Clinical outcomes of different sclerosing agents for hemorrhoids: a network meta-analysis

Background Injection sclerotherapy is widely used for grade I–III internal hemorrhoids, but evidence comparing multiple sclerosing agents head-to-head is limited. Methods Pubmed, Web of Science, Embase, Cochrane Library, CNKI, Wanfang Data, and grey literature sources were searched for randomized controlled trials (RCTs) reporting cure rate as the primary outcome. A Bayesian network meta-analysis was performed using Markov chain Monte Carlo simulations. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and treatments were ranked using surface under the cumulative ranking curve (SUCRA) values. Outcomes assessed included cure rate, recurrence rate, patient satisfaction, and operative complications. Results Sixty-six RCTs were included. Polidocanol foam demonstrated significantly higher cure rates compared with polidocanol liquid (OR = 3.1, 95% CI: 2.3–4.2) and ranked first among all treatments for cure rate and patient satisfaction. It also showed the lowest risk of overall complications (OR = 0.53 vs. polidocanol liquid, 95% CI: 0.22–1.3), with significantly reduced risks of bleeding (OR = 0.4, 95% CI: 0.21–0.9) and rectal stricture (OR < 0.001, 95% CI: <0.001–0.73). XiaoZhiLing, phenol, and 50% dextrose were significantly inferior to polidocanol liquid in cure rate. Subgroup analyses in internal hemorrhoids, grade I/II, and grade I/II/III hemorrhoids consistently supported the superiority of polidocanol foam. Conclusion Polidocanol foam showed best efficacy among all sclerosing agents for treating hemorrhoids, ranking first in cure rate and patient satisfaction with lowest complication risks, particularly for bleeding and rectal stricture. These findings support polidocanol foam as the preferred sclerosing agent in clinical practice. However, as most included trials had follow-up durations of less than 1 year, the long-term durability of these benefits and the risk of late recurrence remain to be established. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261379386 , PROSPERO CRD420261379386.