Hemorrhoids
Topic Overview
What are hemorrhoids?
Hemorrhoids are swollen veins in the anal canal. This common problem can be painful, but it’s usually not serious.
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. You can have both types at the same time. The symptoms and treatment depend on which type you have.
Many people have hemorrhoids at some time.
What causes hemorrhoids?
Too much pressure on the veins in the pelvic and rectal area causes hemorrhoids.
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. This can cause hemorrhoids.
Diarrhea or constipation also may lead to straining and can increase pressure on veins in the anal canal.
Pregnant women can get hemorrhoids during the last 6 months of pregnancy. This is because of increased pressure on the blood vessels in the pelvic area. Straining to push the baby out during labor can make hemorrhoids worse.
Being overweight can also lead to hemorrhoids.
What are the symptoms?
The most common symptoms of both internal and external hemorrhoids include:
- Bleeding during bowel movements. You might see streaks of bright red blood on toilet paper after you strain to have a bowel movement.
- Itching.
- Rectal pain. It may be painful to clean the anal area.
Internal hemorrhoids
With internal hemorrhoids, you may see bright red streaks of blood on toilet paper or bright red blood in the toilet bowl after you have a normal bowel movement. You may see blood on the surface of the stool.
Internal hemorrhoids often are small, swollen veins in the wall of the anal canal. But they can be large, sagging veins that bulge out of the anus all the time. They can be painful if they bulge out and are squeezed by the anal muscles. They may be very painful if the blood supply to the hemorrhoid is cut off. If hemorrhoids bulge out, you also may see mucus on the toilet paper or stool.
External hemorrhoids
External hemorrhoids can get irritated and clot under the skin, causing a hard painful lump. This is called a thrombosed, or clotted, hemorrhoid.
How are hemorrhoids diagnosed?
Your doctor can tell if you have hemorrhoids by asking about your past health and doing a physical exam.
You may not need many tests at first, especially if you are younger than 50 and your doctor thinks that your rectal bleeding is caused by hemorrhoids. Your doctor may just examine your rectum with a gloved finger. Or your doctor may use a short, lighted scope to look inside the rectum.
Rectal bleeding can be a sign of a more serious problem, such as colon, rectal, or anal cancer. So if the first exam does not show a clear cause of your problems, your doctor may use a lighted scope (sigmoidoscope) to look at the lower third of your colon. Or your doctor may use another kind of scope (colonoscope) to look at the entire colon to check for other causes of bleeding.
How are they treated?
For most external hemorrhoids, home treatment is all you need. This includes slowly adding fiber to your meals, drinking more water, and using over-the-counter ointments for a limited time to stop itching. You also may use stool softeners. The same home treatment can be used for most internal hemorrhoids.
If your internal hemorrhoids are severe, you may need other treatment. The doctor may tie off the hemorrhoids with rubber bands or scar the tissue around the hemorrhoids. These treatments reduce the blood supply to the hemorrhoids so that they shrink or go away.
Surgery to remove hemorrhoids may be done if other treatments don’t work.
Healthy habits can help you prevent hemorrhoids or keep them from getting worse. Eat foods that have lots of fiber, such as fruits, vegetables, and whole grains. Also, drink plenty of water, and get plenty of exercise.
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Cause
Hemorrhoids are usually caused by increased pressure on the veins in the pelvic and rectal area. As pressure increases, blood pools in veins and causes them to swell. Eventually, the swollen veins stretch the surrounding tissue, and hemorrhoids develop.
Bowel habits that can cause increased pressure and lead to hemorrhoids include:
- Rushing to complete a bowel movement. Hurrying can lead to excessive straining and can increase pressure on rectal veins.
- Persistent diarrhea or constipation, which may cause straining and increase pressure on veins in the anal canal.
Other things that can lead to the development of hemorrhoids include:
- Being overweight. Excess weight, especially in the abdomen and pelvis, may increase pressure on pelvic veins.
- Pregnancy and labor. Hormonal changes during pregnancy increase blood flow to the pelvis and relax supportive tissues while the growing fetus causes increased pressure on blood vessels. During labor, hemorrhoids may develop because of the intense pressure on the anal area while pushing to deliver the baby.
