Rubber band ligation: what to expect

Rubber band ligation, also called banding, is an office treatment for internal hemorrhoids that bleed or slip down. A doctor places a small rubber band around the base of the hemorrhoid. The band cuts off the blood supply. The banded part shrivels and falls off, most often within a week, and scar tissue forms in what is left, which often shrinks the hemorrhoid ¹.

Banding is for internal hemorrhoids, and only a doctor should do it. The NIDDK page on hemorrhoid treatment is explicit about that ¹. It is a different procedure from the operation that cuts the tissue out.

This page covers the visit itself, pain and bleeding in the first two weeks, complications, how many sessions people need, how often banding works, and how it compares with infrared treatment, injection, artery ligation, and surgery.

What happens before rubber band ligation

Banding is aimed at internal hemorrhoids, the kind above the dentate line, the boundary between the upper and lower anal canal. Internal hemorrhoids can bleed, ache, and prolapse (slip out). External hemorrhoids sit below that line, under the skin. They hurt when they swell or form a clot, and they are a different problem ³. If your lump is a tender clot under the skin, read about external hemorrhoids before you assume banding is the plan.

Doctors grade internal prolapse from 1 to 4. Grade 1 stays inside the anal canal. Grade 2 comes out and goes back on its own. Grade 3 you have to push back. Grade 4 will not go back ³. A 2025 review of hemorrhoidal disease describes office procedures, with rubber band ligation as the first procedure, for grade 1 to grade 3 disease that is still troublesome after fiber, fluids, and less straining. The same review reserves excisional hemorrhoidectomy for grade 3 or 4 prolapse, a clot, or mixed internal and external disease that has not improved with simpler care ³.

What the procedure feels like

The NHS page on piles describes hospital treatments such as banding this way: you are awake, the area may be numbed, and you go home the same day ². Clinics place the band in more than one way. A doctor can use an endoscope, looking forward or bent back on itself, or no endoscope at all. The band can be fired with suction or with forceps. One band or several can go on in a single session. A local anesthetic after the band is sometimes used to cut down pain ⁴.

In a Rome series, two or three hemorrhoids were banded in one session ⁶. In the Montreal series, the median number of bands placed over the whole course of care was two, with a range from 1 to 17 ⁵.

Pain and bleeding in the first two weeks

Mild pain is the most common complication ⁴.

A crossover trial of 94 patients compared banding with infrared coagulation, a heat treatment. Pain scores were higher after banding at 30 minutes and at 6 hours. More people used pain pills after banding at 6 hours (29.6% versus 19.2%) and at 24 hours (22.5% versus 13.5%). By one week, pain scores were similar. Bleeding was also more common right after banding: 32.4% versus 4.3% immediately, and 26.8% versus 10.2% at 24 hours. At 72 hours the bleeding rates were no longer clearly different ⁷.

The HubBLe trial compared banding with hemorrhoidal artery ligation in people with grade 2 or grade 3 hemorrhoids. The day after the procedure, mean pain was 3.4 (standard deviation 2.8) after banding and 4.6 after artery ligation. On day 7 the scores were 1.6 and 3.1. By 21 days and 6 weeks the scores were no longer different ⁸.

A separate series of 206 people found that 46% had moderate anal pain for 24 hours. Two patients (1%) had severe pain and were admitted for a hemorrhoidectomy within a few days ⁶.

Numbing medicine helps the first hour more than the next day. In a three-arm trial of 99 patients, 2% lidocaine ointment, with or without diltiazem, lowered pain at 1 hour compared with placebo ointment. The combination group used about 45% less pain medicine in total and in the hospital, and those patients were more satisfied. The authors said the pain relief looked short term ⁹. A complications review also notes that local anesthetic after ligation is one way clinics try to reduce pain ⁴. Use only what your own clinic gives you, and follow that label.

Bleeding has two usual windows. Early spotting can happen in the first day, as in the infrared comparison above ⁷. Later bleeding is different. A review written as a guide to banding complications says secondary bleeding normally occurs 10 to 14 days after banding, when the tissue separates. People on antiplatelet or anticoagulant medicine have a higher risk, and there are reports of massive, life-threatening hemorrhage ⁴. In the Montreal series, bleeding complicated 2.8% of treatment courses. In the Rome series, 2.4% had rectal bleeding after a week ^5,6.

While the tissue is separating, keep stools soft. In seven hemorrhoid trials, fiber cut the risk of symptoms that did not improve by 47% (relative risk 0.53) and the risk of bleeding by 50% (relative risk 0.50) ¹⁵. Products are compared in our guide to fiber supplements, and food sources are in the hemorrhoid diet.

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Complications, including the serious ones

A 2016 guide to banding complications sorts them into minor problems, which are more common, and major problems, which are uncommon ⁴.

Minor problems in that review include mild bleeding, pain, feeling faint, a band that slips off, trouble urinating, an anal fissure (a small tear), and a chronic sore along the canal. Mild pain is the one that shows up most often.

