Why external haemorrhoids have been off-limits for banding
Internal and external haemorrhoids are separated by the dentate line, and that boundary determines a lot more than anatomy.
Internal haemorrhoids sit above the dentate line and are covered by columnar epithelium with visceral innervation. They’re typically painless, which is exactly why banding works: the patient doesn’t feel the band.
External haemorrhoids sit below the dentate line, covered by anoderm, which is dense with somatic pain receptors and innervated by spinal nerves. Band an external haemorrhoid without anaesthesia and the pain is severe. That’s why, historically, symptomatic external haemorrhoids that failed conservative treatment (fibre, stool softeners, topical corticosteroids) went straight to surgical excision, with all the postoperative pain and recovery time that involves.
Rubber band ligation (RBL) has one long-standing rule: it’s for internal haemorrhoids only. External haemorrhoids have always been out of scope, and for a clear physiological reason. A case series published in Cureus in August 2025 tests whether that rule can be worked around, and the results are worth a closer look, with some important caveats.
What the study did
The paper, Rubber Band Ligation: A New Treatment Option for External Hemorrhoids (Sadik et al., Cureus 17(8): e89701, published 9 August 2025), starts with a single case: a 65-year-old man with a symptomatic, non-thrombosed external haemorrhoid that had failed conservative management three times.
Instead of proceeding to surgical excision, the treating team injected lidocaine into the tissue surrounding the haemorrhoid, numbing the somatic pain receptors that normally make external banding intolerable. Once the area was anaesthetised, a standard rubber band was applied, cutting off blood supply and inducing the same ischaemia-necrosis-sloughing process used in internal RBL.
Based on that result, the same approach was offered to a cohort of 50 additional patients with similar presentations.
What the results showed
Across the 50-patient cohort:
- 50% reported no discomfort at all after the procedure
- 44% had mild pain, managed with over-the-counter analgesics (ibuprofen or paracetamol)
- 3 patients (6%) experienced moderate-to-severe pain (rated 5-7/10), which resolved within a week without narcotic pain medication
- 2 patients (4%) had premature rupture of the band before day 5, requiring in-office debridement of necrotic tissue, without further anaesthesia
- No infections and no bleeding were reported at follow-up
- The band fell off within 5-7 days in all patients, leaving a small superficial ulcer that healed without complication
- About 90% said they were satisfied and would opt for the procedure again, and roughly 90% returned for repeat treatment on other haemorrhoids within 3-4 weeks
No recurrence was noted at the follow-up visits recorded in the study.
What the results don’t show
The authors are direct about the limitations, and so are we:
- This is a single-centre case series, not a randomised controlled trial. There’s no control group to compare against standard care.
- The sample size is 50 patients. That’s enough to generate a promising signal, not enough to change practice on its own.
- Follow-up was short, mostly one to two weeks, with some patients returning every three to four weeks for repeat procedures on other haemorrhoids. Long-term recurrence is explicitly described by the authors as unknown.
- The study didn’t document, in detail, how long or how thoroughly conservative treatment was tried before each patient moved to banding.
In short: this is early-stage evidence of a genuinely new approach, not a validated new standard of care.
Why it’s worth watching
Conservative management remains first-line for external haemorrhoids, and surgical excision remains the go-to for acutely thrombosed cases within the first two to three days of symptom onset. Where this study is interesting is the middle ground: symptomatic, non-thrombosed external haemorrhoids that have failed conservative care and where the patient wants to avoid surgery.
If local anaesthesia can reliably make banding tolerable in that group, it opens a non-surgical option where, until now, there hasn’t been one.
We watch developments like this closely because banding technology is what we do. We’ll be keeping an eye on whether this approach gets tested at larger scale, and with longer follow-up.
Read the full paper: Rubber Band Ligation: A New Treatment Option for External Hemorrhoids, Cureus (2025)
