1. Grading (Goligher’s Classification)

• Grade I: Bleeding, no prolapse.
• Grade II: Prolapse with defecation, reduces spontaneously.
• Grade III: Prolapse requires manual reduction.
• Grade IV: Irreducible prolapse, often thrombosed or strangulated.

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2. Management by Grade

Grade I (Bleeding only)

• Definitive:
  • Daflon® (Diosmin + Hesperidin, MPFF)
    • 1000 mg po bid (2 g/day) × 4–6 weeks.
  • Treat constipation → fiber, fluids, stool softeners.
• Supportive:
  • Sitz baths, topical agents (hydrocortisone, witch hazel, lidocaine).
• Surgery: ❌ Not indicated.

Grade II (Prolapse reduces spontaneously)

• Definitive:
  • Daflon® acute regimen for bleeding/prolapse episodes (3000 mg/day × 4 days → 2000 mg/day × 3 days).
  • Rubber band ligation (RBL) if persistent bleeding/prolapse.
• Supportive: Same as Grade I.
• Surgery: Rarely needed; consider only if refractory.

Grade III (Manual reduction required)

• Definitive:
  • Office procedure (preferred): Rubber band ligation.
  • Alternative: Infrared coagulation, sclerotherapy.
  • If failed → hemorrhoidectomy or stapled hemorrhoidopexy.
• Supportive: Daflon, fiber, stool softeners, sitz baths.
• Surgery: Consider if symptoms severe, recurrent bleeding, or RBL fails.

Grade IV (Irreducible prolapse)

• Definitive:
  • Surgical treatment required (ASCRS, Thai CPG).
    • Excisional hemorrhoidectomy (Milligan-Morgan or Ferguson).
    • Stapled hemorrhoidopexy (for circumferential prolapse).
• Supportive: Daflon + stool regulation until surgery.
• Surgery: ✅ Always indicated.

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3. Pharmacologic Management (for all grades, supportive role)

• Daflon® (Diosmin + Hesperidin)
  • Acute: 3000 mg/day (tid) × 4 days → 2000 mg/day (bid) × 3 days.
  • Chronic maintenance: 1000 mg/day.
• Analgesics: Paracetamol 500 mg po tid × 5 days (avoid NSAIDs if bleeding).
• Topicals: Hydrocortisone suppository 25 mg PR bid × 5–7 days, Lidocaine ointment tid prn.
• Stool softeners: Docusate 100 mg tid po or Lactulose syrup 15–30 mL po hs prn.

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4. Monitoring & Complications

• Complications: Strangulation, ulceration, secondary infection, anemia from chronic bleeding.
• Monitoring:
  • Hemoglobin if recurrent bleeding.
  • Bowel habits, pain control, prolapse progression.

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5. Patient Education

• High-fiber diet (20–35 g/day) + hydration.
• Avoid prolonged sitting/straining.
• Use sitz baths for symptom relief.
• Return if: heavy bleeding, fever, severe anal pain, or irreducible prolapse.

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✅ Summary Table (High-Yield for Exams)

👉 In short:

• Grade I–II = Medical + office procedures.
• Grade III = Start with office procedure → surgery if refractory.
• Grade IV = Surgery is definitive.