A 42-year-old woman has symptomatic internal haemorrhoids that prolapse on straining and require manual reduction after defecation. Conservative measures have failed. What is the most appropriate next step in management?

• A Stapled haemorrhoidopexy is contraindicated at this grade
• B Injection sclerotherapy
• C Excisional haemorrhoidectomy
• D Rubber band ligation ✓

Explanation

Prolapse requiring manual reduction defines third-degree haemorrhoids. Rubber band ligation is effective for first to third degree disease and is the standard office procedure when conservative measures fail. Injection sclerotherapy is largely reserved for first degree disease. Excisional haemorrhoidectomy such as Milligan-Morgan is reserved for fourth degree piles, fibrosed or strangulated piles, or failure of banding. Stapled haemorrhoidopexy is a valid option for circumferential third and fourth degree disease, so calling it contraindicated is false.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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