OBJECTIVE: To determine whether any method of hemorrhoid therapy has been shown to be superior in randomized trials. METHOD: A meta-analysis of all randomized controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. MAIN OUTCOME MEASURES: Response to therapy, the need for further therapy, complications and pain. RESULTS: Eighteen trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilatation of the anus (p = 0.0017) and associated with less need for further therapy (p = 0.034), no significant difference in complications (p = 0.60) but more pain (p < 0.001). Patients who underwent hemorrhoidectomy had a better response to treatment than did patients who were treated with rubber-band ligation (p = 0.001), although complications were greater (p = 0.02), as was pain (p < 0.0001). Rubber-band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (p = 0.005) and for hemorrhoids stratified by grade (grades 1 and 2, p = 0.007, grade 3, p = 0.042), with no difference in the complication rate (p = 0.35). Patients treated with sclerotherapy (p = 0.031) or infrared coagulation (p = 0.0014) were more likely to require further therapy than those treated with rubber-band ligation, although pain was greater after rubber-band ligation (p = 0.03 for sclerotherapy, p < 0.0001 for infrared coagulation). CONCLUSIONS: Rubber-band ligation is recommended as the initial mode of therapy for grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response, it is associated with more complications and pain than rubber-band ligation. Thus, it should be reserved for patients whose hemorrhoids fail to respond to rubber-band ligation.

OBJECTIVE: To compare simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately for the treatment of 2nd degree haemorrhoids. PATIENTS AND METHODS: Between 1993 and 1996, 255 patients that suffered from 2nd degree haemorrhoids were divided into 3 groups of 85 patients, each to receive either simultaneous sclerotherapy for smaller and rubber band ligation for larger piles (SCL/RBL) in one session, or sclerotherapy (SCL), or rubber band ligation (RBL), respectively. After a period of 4 years all patients were examined and their symptoms were recorded. RESULTS: The patients of the SCL group developed significantly fewer complications after treatment compared to the other two methods (P < 0.001), which did not differ from each other. After the SCL/RBL treatment, significantly more patients were symptom free (46%) than after SCL (8%), P < 0.001. There was no significant difference between the SCL/RBL (46%) and the RBL (31%) groups (P = 0.217), although the combined treatment seemed to be more effective than rubber band ligation. Only 10% of the patients of the SCL/RBL group needed additional sessions 6-24 months after the initial treatment compared to 30% of the patients of the SCL group (P = 0.001). However, there was no significant difference between SCL/RBL and RBL (17%) groups (P = 0.151). CONCLUSION: The combination of sclerotherapy and rubber band ligation for treatment of 2nd degree haemorrhoids is significantly more efficient than sclerotherapy on its own.

Hemorrhoids are a pathophysiological consequence of hyperplasia of the corpus cavernosum recti, and can be classified into three grades of severity. Clinically, they usually manifest in the form of peri-anal bleeding, a diffuse sensation of discomfort, itching and secretion of mucus. The diagnosis is established on the basis of the dinical presentation. Treatment is mainly conservative, but is likely to be successful only in the early stages. Already second degree symptomatic hemorrhoids require definitive treatment. Although peri-anal thrombosis is sometimes a very painful condition, it is usually harmless. If pain is severe, surgical incision is indicated.