Infrared coagulation is considered medically necessary for first-degree or second-degree (i.e., Grade I or Grade II) internal hemorrhoids that are painful or persistently bleeding. A maximum of four treatments within a six-month period are considered medically necessar

Internal hemorrhoids are graded as follows:

Grade I: Bleeding without prolapse
Grade II: Prolapse with spontaneous reduction (with or without bleeding)
Grade III: Prolapse with manual reduction
Grade IV: Incarcerated, irreducible prolapse

This system has been in place for many years and correlates relatively well with treatment algorithms (i.e., Grade I and II hemorrhoids are often successfully treated by nonoperative means while Grade III and Grade IV hemorrhoids are more likely to require surgery).

Infrared coagulation (IRC) is one of several non-surgical treatments for the management of hemorrhoids. The infrared photocoagulator generates infrared radiation that coagulates tissue protein and evaporates water from cells. The amount of destruction depends upon the intensity and the duration of application. Usually three to four applications are enough to achieve coagulation of each hemorrhoid. The infrared coagulator is not particularly effective in treating large amounts of prolapsing tissue, therefore is most beneficial in Grade I and small Grade II hemorrhoids. It has been described to be slightly less painful than rubber banding.

The American Society of Colon & Rectal Surgeons practice parameters for the treatment of hemorrhoids notes that controlled trials indicate that IRC is useful for first-degree and second-degree hemorrhoids; however, first-degree and second-degree hemorrhoids may need repetitive treatments and alternative methods may be more efficacious (i.e., rubber band ligations). Generally, when additional treatments are necessary, they are one month apart (MacKay, 2001).

In a randomized study, Gupta compared infrared coagulation and rubber band ligation (RBL) in terms of effectiveness and discomfort (Gupta, 2003).  One hundred patients with second-degree bleeding hemorrhoids were randomized prospectively to either RBL (N=54) or infrared coagulation (N=46).  Parameters measured included postoperative discomfort and pain, time to return to work, relief in incidence of bleeding, and recurrence rate.  Pain was assessed using a visual analogue scale from “0” (no pain at all) to “10” (the worst pain the patient had ever experienced).  Postoperative pain during the first week was stronger in the band ligation group (2-5 versus 0-3 on a visual analogue scale).  Post-defecation pain and rectal tenesmus was more intense with band ligation.  The patients in the infrared coagulation group resumed their duties earlier (2 versus 4 days), but also had a higher recurrence or failure rate.  The author concluded that band ligation, although more effective in controlling symptoms and obliterating hemorrhoids, is associated with more pain and discomfort to the patient.  As infrared coagulation can be conveniently repeated in case of recurrence, it could be considered to be a suitable alternative office procedure for the treatment of early stage hemorrhoids.

Accarpio and colleagues (2002) reported on results of 7850 cases of non-surgical outpatient treatment of hemorrhoids with a combined technique. The patients received a combined treatment consisting of sclerotherapy, rubber band ligation, and infrared coagulation.  On the first visit, patients underwent sclerotherapy to decongest the area and reduce the size of the prolapse, when present.  Fifteen days later, rubber band ligation was performed with infrared coagulation on the tissue strangulated by the rubber band.  This combined treatment was repeated every 15 days until complete obliteration of all redundant hemorrhoidal tissue was achieved, as well as relief of symptoms.  This usually took a total of three treatments; rarely up to seven treatments were necessary.

Linares and colleagues (2001) prospectively studied the effectiveness of the treatment of internal hemorrhoids with rubber band ligation (RBL) and infrared photocoagulation (IRC) in 358 patients with a total of 817 hemorrhoid groups and follow-up period of 36 months. The mean number of hemorrhoids treated per patients was 2.3.  Rubber band ligation was performed with McGown ligator and suction pump, placing the band at the base of the hemorrhoid.  Infrared coagulation was performed with Lumatec coagulation system, applying at least four shoots around each hemorrhoid, with an exposition time ranging between 1 and 1.5 seconds.  Treatment was considered effective when patients became asymptomatic (relief of pain, bleeding, or anal itching) and the obliteration of hemorrhoids after the treatment was confirmed by anal inspection and anoscopy.  Of the 358 patients, 295 were treated with RBL (82.4%).  This treatment was effective in 98% of the patients after 180 days and very good after 36 months.  There were 6/295 relapses at 36 months (2%).  Those treated with IRC included 63 of 358 patients (17.6%).  In this group, relapses were observed in 6/63 patients (9.5%) at 36 months, all of them with grade III hemorrhoids that required additional treatment with RBL.  The treatment with RBL or IRC depended on the number of hemorrhoids and the hemorrhoidal grade.  No significant differences were found regarding the effectiveness between RBL and IRC for the treatment of grade I-II hemorrhoids, while RBL was more effective for grade III and IV hemorrhoids.  The authors concluded that RBL and IRC should be considered as a good treatment for all grades of hemorrhoids, due to its effectiveness, its cost-benefit and its small short and long-term morbidity.

A literature search from January 2006 to March 2007 resulted in no new published literature that would change the current guideline.