Treatment Options for Grade II Internal Hemorrhoids: A Case of Treatment Decision Complexity

Case at a Glance

A 21-year-old male presented with asymptomatic grade II internal hemorrhoids with only prolapse symptoms, seeking treatment options and encountering conflicting medical recommendations regarding rubber band ligation versus laser therapy.

Patient's Story

The patient reported a 10-year history of hemorrhoids dating back to childhood, when he developed chronic straining during defecation due to time constraints before school. Currently, he experiences only prolapse of hemorrhoids without associated bleeding, pruritus, pain, or mucus discharge. The patient attributes the absence of irritative symptoms to consistent use of a bidet for hygiene. His primary concern is the physical discomfort and psychological distress from the prolapsing tissue.

Initial Assessment

Physical examination confirmed the presence of grade II internal hemorrhoids with prolapse that reduces spontaneously. No signs of thrombosis, ulceration, or active bleeding were noted. The patient reported no pain, itching, or discharge. Anal hygiene appeared excellent with no evidence of perianal dermatitis or excoriation.

The Diagnostic Journey

The diagnosis of grade II internal hemorrhoids was straightforward based on clinical presentation and physical examination. The complexity arose in treatment selection when the consulting proctologist recommended against rubber band ligation (RBL), stating it was no longer performed due to complications, and instead advocated for laser hemorrhoidoplasty at significantly higher cost.

Final Diagnosis

Grade II internal hemorrhoids with prolapse, asymptomatic except for mechanical discomfort

Treatment Plan

Initial consultation recommended laser hemorrhoidoplasty over traditional rubber band ligation. However, seeking second opinion revealed that RBL remains a standard, first-line treatment for grade II hemorrhoids in many medical centers and is still actively taught in gastroenterology and surgical residency programs.

Outcome and Follow-up

Patient sought additional medical opinions to clarify treatment options. Multiple specialists confirmed that rubber band ligation remains an appropriate and widely-used treatment for grade II hemorrhoids, particularly in asymptomatic cases like this one. The patient was counseled on both treatment modalities, their respective risks, benefits, and cost considerations to make an informed decision.