- Medical conditions. For example, long-term heart and liver disease may cause blood to pool in the abdomen and pelvic area, enlarging the veins.
Symptoms
Bleeding during bowel movements, itching, and rectal pain are the most common hemorrhoid symptoms.
External hemorrhoids
Rectal pain occurs mainly with external hemorrhoids. Blood may pool under the skin, forming a hard, painful lump. This is called a thrombosed, or clotted, hemorrhoid. You might also notice streaks of blood on the toilet paper after straining to pass a stool.
Internal hemorrhoids
The most common symptom of internal hemorrhoids is rectal bleeding. You may find bright red streaks of blood on the toilet paper or bright red blood in the toilet bowl after having a normal bowel movement. Blood also may be visible on the surface of the stool.
Other symptoms of internal hemorrhoids may include:
- Itching. This is a frequent complaint, because internal hemorrhoids often seep mucus, which can irritate the anal skin and cause itching.
- Skin irritation. Large hemorrhoids that bulge from the anus may secrete mucus, causing mild irritation.
- Discomfort. You may still feel the urge to pass stool right after having a bowel movement. This uncomfortable feeling is caused by the bulging of the hemorrhoid in the end portion of the large intestine (anal canal). In general, the larger the hemorrhoid, the greater the discomfort.
- Pain. Most internal hemorrhoids are not painful. But large hemorrhoids that bulge from the anus may become painful if they swell and are squeezed by the muscles that control the anus. Severe pain may be a sign that the blood supply to the hemorrhoid is being cut off (strangulated hemorrhoid). Emergency treatment is needed.
Rectal bleeding and pain and recent changes in bowel habits are also symptoms of colon, rectal, or anal cancer. People who have these symptoms, especially those age 50 or older or those with a family history of colon cancer, need to talk to their doctors.
Other conditions with symptoms similar to hemorrhoids include:
- Anal fissure or anal fistula.
- Anorectal abscess.
- Colon polyp.
- Inflammatory bowel disease, particularly Crohn’s disease.
- Rectal prolapse.
What Happens
Hemorrhoids form when increased pressure on the pelvic veins causes veins in the anal canal to swell and gradually stretch out of shape. Pressure increases can be caused by rushing to complete a bowel movement, persistent diarrhea or constipation, or other factors including being overweight or pregnant.
Persistent pressure also weakens tissues that support the veins in the anal canal. If those tissues become so weak that they can no longer hold the veins in place, the swollen veins and tissues bulge into the anal canal (internal hemorrhoids) or under the skin surrounding the anal opening (external hemorrhoids).
For some people, hemorrhoids may cause a little discomfort for a limited time. Other people have recurrent bouts of discomfort when hemorrhoids flare up. Some people struggle with hemorrhoid pain, discomfort, and itching much of their lives. The degree and duration of discomfort depend on where the hemorrhoids are.
Hemorrhoids frequently develop during pregnancy because of extra pressure on veins (from the enlarged uterus).
During labor, hemorrhoids may start or get worse because of the intense straining and pressure on the anal area while pushing to deliver the baby. For more information, see the topic Pregnancy.
External hemorrhoids
Because external hemorrhoids may not cause any symptoms, you may not be aware that you have hemorrhoids.
When a vein within an external hemorrhoid gets irritated, blood may clot under the skin, forming a hard, bluish lump. This is known as a thrombosed, or clotted, hemorrhoid. Thrombosed hemorrhoids can be very painful.
Internal hemorrhoids
Small internal hemorrhoids may not grow larger if bowel habits or other factors change to lower pressure on the veins in the bowel.
Large internal hemorrhoids may bulge from the anus. After bowel movements, you may have to push them back through the anus. At worst, large internal hemorrhoids stick out all the time.
In rare cases, hemorrhoids may bulge through the anus and swell. Muscles that control the opening and closing of the anus may cut off a hemorrhoid’s blood supply (strangulated hemorrhoid). This may cause the hemorrhoid tissues to die. If this happens, you will feel severe rectal pain and may see blood and pus at the anus. You will need urgent surgery to prevent further complications, such as death of the affected tissue and infection.
