Hemorrhoidal Disease Review Highlights Graded Management and Treatment Efficacy

A new clinical review published in JAMA provides a detailed summary of hemorrhoidal disease—its types, treatment options, and patient outcomes—highlighting its widespread impact and the value of a graded, symptom-driven management approach.

“Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US,” the authors noted. “Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse.”

Hemorrhoids are classified into internal, external, or mixed forms. Internal hemorrhoids, which originate above the dentate line, are graded based on the degree of prolapse: from grade I (limited to the anal canal) to grade IV (irreducible). External hemorrhoids, developing below the dentate line, are typically symptomatic when engorged or thrombosed, often causing rectal pain.

First-line management for all types includes increased fiber and water intake and avoidance of straining during defecation. Phlebotonics—particularly flavonoids—may reduce symptoms like bleeding and swelling, though up to 80% of patients experience recurrence within months after stopping treatment.

For internal hemorrhoids (grades I–III) that do not respond to conservative therapy, several office-based procedures are available:

• Rubber band ligation resolves symptoms in 89% of cases, though up to 20% may require repeat treatment.

• Sclerotherapy offers short-term relief in 70%–85% of patients, with long-term remission seen in only one-third.

• Infrared coagulation yields symptom improvement in 70%–80% of cases.

“Surgical excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches,” the review states. This option provides low recurrence rates (2%–10%) but requires longer recovery (9–14 days).

For external hemorrhoidal disease, surgery is generally reserved for acute thrombosis. When performed within 72 hours of symptom onset, clot evacuation can significantly reduce pain and future recurrence. Beyond this window, medical management with stool softeners and topical analgesics like 5% lidocaine is preferred.

“First-line treatment is increased fiber intake, avoidance of straining during defecation, and phlebotonics,” the authors concluded. “In-office rubber band ligation for grade I to III internal hemorrhoid disease is first-line procedural treatment for persistent symptoms despite conservative therapies.”

Reference
Ashburn JH. Hemorrhoidal disease: a review. JAMA. Published online August 18, 2025. doi:10.1001/jama.2025.13083