EPD510 - Rubber Band Ligation for Symptomatic External Hemorrhoids: A Novel Approach

Purpose/Background: Objective

Evaluate the feasibility, safety, and tolerability of RBL with lidocaine infiltration for symptomatic external hemorrhoids.

Background

External hemorrhoids arise from dilated veins of the inferior rectal plexus and frequently present as perianal redundant skin. Symptoms include discomfort, pruritus, bleeding, and hygiene difficulties. Thrombosed external hemorrhoids are associated with acute severe pain, while non-thrombosed hemorrhoids typically lead to irritation with defecation, wiping, or persistent discomfort.

Conventional management involves conservative measures (sitz baths, topical hydrocortisone/Preparation-H, analgesics), with excisional hemorrhoidectomy reserved for definitive treatment. Hemorrhoidectomy, however, carries significant postoperative pain and prolonged recovery. To address these limitations, rubber band ligation (RBL)-traditionally used for internal hemorrhoids-was adapted with local anesthetic infiltration as a minimally invasive alternative for symptomatic external hemorrhoids.

Methods/Interventions: Patients with symptomatic, non-thrombosed external hemorrhoids refractory to conservative therapy were included. Exclusion criteria were thrombosed hemorrhoids, active anorectal infection, or inability to tolerate office-based procedures.

Each treatment session targeted one hemorrhoid only. After infiltrating 2 mL of 1 % lidocaine at the hemorrhoid base with a 27-gauge needle, a single rubber band was applied to induce ischemic necrosis. The band detached spontaneously within 5-10 days, leaving a localized scar. When additional hemorrhoids required treatment, subsequent ligations were performed one at a time at 3-4-week intervals, allowing complete assessment of pain, healing, and any complications before the next session.

Seventy patients (45 women, 25 men) underwent 165 ligations: 5 patients received 4 staged ligations, 30 received 3, 20 received 2, and 15 required only 1.

Results/Outcomes: Premature detachment occurred in 5 cases and was managed with simple office debridement of residual necrotic tissue without anesthesia. Sixty percent reported mild to moderate pain controlled with acetaminophen and sitz baths, with optional antibiotic ointment. No patient required narcotic analgesia. No significant bleeding, infection, or urinary retention was observed. At 4-12 week follow-up, all patients reported symptomatic improvement, with no recurrence of treated hemorrhoids.

Conclusion/Discussion: Discussion

This pilot study demonstrates that RBL with lidocaine infiltration is safe and well tolerated. Compared with hemorrhoidectomy, RBL results in significantly less postoperative pain-partly from localized denervation-while eliminating narcotic use and maintaining a low complication rate. Notably, most patients returned for second, third, and even fourth staged ligations, indicating that discomfort from external banding is modest and does not deter continued treatment when indicated. Limitations include the single-center design and lack of a comparative control group. Larger prospective trials are needed to assess long-term recurrence and cost-effectiveness.

Conclusion

RBL with lidocaine infiltration provides a minimally invasive alternative to excisional hemorrhoidectomy for symptomatic external hemorrhoids. It offers effective symptom relief, reduced postoperative pain, and favorable short-term outcomes, supporting its potential as a first-line procedural option in selected patients.

Rubber Band Ligation of External Hemorrhoid
External hemorrhoid immediately after rubber band ligation, with a well-healed posterior scar from a prior ligation visible in the background.