Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue however, this procedure has several potential postoperative complications. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. Many Americans between 45 and 65 years of age experience hemorrhoids.
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