Hemorrhoids are clumps of dilated (enlarged) blood vessels in the anus and lower rectum. The rectum is the last area of the large intestine before it exits to the anus. The anus is the end of the digestive tract where feces leaves the body.
Sometimes hemorrhoids swell when the veins enlarge and their walls become stretched, thin, and irritated by passing stool. Hemorrhoids are classified into two general categories:
- internal, originating in the rectum, and
- external, originating in the anus.
Hemorrhoids (also termed piles) have caused pain and irritation throughout human history. The word comes from Greek, “haimorrhoides,” meaning veins that are liable to discharge blood. If you've had a bout of hemorrhoid pain, you're not alone. It's estimated that three out of every four people will have hemorrhoids at some point in their lives. Even Napoleon suffered from hemorrhoids, which distracted him with severe pain during his defeat at Waterloo.
Enlarged Hemorrhoid Symptoms
Enlarged hemorrhoids are associated with symptoms such as
- mucus discharge,
- burning at the anus,
- severe pain,
- a sensation that the bowel is not really empty, and
- bleeding without pain.
In this article, our medical experts will explain where hemorrhoid pain comes from, what hemorrhoids feel like, and how they are diagnosed. Then you will discover the various treatments for hemorrhoids both at home and at hospital, along with the positive attributes and drawbacks of each hemorrhoid treatment.
Internal hemorrhoids sit in the inside lining of the rectum and are not obvious unless they are substantially enlarged, in which case they can be felt. Internal hemorrhoids are usually painless and become apparent because they cause bleeding with a bowel movement.
Sometimes internal hemorrhoids prolapse or protrude outside the anus. If so, you may be able to see or feel them as moist pads of skin that are pinker than the surrounding area. Prolapsed hemorrhoids may hurt because the anus is dense with pain-sensing nerves. Prolapsed hemorrhoids usually recede into the rectum on their own. If they don't, they can be gently pushed back into place.
External hemorrhoids are located underneath the skin that surrounds the anus, and are lower than internal hemorrhoids. They can be felt when they swell, and may cause
- pain, or
- bleeding with a bowel movement.
If an external hemorrhoid prolapses to the outside (usually in the course of passing a stool), you can see and feel it.
Blood clots sometimes form within prolapsed external hemorrhoids, which can cause an extremely painful condition called a thrombosis. If an external hemorrhoid becomes thrombosed, it can look rather frightening, turning purple or blue, and could possibly bleed.
Despite their appearance, thrombosed hemorrhoids usually are not serious, though they can be very painful. They will resolve on their own in a couple of weeks. If the pain is unbearable, your doctor can remove the blood clot from the thrombosed hemorrhoid, which stops the pain.
Although most people think hemorrhoids are abnormal, everyone has them. Hemorrhoids help control bowel movements. Hemorrhoids cause problems and can be considered abnormal or a disease only when the hemorrhoidal clumps of vessels enlarge.
Hemorrhoids occur in everyone, and an estimated 75% of people will experience enlarged hemorrhoids at some point. However only about 4% will go to a doctor because of hemorrhoid problems. Hemorrhoids that cause problems are found equally in men and women, and their prevalence peaks between 45 and 65 years of age.
Hemorrhoids are caused by swelling in the anal or rectal veins. This makes them susceptible to irritation.
This swelling can be caused by several things, including
Diet is believed to have a big impact in causing—and preventing—hemorrhoids. People who consistently eat a high-fiber diet are less likely to get hemorrhoids, while those people who prefer a diet high in processed foods face a higher hemorrhoid risk. A low-fiber diet can cause constipation, which can contribute to hemorrhoids in two ways:
- It promotes straining on the toilet; and
- It also aggravates the hemorrhoids by producing hard stools that further irritate the swollen veins.
The most common symptom and sign from hemorrhoids is painless bleeding. A hemorrhoid sufferer may notice bright red blood on the outside of the stools, on the toilet paper, or dripping into the toilet.
The bleeding usually resolves itself without treatment. Nevertheless, bleeding with a bowel movement is never normal and should prompt a visit to a health care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons for bleeding, including
- inflammatory bowel disease,
- infection, and
Learn more symptoms of internal and external hemorrhoids in the following slides.
Many physicians use a grading system to categorize hemorrhoids along four stages:
- First-degree hemorrhoids: Hemorrhoids that bleed, but do not prolapse. These are slightly enlarged hemorrhoids, but they do not protrude outside the anus.
- Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or without bleeding). These may come out of the anus during certain activities like passing stool, and then return back inside the body.
- Third-degree hemorrhoids: Hemorrhoids that prolapse and must be pushed back in by a finger.
- Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in the anal canal. Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the lining of the rectum through the anus.
Internal hemorrhoids prolapse when their blood vessels swell and extend from their location in the rectum through the anus. In the anal canal, the hemorrhoid is exposed to the trauma of passing stool, particularly hard stools associated with constipation. The trauma can cause bleeding and sometimes pain when stool passes.
