Hemorrhoid procedures: banding, surgery and other options

Hemorrhoid procedures are the next step when fiber, soaks, and a short course of cream have not stopped the bleeding or a lump that slips out. Most of these treatments are for internal hemorrhoids. Some happen in the office while you are awake. Others are operations with anesthesia. This page compares rubber band ligation, sclerotherapy, infrared coagulation, hemorrhoidal artery ligation, excisional hemorrhoidectomy, and stapled hemorrhoidopexy on recurrence, pain, and recovery.

The NHS page on piles treatment says hospital treatment is for hemorrhoids that do not improve with home care, or that are large ². Office treatments are done while you are awake. The area may be numbed, and you should be able to go home the same day ². Surgery usually means you are asleep, and you may go home the same day or the next day ². The full ladder, from home care up to this point, is in hemorrhoid treatment.

No procedure promises the hemorrhoid will never return. The NHS says treatment does not always prevent piles from coming back ². Ask a surgeon which option fits the grade, how much pain you will trade for fewer repeat treatments, and what the first week at home will feel like.

How a surgeon matches the procedure to the hemorrhoid

Internal hemorrhoids are graded by how far they slip out. A family medicine review describes four grades ⁴. Grade 1 bulges inside and may bleed, without coming out. Grade 2 slips out and goes back on its own when you stop straining. Grade 3 has to be pushed back in. Grade 4 stays out. Painless bleeding can happen at any grade ⁴. The pictures and what each grade feels like are in internal hemorrhoids. If a hemorrhoid is out right now, how to push a prolapsed hemorrhoid back in explains the safe way to ease it in.

A 2026 American Gastroenterological Association expert review says banding or infrared coagulation should come before hemorrhoidectomy for grades 1 to 3 ³. Grade 4 internal hemorrhoids need an operation that cuts them out ³. The same review says to offer a surgeon’s visit to people with grade 3 hemorrhoids who do not get better with banding, or who also have external hemorrhoids ³.

External hemorrhoids, under the skin at the opening, are a different problem. A sudden hard, very painful lump is often a clot. The gastroenterology review says those acutely thrombosed hemorrhoids are often extremely painful and are best treated by opening and draining the clot ³. That decision is time-sensitive, and it is covered in a thrombosed hemorrhoid.

Rubber band ligation

Rubber band ligation, also called banding, is the office treatment earlier trials supported first. A clinician places a small rubber band around the base of an internal hemorrhoid, above the part of the canal that feels sharp pain. The NIDDK description of rubber band ligation says the band cuts off the blood supply, the banded part shrivels and falls off, most often within a week, and scar tissue shrinks what remains ¹. Only a doctor should do this. It is not a kit for home.

A 1995 meta-analysis of 18 randomized trials compared the main treatments ⁵. Banding worked better than sclerotherapy, the injection treatment, across the grades studied. People treated with sclerotherapy or with infrared coagulation were more likely to need another treatment than people who were banded. Banding caused more pain than those two. Hemorrhoidectomy, the operation that cuts the hemorrhoid out, worked better than banding and caused more complications and more pain. The authors recommended banding as the first treatment for grades 1 to 3, and hemorrhoidectomy for people who do not respond to banding ⁵.

A Cochrane review of banding versus excisional hemorrhoidectomy looked at three trials, all of poor quality ⁶. For grade 3 hemorrhoids (they have to be pushed back in), cutting them out worked better: relative risk 1.23, from two trials with 116 patients. For grade 2 hemorrhoids (they slip out and go back on their own), one small trial of 32 patients found no clear difference. Fewer people needed a repeat procedure after surgery (relative risk 0.20). Pain was more common after surgery (relative risk 1.94). The authors also said surgery meant more time off work, and that patient satisfaction looked similar after the two treatments ⁶. They suggested banding for grade 2, and surgery for grade 3 or for a hemorrhoid that comes back after banding ⁶.

What the first week feels like, including the urge to have a bowel movement, is in rubber band ligation: what to expect.

Mild pain is the most common problem after banding ¹⁰. Bleeding that shows up later often arrives 10 to 14 days afterward, when the banded tissue falls off ¹⁰. People taking antiplatelet or anticoagulant medicine have a higher risk, and there are reports of life-threatening bleeding ¹⁰. Serious infection is uncommon. A review of published complications found rare deaths from infection after banding, seven in the reports it collected, and said early recognition is what changes the outcome ¹⁰.

Sclerotherapy

Sclerotherapy is an injection. NIDDK says a doctor injects a solution into an internal hemorrhoid, scar tissue forms, the blood supply is cut off, and the hemorrhoid often shrinks ¹. The NHS lists it among treatments you have while awake, with a same-day trip home ².

In the 1995 meta-analysis, banding worked better than sclerotherapy, with a similar complication rate, and people who had the injection were more likely to need another treatment ⁵. Banding hurt more ⁵. Injection still has a place when a clinician wants to avoid a band.

Infrared coagulation

Infrared coagulation, also called infrared photocoagulation, uses a short burst of heat. NIDDK says the heat creates scar tissue, which cuts off the blood supply and often shrinks the hemorrhoid ¹. The NHS lists it with the other awake, same-day treatments ². The gastroenterology review says infrared coagulation and banding have similar benefits in the short term, and that banding holds up better for prolapse and for bleeding that keeps coming back ³.

A crossover trial of 94 people treated one hemorrhoid with banding and another with infrared, two weeks apart ⁸. Pain was higher after banding at 30 minutes and at 6 hours, and more people used pain medicine after banding at 6 hours (29.6 percent versus 19.2 percent) and at 24 hours (22.5 percent versus 13.5 percent). By 72 hours the scores were similar. Bleeding right after treatment was more common with banding (32.4 percent versus 4.3 percent). Ninety-one of 94 people were treated successfully, and when they chose a method for a third hemorrhoid, the split was even ⁸.