Major problems in the same review include massive bleeding, a thrombosed (clotted) hemorrhoid, severe pain, urinary retention that needs a catheter, pelvic sepsis (a deep infection), and death. The review says seven deaths from infectious complications had been described in published reports, including cases of pelvic sepsis, Fournier’s gangrene, liver abscess, tetanus, and bacterial endocarditis. Those are case reports gathered over many years of a very common procedure, not the usual outcome. The review’s point is that early recognition changes the result ⁴.

The Montreal series put numbers on a few of these events per treatment course: bleeding 2.8%, thrombosed external hemorrhoids 1.5%, and bacteremia 0.09% ⁵. In HubBLe, serious adverse events that needed a hospital stay were uncommon after banding. After one patient with a rectal tumor that was already there was set aside, 2 of the remaining serious events were in the banding group (about 1%) and 12 were in the artery-ligation group (about 7%). The banding events were pain in one person and bleeding that did not need a transfusion in another ⁸.

The screening line is there because hemorrhoids are a common reason for blood, and they are not the only reason. The US Preventive Services Task Force recommends colorectal cancer screening starting at age 45 ¹⁴. New bleeding still deserves a look if you have not been screened. More on what is typical is in bleeding hemorrhoids, and the signs that should not wait are in when to see a doctor.

How many banding sessions will you need?

There is no single number. It depends on how many hemorrhoids you have and whether the first band is enough.

In the Rome series, two or three hemorrhoids were banded at the first visit, and 20% of patients had a second session after one month ⁶. In Montreal, the median gap between bandings was 4.7 weeks, with a range from 1.1 to 35.6 weeks. Needing four or more bands was tied to a trend toward more failure and a greater need for hemorrhoidectomy later ⁵.

HubBLe makes the repeat-visit pattern clear. At one year, 49% of the banding group (87 of 176) and 30% of the artery-ligation group (48 of 161) met the trial’s definition of recurrence. The gap was mostly extra procedures: 32% after banding had another hemorrhoid procedure, compared with 14% after artery ligation ⁸. A 2025 review puts the same idea in round numbers: symptoms resolve in 89% of patients, and repeated banding is needed in up to 20% ³. Those figures mix older studies with different definitions of success.

The HOLLAND trial allowed up to two banding sessions when it compared banding with hemorrhoidectomy for grade 3 hemorrhoids ¹³. One visit is common. A second visit a few weeks later is ordinary. A long string of bands is a reason to talk about surgery.

How often banding works, and how often hemorrhoids return

Success depends on the definition and on how long you watch.

The Montreal series is the largest here: 805 patients and 2,114 bands. Of those, 104 never returned and were left out. Among the 701 who were followed, for a median of 1,204 days, success was 70.5% (494 people) and failure was 29.5% (207). Success meant lasting relief, marked improvement with bleeding no more than once a month, or relief for at least 100 days. Rates were similar for every degree they treated. Banding a recurrence worked in 73.6% of first recurrences, 61.4% of second recurrences, and 65% of third recurrences. Counting those repeat treatments, cumulative success was 80.2%. Later recurrences returned sooner ⁵.

In Rome, at one year, 90% of people with grade 2 hemorrhoids and 75% with grade 3 hemorrhoids had no leftover symptoms. Phone follow-up at 10 and 17 years reached 138 of 206 patients (67%). Of those reached, 69% had no symptoms, 28% still had some, and 3% had needed more surgery ⁶.

A 1995 meta-analysis recommended banding first for grades 1 to 3, and surgery if banding failed, because hemorrhoidectomy responded better and caused more pain and more complications ¹⁰.

How banding compares with other treatments

The Cochrane review of banding versus excisional hemorrhoidectomy found three poor-quality trials. Complete remission favored surgery (relative risk 1.68), and the trials disagreed with each other. For grade 3, two trials and 116 patients still favored surgery (relative risk 1.23). For grade 2, one trial of 32 patients found no clear difference. Fewer people needed another treatment after surgery (relative risk 0.20). Pain was more common after surgery (relative risk 1.94), and so were delayed complications. Satisfaction looked similar. The authors’ split was banding for grade 2, and surgery for grade 3 or for recurrence after banding ¹¹.

A 2021 meta-analysis of eight trials found better symptom control after surgery, less pain after banding, more complications after surgery (bleeding, urinary retention, continence trouble, or narrowing), and equal satisfaction. One study found an earlier return to work after banding. The authors said the trials were too uneven to name a winner for grade 2 or 3 ¹².

HOLLAND assigned adults with grade 3 hemorrhoids to banding (up to two sessions) or excisional hemorrhoidectomy. Among 79 patients (46 banding, 33 surgery), surgery gained 0.08 quality-adjusted life years and had a recurrence rate 33.5 percentage points lower (95% confidence interval 15.3% to 51.7%). The sample is small ¹³.

If you and your surgeon choose the operation, read the hemorrhoidectomy recovery timeline before the date. Office treatments and surgery are compared in hemorrhoid procedures and the treatment overview.

After banding, fiber, fluid, and short toilet sits are the habits that keep stool soft. A heavy bleed, a fever, or pain with inability to urinate is a same-day call ^4,14.