The presence of
- inflammation, and
- constant moisture
can lead to anal itchiness (pruritus ani), and occasionally the constant feeling of needing to have a bowel movement. The prolapsing hemorrhoid usually returns into the anal canal or rectum on its own or can be pushed back inside with a finger, but it prolapses again with the next bowel movement.
External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids.
External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as thrombosis. Thrombosis of an external hemorrhoid causes an anal lump that is
- very painful,
- tender, and
- often requires medical attention.
The thrombosed hemorrhoid may heal with scarring, and leave a tag of skin protruding in the anus. Occasionally, the tag is large, which can make anal hygiene (cleaning) difficult or irritate the anus.
Most individuals who have hemorrhoids discover them by either
- feeling the lump of an external hemorrhoid when they wipe themselves after a bowel movement,
- noting drops of blood in the toilet bowl or on the toilet paper, or
- feeling a prolapsing hemorrhoid (protruding from the anus) after bowel movements.
With a history of symptoms, a physician can begin diagnosis on the basis of a careful examination of the anus and anal canal. Although the physician should try his or her best to identify the hemorrhoids, it is perhaps more important to exclude other causes of hemorrhoid-like symptoms that require different treatment such as
- anal fissures,
- perianal (around the anus) skin diseases,
- infections, and
Seeing a Doctor About Hemorrhoids
Many people are embarrassed to go to their doctor about their hemorrhoid problems, which is probably why only an estimated 4% of people see the doctor even if 75% of us experience enlarged hemorrhoids at some point in time. Despite the embarrassment, hemorrhoids should always be examined professionally. Getting a medical exam will help your doctor recommend an effective treatment, and will also rule out more serious causes for your symptoms.
When you visit your doctor, you will probably be asked to describe your symptoms. The doctor will perform an examination to see whether your anus is inflamed, and whether enlarged hemorrhoids are present.
The doctor will want to know if you have found blood in your stool, which may prompt a bowel endoscopy examination. The doctor will likely feel for anything unusual through a digital rectal examination.
Remember that while this might be a little embarrassing and uncomfortable, hemorrhoid exams are usually painless. Also, your doctor is accustomed to caring for this sort of problem, which is very common.
If you seem to have enlarged hemorrhoids, the doctor will probably recommend a proctoscopy. During a proctoscopy, a short tube with light and a lens will be used to examine the membranes lining your rectum. This will let your doctor see the enlarged hemorrhoids and determine their size. Again, this procedure is usually painless.
The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, the rectal examination is more helpful in excluding rare cancers that begin in the anal canal and adjacent rectum.
A more thorough examination for internal hemorrhoids is done visually using an anoscope, which is similar to a proctoscope, but smaller. Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude other important causes of bleeding other than hemorrhoids such as
- colon cancer,
- polyps, and
External hemorrhoids appear as a bump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Any lump needs to be carefully followed, however, and should not be assumed to be a hemorrhoid since there are rare cancers of the anal area that may masquerade as external hemorrhoids.
Treating enlarged hemorrhoids is important, because they tend to get worse over time. Hemorrhoids are treated with a variety of measures including diet, over-the-counter medicine like
- pads, and
and various procedures like
- rubber band ligation, and
Individuals with hemorrhoids should soften their stools by increasing the fiber in their diets.
Fiber is found in numerous foods, including
- fresh and dried fruits,
- grains, and
In general, 20 to 30 grams of fiber per day is recommended, whereas the average American diet contains less than 15 grams of fiber. Supplemental fiber like the following:
- methylcellulose, and
- calcium polycarbophil
also may be used to increase the intake of fiber. Stool softeners and increased drinking of liquids also may be recommended. Nevertheless, the benefits of fiber, liquids, and stool softeners have not been well-tested with respect to hemorrhoidal control in scientific studies.
Products used to treat hemorrhoids are available as
- foams, and
When used around the anus, ointments, creams, and gels should be applied as a thin covering. When applied to the anal canal, these products should be inserted with a finger or a "pile pipe." Pile pipes are most efficient when they have holes on the sides as well as at the end. Pile pipes should be lubricated with ointment prior to insertion. Suppositories or foams do not have advantages over ointments, creams, and gels.
A sitz bath refers to sitting in a few inches of warm water three times a day for 15 to 20 minutes. A sitz bath may help decrease the inflammation of hemorrhoids. Drying off the anal area completely after each sitz bath is important for minimizing moisture that irritates the skin surrounding the anus.
Stool softeners may help, but once hemorrhoids are present, even liquid stools may cause inflammation and infection of the anus. Your health care professional and pharmacist are good resources for discussing the use of stool softeners as hemorrhoid treatments.
Sclerotherapy is one of the oldest forms of treatment for hemorrhoids. During sclerotherapy, a liquid (phenol or quinine urea) is injected into the base of the hemorrhoid.
The veins thrombose, inflammation sets in, and ultimately scarring takes place. Ultimately sclerotherapy causes the hemorrhoid to shrink. Pain may occur after sclerotherapy, but usually subsides by the following day. Symptoms of hemorrhoids frequently return after several years and may require further treatment.
The principle of ligation with rubber bands is to encircle the base of the hemorrhoidal clump with a tight rubber band. The tissue cut off by the rubber band dies, and is replaced by an ulcer that heals with scarring.
