservative management is insufficient, the next step involves specialists who perform intermediate, office-based procedures, most often Gastroenterologists or specialized Colorectal Surgeons. These specialists manage internal hemorrhoids, particularly Grade I, II, and sometimes early Grade III, which prolapse but can be manually reduced. These interventions require minimal recovery time and can be performed without general anesthesia in an outpatient setting.
The most common procedure is Rubber Band Ligation (RBL), where a small rubber band is placed around the base of the internal hemorrhoid, cutting off its blood supply. The banded tissue shrivels and falls off, typically within a week, leaving scar tissue that prevents future prolapse. Another technique is Sclerotherapy, which involves injecting a chemical solution directly into the hemorrhoid tissue, causing it to scar and shrink.
Infrared Coagulation (IRC) is a third office-based option, utilizing a small probe to expose the hemorrhoid to short bursts of infrared light. The heat energy causes coagulation and scarring, resulting in the hemorrhoid shrinking. RBL is considered to have the highest long-term efficacy among these three methods, though all provide effective relief for moderate cases.
When Surgical Intervention is Necessary
Surgical intervention is the final recourse, reserved for severe, complex, or recurrent hemorrhoid disease, especially Grade III and Grade IV internal hemorrhoids that are permanently prolapsed. This treatment is almost exclusively performed by a Colorectal Surgeon, a specialist with advanced training in treating disorders of the colon, rectum, and anus. Surgery is considered when non-surgical treatments have failed or when the hemorrhoids are too large or severe to respond to less invasive methods.
The most definitive surgical treatment is the traditional excisional hemorrhoidectomy, which physically removes the excess tissue and vascular cushions. This procedure, performed under anesthesia, offers the lowest recurrence rate but is associated with a more painful and longer recovery period, often requiring two to four weeks for full healing. Colorectal Surgeons may also perform stapled hemorrhoidopexy.
Stapled hemorrhoidopexy involves using a circular stapling device to remove a ring of tissue above the hemorrhoids, lifting the remaining tissue back into its proper anatomical position. This technique disrupts the blood flow to the hemorrhoidal cushions, causing them to shrink over time. While often resulting in less post-operative pain than a traditional excision, it is primarily effective for prolapse and may not be suitable for all types of hemorrhoidal disease.