Hemorrhoids are usually caused by increased pressure due to pregnancy, being overweight, or straining during bowel movements. By midlife, hemorrhoids often become an ongoing complaint. By age 50, about half the population has experienced one or more of the classic symptoms, which include rectal pain, itching, bleeding, and possibly prolapse (hemorrhoids that protrude through the anal canal). Although hemorrhoids are rarely dangerous, they can be a recurrent and painful intrusion. Fortunately, there’s a lot we can do about hemorrhoids.
Hemorrhoids (HEM-uh-roids), also called piles, are swollen veins in your anus and lower rectum, similar to varicose veins. Hemorrhoids can develop inside the rectum (internal hemorrhoids) or under the skin around the anus (external hemorrhoids).
Nearly three out of four adults will have hemorrhoids from time to time. Hemorrhoids have a number of causes, but often the cause is unknown.
Fortunately, effective options are available to treat hemorrhoids. Many people get relief with home treatments and lifestyle changes.
Hemorrhoids are when the veins or blood vessels in and around your anus and lower rectum become swollen and irritated. This happens when there is extra pressure on these veins.
Hemorrhoids can be either inside your anus (internal) or under the skin around your anus (external).
Hemorrhoidal venous cushions are normal structures of the anorectum and are anatomically present unless a previous intervention has taken place. Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology. Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding.
Although hemorrhoids are a common condition diagnosed in clinical practice, many patients are too embarrassed to seek treatment. Consequently, the true prevalence of pathologic hemorrhoids is not known. In addition, although hemorrhoids are responsible for a large portion of anorectal complaints, it is important to rule out more serious conditions, such as other causes of gastrointestinal (GI) bleeding, before reflexively attributing symptoms to hemorrhoids.
In a study of 198 physicians from different specialties, Grucela et al found the rate of correct identification for seven common, benign anal pathologic conditions (including anal abscess, fissure, and fistula; prolapsed internal hemorrhoid; thrombosed external hemorrhoid; condyloma acuminata; and full-thickness rectal prolapse) was greatest for condylomata and rectal prolapse and was lowest for hemorrhoidal conditions. There was no correlation between diagnostic accuracy and years of physician experience. The investigators found the overall diagnostic accuracy among the physicians to be 53.5%, with the accuracy for surgeons being 70.4% and that for the rest of the doctors being less than 50%.
What Should You Know About Hemorrhoids?
What Are the Symptoms of Hemorrhoids?
Symptoms of hemorrhoids include:
- extreme itching around the anus
- irritation and pain around the anus
- itchy or painful lump or swelling near your anus
- fecal leakage
- painful bowel movements
- blood on the tissue after having a bowel movement
Although hemorrhoids are painful, they aren’t life threatening and often go away on their own without treatment.
If you ever have bleeding or black bowel movements, however, you should see your doctor. Bleeding can be caused by something other than hemorrhoids and must be evaluated.
It is important to remember that rectal bleeding or blood in the stool is never normal and, while it may come from a relatively benign cause like hemorrhoids, more serious causes can be life-threatening. These include bleeding from ulcers, diverticulitis, inflammatory bowel disease, and tumors. If rectal bleeding occurs, it is important to contact your health care professional or seek emergency medical care. This is especially important if the person is taking blood-thinning medications.
When internal hemorrhoid becomes inflamed, it can cause swelling. This in itself does not cause pain because there are no pain fibers attached to the veins above the pectinate line. Passing a hard stool can scrape off the thinned lining of hemorrhoids causing painless bleeding. However, swollen hemorrhoids can also cause spasm of the muscles that surround the rectum and anus causing pain, especially if they protrude or prolapse through the anus. A lump can be felt at the anal verge. Internal hemorrhoids can also thrombose (clot) leading to severe pain.
Inflamed hemorrhoids can leak mucus that can cause inflammation of the skin surrounding the anus causing burning and itching, known as pruritis ani. However, other causes of itching include yeast and other skin infections and parasites like pinworms. Most importantly, just as blood in the stool should not be ignored because it might be a sign of colon cancer, anal itching or bleeding should not be presumed to be due to hemorrhoids because it can be a sign of anal cancer tumor.
External hemorrhoids behave differently since they are covered by “regular skin” and have pain fibers associated with them. A thrombosed external hemorrhoid occurs when an underlying vein within the hemorrhoid clots off causing intense pain from the rapid stretching of the skin covering hemorrhoids. A hard painful lump can be felt at the anus. External hemorrhoids can also result in excess skin tags that can be felt at the anal verge and can cause difficulties with cleaning after a bowel movement, leading to secondary skin infections.
What Causes Hemorrhoids?
While the presence of hemorrhoids is a reflection of the normal anatomy, most people and care professionals refer to hemorrhoids as an abnormal finding because they only present when they swell and cause problems.
Hemorrhoid swelling occurs when there is an increase in the pressure in the small vessels that make up hemorrhoids causing them to swell and engorge with blood. This causes them to increase in size leading to symptoms. Increased pressure may be caused by a variety of factors:
- A low-fiber diet and smaller caliber stool cause a person to strain when having a bowel movement, increasing the pressure within the blood vessels.