A similar procedure was described in 460 BC by the Greek physician Hippocrates:
“And hemorrhoids … you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not foment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of Hellebore.”
Rubber band ligation can be used with first-, second-, and third-degree hemorrhoids, and may be more effective than sclerotherapy. Symptoms frequently recur several years later, but usually can be treated with further ligation.
The most common complication of ligation is pain. However, bleeding one or two weeks after ligation or bacterial infection in the tissues surrounding the hemorrhoids (cellulitis) may occur.
There are several treatments that use heat to destroy hemorrhoidal tissue, and promote inflammation and scarring, including
- bipolar diathermy,
- direct-current electrotherapy, and
- infrared photocoagulation.
Such procedures destroy the tissues in and around the hemorrhoids and cause scar tissue to form. They are used with first-, second-, and third-degree hemorrhoids. Pain is frequent, though probably less frequent than with ligation, and bleeding occasionally occurs. Other methods such as laser and radiowave ablation have been done. Non-surgical treatments are usually done on hemorrhoids graded I to II and some grade III; you should discuss the treatment and its projected outcome and recurrence rates with your doctor.
The vast majority of patients can manage their symptom-causing hemorrhoids with non-surgical techniques. Non-operative treatment is preferred because it is associated with less pain and fewer complications than operative treatment. It is estimated that fewer than 10% of patients require surgery if the hemorrhoids are treated early.
Surgical removal of hemorrhoids, known as a hemorrhoidectomy or stapled hemorrhoidectomy, is reserved for patients with third- or fourth-degree hemorrhoids.
History of Hemorrhoid Surgeries
Surgery for hemorrhoids dates back to ancient times. Ancient Greeks, Romans, and Indians all described surgeries used to alleviate the pain and discomfort of enlarged hemorrhoids. These procedures improved greatly by the 13th century, and surgical treatments accelerated once again in the 19th century.
During a hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are cut out. The wounds left by the removal may be sutured (stitched) together (closed technique) or left open (open technique). The results with both techniques are similar.
A proctoplasty, which extends the removal of tissue higher into the anal canal so that redundant or prolapsing anal lining is also removed, is sometimes also performed. Postsurgical pain is a major problem with hemorrhoidectomy, and potent pain medications (narcotics) are usually required.
The stapled hemorrhoidectomy is a newer surgical technique that is rapidly becoming the treatment of choice for third-degree hemorrhoids. This surgery does not remove the hemorrhoids, but rather the expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward.
This procedure involves several steps:
- A circular, hollow tube is inserted into the anal canal and a suture (a long thread) is placed through it and woven circumferentially within the anal canal above the internal hemorrhoids.
- The ends of the suture are brought out of the anus through the hollow tube.
- The stapler is placed through the hollow tube and the ends of the suture are pulled, expanding the hemorrhoidal supporting tissue into the jaws of the stapler.
- The hemorrhoidal cushions are pulled back up into their normal position within the anal canal.
- The stapler is then fired, cutting off the circumferential ring of expanded hemorrhoidal supporting tissue trapped within the stapler.
- At the same time staples bring together the upper and lower edges of the cut tissue.
Stapled hemorrhoidectomy is less painful and faster than a traditional hemorrhoidectomy. It takes approximately 30 minutes to perform.
The best way to prevent hemorrhoids is to keep your stools soft so they are easy to pass and don't require straining. Eating a high-fiber diet and drinking plenty of fluids (six to eight glasses each day) can help you stay regular and keep your stools soft, and may reduce constipation and the need to strain on the toilet, lowering your risk of developing new hemorrhoids.
IMAGES PROVIDED BY:
- Getty Images
- Getty Images
- Armin Kübelbeck licensed under the Creative Commons Attribution 3.0 Unported license.
- Mikael Häggström
- Getty Images
- Getty Images
- Getty Images
- Hemorrhoids: By Andrea C. Bafford, M.D. and Ronald Bleday, M.D
- Medscape - Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
- Medscape - Images reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
- Getty Images
- eMedicineHealth: Hemorrhoids
© 2005 - 2013 WebMD, LLC. eMedicineHealth. All rights reserved.
Source article on eMedicineHealth
- Harper, Douglas, PhD. “Hemorrhoids.” Online Etymology Dictionary.
- Informed Health Online. “Enlarged Hemorrhoids: Overview.”
- Journal of Surgical Technique and Case Report. “Surgical Management of Hemorrhoids.”
- MedicineNet: Hemorrhoids
© 1999 - 2013 MedicineNet, Inc. All rights reserved.
Source article on MedicineNet
- National Institute of Health. “Hemorrhoids.”
- Villalba, Herman, MD, et al. “Hemorrhoids: Modern Remedies for an Ancient Disease.” Permanente Journal.
- WebMD: Hemorrhoid Surgery
© 2005 - 2013 WebMD, LLC. All rights reserved.
Source article on WebMD
- WebMD: Understanding Hemorrhoids - The Basics
© 2005 - 2013 WebMD, LLC. All rights reserved.
Source article on WebMD