Purpose: Rubber band ligation (RBL) is the first-line non-operative procedure for internal haemorrhoidal disease. Pain is more common following RBL than alternative non-operative procedures, and there is currently no consensus around analgesic approach, with submucosal local anaesthetic injection (SLAI), pudendal nerve blocks (PNBs) and no locoregional anaesthesia used in practice. Evidence for SLAI use is limited and no studies have assessed the use of PNB in RBL. The aim of this study was to determine the relative effectiveness of SLAI and PNB in reducing pain following RBL. Methodology: A double-blinded randomised controlled trial was conducted across five hospitals. Patients undergoing RBL were randomised to receive SLAI (0.5% bupivacaine with adrenaline injected deep to the band), PNB (1% ropivacaine injected at the pudendal nerve using anatomic landmarks), or no locoregional anaesthesia (control). Primary outcomes were patient-reported pain scores on a 10-point Numeric Rating Scale at 30 minutes, 2 hours, 4 hours, 24 hours and 2 weeks following RBL. Secondary outcomes were post-procedural analgesia use, time-to-discharge, days until return to work, patient satisfaction and complications. Results: A total of 120 participants (42 control, 36 SLAI, 42 PNB) were included. Median pain scores in intervention groups were significantly lower than the control group at 30 minutes, 2 hours (SLAI) and 4 hours. Median pain scores (IQR) in control, SLAI and PNB groups, respectively, were: at 30 minutes, 4 (1-5), 0.5 (0-2.75) and 1.5 (0-4.25), p= 0.004; at 2 hours, 2 (0-4), 0 (0-2) and 0 (0-4), p=0.035; and at 4 hours, 1 (0-3), 0 (0-1) and 0 (0-2), p=0.005. At 24 hours and 2 weeks, median pain score in all groups was 0. There were no significant differences in secondary outcomes between treatment groups. Conclusion: Following RBL, SLAI and PNB reduce pain in the early post-operative period. There was no difference in the effectiveness of SLAI and PNB at any timepoint.