- Pregnancy is associated with hemorrhoid swelling and is likely due to increased pressure of the enlarged uterus on the rectum and anus. In addition, hormonal changes with pregnancy may weaken the muscles that support the rectum and anus.
- Prolonged sitting on the toilet may increase pressure within the hemorrhoid blood vessels.
- Diarrhea, both acute and chronic
- Colon cancer
- Previous rectal surgery
- Spinal cord injury and lack of erect posture
Your doctor will ask about your medical history and symptoms. They’ll probably need to do one or both of these examinations:
- Physical exam. Your doctor will look at your anus and rectum to check for lumps, swelling, irritation, or other problems.
- Digital rectal exam. Your doctor will put on gloves, apply lubrication, and insert a finger into your rectum to check muscle tone and feel for tenderness, lumps, or other problems.
To diagnose internal hemorrhoids or rule out other conditions, you might need a more thorough test, including:
- Anoscopy. Your doctor uses a short plastic tube called an anoscope to look into your anal canal.
- Sigmoidoscopy. Your doctor looks into your lower colon with a flexible lighted tube called a sigmoidoscope. They can also use the tube to take a bit of tissue for tests.
- Colonoscopy. Your doctor looks at all of your large intestine with a long, flexible tube called a colonoscope. They can also take tissue samples or treat other problems they find.
Dramatic relief for most hemorrhoid symptoms can be found with simple, home remedies for hemorrhoids. To avoid occasional flare-ups, try the following.
Get more fiber. Add more fiber to your diet from food, a fiber supplement (such as Metamucil, Citrucel, or Fiber Con), or both. Along with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids. High-fiber foods include broccoli, beans, wheat and oat bran, whole-grain foods, and fresh fruit. Fiber supplements help decrease hemorrhoidal bleeding, inflammation, and enlargement. They may also reduce irritation from small bits of stool that are trapped around the blood vessels. Some people find that boosting fiber causes bloating or gas. Start slowly, and gradually increase your intake to 25–30 grams of fiber per day. Also, increase your fluid intake.
Exercise. Moderate aerobic exercise, such as brisk walking 20–30 minutes a day, can help stimulate bowel function.
Take time. When you feel the urge to defecate, go to the bathroom immediately; don’t wait until a more convenient time. Stool can back up, leading to increased pressure and straining. Also, schedule a set time each day, such as after a meal, to sit on the toilet for a few minutes. This can help you establish a regular bowel habit.
Sitz. A sitz bath is a warm water bath for the buttocks and hips (the name comes from the German “sitzen,” meaning “to sit”). It can relieve itching, irritation, and spasms of the sphincter muscle. Pharmacies sell small plastic tubs that fit over a toilet seat, or you can sit in a regular bathtub with a few inches of warm water. Most experts recommend a 20-minute sitz bath after each bowel movement and two or three times a day in addition. Take care to gently pat the anal area dry afterward; do not rub or wipe hard. You can also use a hair dryer to dry the area.
Seek topical relief for hemorrhoids. Over-the-counter hemorrhoid creams containing a local anesthetic can temporarily soothe pain. Witch hazel wipes (Tucks) are soothing and have no harmful effects. A small ice pack placed against the anal area for a few minutes can also help reduce pain and swelling. Finally, sitting on a cushion rather than a hard surface helps reduce the swelling of existing hemorrhoids and prevents the formation of new ones.
Treat the clot. When an external hemorrhoid forms a blood clot, the pain can be excruciating. If pain is tolerable and the clot has been present for longer than two days, apply home treatments for the symptoms while waiting for it to go away on its own. If the clot is more recent, the hemorrhoid can be surgically removed or the clot withdrawn from the vein in a minor office procedure performed by a surgeon.
The risk of developing hemorrhoids is greatly reduced when stools are kept soft. This can be helped in the following ways:
- Nutrition: Eating plenty of foods rich in fiber, such as fruits and vegetables, as well as whole grains, means stools will nearly always be soft. Similarly, drinking plenty of fluids helps keep stools soft. OTC fiber supplements also ease constipation.
- Avoiding over-straining: When using the toilet, try not to strain. This creates pressure in the veins in the lower rectum.
- Going to the toilet when needed: People should not wait if they need to use the toilet. The longer the wait, the drier the stools will be.
- Physical activity: Sitting or standing still for long periods puts pressure on the veins. Physical activity also helps stool move through the bowel, so bowel movements are more regular.
- Maintaining a healthy body weight: Being overweight significantly raises the risk of having hemorrhoids.
using over-the-counter (OTC) hemorrhoid creams or suppositories (medications inserted into the rectum) for around 1 week before talking to a healthcare professional
using OTC laxatives or stool softeners
avoiding lifting heavy objects when possible and lifting with the knees
trying to avoid straining during bowel movements, holding in bowel movements, or sitting on the toilet too long
staying hydrated by drinking water, fruit juices, clear soups, or other liquids that may help fiber from foods work better
using OTC pain medications
taking a sitz bath, sitting in a bath of warm water, several times daily
maintaining a body weight within the recommended healthful range
avoiding having anal intercourse
getting enough exercise