The 1995 meta-analysis still found infrared treatment more likely to need a repeat than banding, with less pain after infrared ⁵. If the hemorrhoid keeps slipping out, the longer comparisons favor banding ^3,5. The NHS also lists electrotherapy, a gentle electric current, among the awake treatments ². These trials do not rank it against banding.

Hemorrhoidal artery ligation

Hemorrhoidal artery ligation, also called HAL, finds the artery feeding the hemorrhoid and ties it with a stitch so the hemorrhoid shrinks. The NHS describes it that way, and says you are usually asleep, going home the same day or the next ². The large UK comparison used Doppler-guided HAL, which means a small ultrasound probe helps find the artery ⁷.

The HubBLe trial compared HAL with banding for grade 2 and grade 3 hemorrhoids at 17 UK hospitals ⁷. Recurrence at 1 year was 87 of 176 people (49 percent) after banding and 48 of 161 (30 percent) after HAL. The gap was mostly extra procedures: 57 people (32 percent) after banding had another hemorrhoid procedure, versus 23 (14 percent) after HAL ⁷.

The day after treatment, mean pain was 3.4 out of 10 after banding and 4.6 after HAL. At day 7 it was 1.6 after banding and 3.1 after HAL. By 21 days and at 6 weeks, the scores were no longer different ⁷. Serious events that needed a hospital stay were more common after HAL (12 people, 7 percent) than after banding (2 people, 1 percent), once a pre-existing rectal tumor was set aside ⁷. The authors wrote that patients might prefer repeat banding to the artery operation ⁷.

Excisional hemorrhoidectomy

Excisional hemorrhoidectomy cuts the hemorrhoid out. NIDDK says it is for large external hemorrhoids and for prolapsing internal hemorrhoids that have not responded to other treatments, and that you have anesthesia ¹. The NHS says you are usually asleep and may go home the same day or the next day ². The gastroenterology review reserves this operation for grade 4 hemorrhoids, and for grade 3 hemorrhoids that fail banding or that come with external hemorrhoids ³.

A PROSPECT review of pain after this operation recommends a pudendal nerve block (a numbing injection near a pelvic nerve), acetaminophen, an anti-inflammatory drug, an opioid if needed, a topical lidocaine product, laxatives, and oral metronidazole ¹¹. The review drew those steps from separate studies ¹¹. Week-by-week recovery, including the first bowel movement, is in hemorrhoidectomy recovery.

Stapled hemorrhoidopexy

Stapled hemorrhoidopexy, sometimes called hemorrhoid stapling, does not cut the hemorrhoid out in the same way. NIDDK says a surgeon uses a stapling tool to remove internal hemorrhoid tissue and pull a prolapsing hemorrhoid back into the anus, with anesthesia ¹. The NHS says the piles are stapled back inside ².

The eTHoS trial compared stapled hemorrhoidopexy with traditional excisional surgery in 777 adults with grade 2 to 4 hemorrhoids ⁹. Stapled surgery hurt less in the short term, and serious complication rates were similar: 24 of 338 people (7 percent) after stapling and 33 of 352 (9 percent) after traditional removal. Over 24 months, quality of life was better after traditional surgery. In the first 6 weeks, quality of life was higher after stapling, and after that the traditional-surgery group pulled ahead ⁹. The authors said traditional removal should be considered the surgical treatment of choice, as part of a plan matched to the person ⁹.

Pain, recurrence, and recovery compared

What to ask before you book

The answers change the procedure.

• What grade is this, and is there an external hemorrhoid as well? Grade 4, and grade 3 that has already failed banding, point toward excision ³.
• For grades 1 to 3, the gastroenterology review puts banding or infrared ahead of surgery ³.
• If the platelet count is under 50,000 per microliter, or the INR (a clotting-time test) is over 2.0, that review prefers infrared coagulation to banding ³. Tell them every blood thinner you take.
• If you have Crohn’s disease or ulcerative colitis, procedures wait until it is in remission ³.
• In cirrhosis, the review says to make sure the swelling is a hemorrhoid and not a rectal varix. Portal hypertension by itself does not rule out banding or infrared ³.
• Excision means more time off work than banding ⁶. Stapling hurts less in the first weeks, and traditional removal had better quality of life over 24 months ⁹.

After the procedure

Keep the home measures that reduce straining. In seven trials, fiber lowered the chance of hemorrhoid bleeding by about half ¹³. A fiber supplement is a practical way to keep that going while you heal. Options are on the best fiber supplements for hemorrhoids. Laxatives are part of the pain plan after excisional surgery in the PROSPECT review ¹¹. Short-term softeners are compared on the best stool softeners for hemorrhoids.

Warm soaks are a common instruction after surgery. How to do them, and the trial that found ice packs eased pain more than soaks in the first 16 hours after hemorrhoidectomy, is in how to take a sitz bath. Creams you were using before the procedure have their own time limits, covered in over-the-counter hemorrhoid treatment.

New or heavy rectal bleeding still needs a diagnosis. Other diseases cause it too. The US Preventive Services Task Force recommendation on colorectal cancer screening says screening should start at age 45 for adults at average risk ¹².

The gastroenterology review says anyone having a hemorrhoid procedure should know that pelvic sepsis is a small possibility, and should go to an emergency department promptly if that risk becomes real ³. NIDDK says to seek care right away for severe anal pain and rectal bleeding, particularly with abdominal discomfort, diarrhea, or fever ¹. What a routine visit includes is in when to see a doctor for hemorrhoids.

GuideBleeding hemorrhoids: what is normal and what is not

Bright red hemorrhoid bleeding: what is typical, what is not, why it still needs a check from age 45, and how fiber and banding help.