What are hemorrhoids?

Hemorrhoids are swollen veins in the anal canal. Normally, tissue inside the anus fills with blood to help control bowel movements. If you strain or sit on the toilet a long time to move stool, the increased pressure causes the veins in this tissue to swell and stretch. Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the opening of the anus to form external hemorrhoids. Symptoms and treatment depend on which types of hemorrhoids are present.

What causes hemorrhoids? 

Too much pressure on the veins in the pelvic and rectal area causes hemorrhoids. This often happens in individuals with constipation who have to do a lot of straining to have bowel movements. Chronic diarrhea may also lead to straining and the development of hemorrhoids. Pregnant women can get hemorrhoids during the last 6 months of pregnancy. This is because of the increased pressure on the blood vessels in the pelvic area. Straining to push the baby out during labor can make hemorrhoids worse. Being overweight is also frequently associated with hemorrhoids.

What are the symptoms of hemorrhoids?

Hemorrhoids are common. By age 50, about half of adults have had to deal with symptoms related to hemorrhoids. The most common symptoms of both internal and external hemorrhoids include:

  • Bleeding during bowel movements. You might see small amounts of bright red blood on the toilet paper or in the toilet bowl. Some blood may be visible on the surface of the stool. Bleeding is often painless unless additional complications develop (see below).
  • Itching or irritation of the skin in the anal region. Itching may be intermittent and related to bowel movements or it may persist for long periods of time.
  • Rectal pain. External hemorrhoids or prolapsing internal hemorrhoids may make it painful to clean the anal area. Sometimes a sensitive or painful lump may be felt near the anus.

How are hemorrhoids diagnosed?

To diagnose hemorrhoids, your doctor will take a complete medical history and perform a physical exam. You may not need many tests at first, especially if you are younger than 50 years of age and your doctor believes, based on your medical history, that your symptoms are likely due to hemorrhoids. Your doctor may just examine the anal area visually and perform a rectal exam with a gloved finger. Sometimes an anoscopy (an examination of the anal canal with a small caliber rigid tube) or an endoscopy (examination with a flexible endoscope) may be done to examine the rectum and anal canal in more detail.

If you are 50 years of age or older, or if your medical history and your symptoms are not entirely typical for hemorrhoids, your doctor may recommend a colonoscopy to more completely examine your lower bowels and rule out other causes of bleeding or pain in this area.

What are complications of hemorrhoids? 

As long as internal hemorrhoids are small, they remain inside the anal canal. If they get larger, they may bulge and prolapse out of the anus with bowel movements and eventually all of the time. They can then become painful if they bulge out and are squeezed by the anal muscles. They may be very painful if they become strangulated, that is, if the blood supply to the hemorrhoid is reduced.

External hemorrhoids can get irritated and clot under the skin, causing a hard painful lump. This is called a thrombosed, or clotted, hemorrhoid.

Anemia (low red blood cell count) is an uncommon complication of internal or external hemorrhoids and occurs if bleeding from hemorrhoids goes on for a long time eventually leading to a significant loss of red blood cells. This may result in fatigue and weakness.

How are hemorrhoids treated? 

If hemorrhoids are found incidentally and are not causing significant symptoms, they can be left alone and do not require treatment.

If symptoms are present, home treatment is often all you need for uncomplicated external hemorrhoids. This includes

  • lowly adding fiber to your meals
  • drinking more water
  • using over-the-counter ointments for a limited time to stop itching.
  • Your doctor may also recommend stool softeners to avoid constipation.

If your internal hemorrhoids are causing persistent bleeding and/or pain, your doctor may recommend one or more additional types of treatments. Learn about these treatment options and talk to your doctor about what might be the best option for you.

  • Rubber band ligation: After visualizing the hemorrhoids with anoscopy, your doctor places a tiny rubber band around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week. This procedure is effective for many people and can usually be done in the doctor's office or an outpatient endoscopy center. Rubber band ligation may sometimes cause mild discomfort or it can result in bleeding which might begin 2-4 days after the procedure but is rarely severe.
  • Injection (sclerotherapy): In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
  • Coagulation (infrared, laser, or bipolar): Coagulation techniques using laser, infrared light or heat cause small, bleeding internal hemorrhoids to harden and shrivel. While coagulation has few side effects, studies show that it may be associated with a higher rate of hemorrhoids coming back compared to rubber band ligation.
  • Surgical procedures: Surgery to treat hemorrhoids may be done if other treatments don't work. Hemorrhoidectomy (removal of hemorrhoids) may be done to remove excessive tissue that causes bleeding. Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids. Complications may include temporary difficulty emptying the bladder and urinary tract infections associated with this problem. The surgery may be done on an outpatient basis or with an overnight stay in the hospital.

Pain and discomfort after surgery may be significant and can last for several days, limiting patients' activities. Hemorrhoid stapling is a surgical technique that blocks the flow of blood to hemorrhoidal tissue. Stapling generally involves less pain than hemorrhoidectomy and allows an earlier return to regular activities. Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrent and rectal prolapse, in which part of the rectum protrudes from the anus.

Can hemorrhoids be prevented? 

Healthy habits can help you prevent hemorrhoids or keep them from getting worse. Doctors often recommend eating foods that have lots of fiber, such as fruits, vegetables, and whole grains. Drinking plenty of water, and getting plenty of exercise is also often recommended.