What Increases Your Risk
Bowel habits, physical stresses, and other conditions can raise the risk of developing hemorrhoids or make existing hemorrhoids worse. Some of these factors can be prevented.
Things that increase your risk
- Constipation or diarrhea that does not go away. These conditions may lead to straining with bowel movements.
- Being overweight
- A family history of hemorrhoids. You may inherit the tendency to get them.
- Being age 50 or older. Half of people who are older than 50 seek treatment for hemorrhoids.
- Pregnancy and labor and delivery. As the fetus grows during the last 6 months of pregnancy, blood volume and pressure on pelvic blood vessels increase. The strain of labor also can cause hemorrhoids to start or get worse.
- Liver disease, heart disease, or both. These conditions may cause blood to back up in the pelvis and abdomen.
Things that may make hemorrhoids worse
Hemorrhoids may be made worse by:
- Prolonged sitting or standing. This may cause blood to pool in the anal area and increase pressure on the veins.
- Frequent heavy lifting or holding your breath when lifting heavy objects. This can cause a sudden increase of pressure in blood vessels.
When should you call your doctor?
Common symptoms of hemorrhoids may be a sign of other serious health problems. Colon or rectal cancer and other conditions have many of the same symptoms as hemorrhoids. Call your doctor if you have symptoms like these:
- Stools are black or tarry.
- A lump or bulge that is not tender and does not go away develops at the anal opening.
If you have hemorrhoids, call your doctor if:
- Moderate rectal pain lasts longer than 1 week after home treatment.
- Pain or swelling is severe.
- Tissue from inside the body bulges from the anus and does not return to normal after 3 to 7 days of home treatment.
- A lump inside the anus becomes bigger or more painful.
If rectal bleeding becomes heavy or changes color (such as from bright red to dark red), or if stools change size, shape, or color (from brown to maroon or black), be sure to see your doctor.
Watchful waiting
Watchful waiting is a wait-and-see approach. And in most cases, bleeding caused by hemorrhoids should stop after 2 to 3 days. Continue home treatment to prevent bleeding from starting again. Call your doctor if bleeding:
- Occurs for more than 1 week without improvement.
- Starts again.
- Occurs when there is no reason to expect it.
If you are older than age 50 or have a family history of colon cancer, it is a good idea to tell your doctor any time you have new rectal bleeding, notice blood on your stools, have changes in bowel habits, or have anal pain. These symptoms may be signs of colon cancer or other conditions. Your doctor may recommend screening tests to see if you have a more serious problem. See Exams and Tests.
Who to see
The following professionals can evaluate and treat hemorrhoids:
- Family medicine doctor
- Internist
- Nurse practitioner
- Physician assistant
- Obstetrician
- Gastroenterologist
- Gynecologist
- General surgeon
If medical treatment or surgery is needed, you may be referred to a:
- Gastroenterologist.
- General or colorectal surgeon.
- Doctor who specializes in problems affecting the rectum and anus (proctologist).
Exams and Tests
A doctor can evaluate symptoms of hemorrhoids to rule out other, more serious problems. A number of conditions that affect the anus and colon (large intestine) can cause bleeding, mucus drainage, itching, and discomfort. Most people who have these symptoms think they have hemorrhoids, but often they do not.
If hemorrhoids are present, the doctor will evaluate their location and size and develop a treatment plan based on the hemorrhoids’ degree of severity.
The diagnosis of hemorrhoids is based on a medical history and physical exam. A digital rectal exam and an anoscopy may be the only tests needed at first. Your doctor will decide which tests to use. If hemorrhoids are the obvious cause of rectal bleeding, you are younger than age 50, and you do not have risk factors for colon cancer, you may not need more tests.
To make sure nothing else (like colon cancer) is causing your symptoms, you may need other tests, such as:
- Flexible sigmoidoscopy. This test allows a doctor to look inside the anus, rectum, and lower part of the large intestine (colon) for abnormal growths or other signs of disease.
- Barium enema.
- Colonoscopy.
These tests are not used routinely to diagnose hemorrhoids.
Treatment Overview
Most hemorrhoids can be treated with simple changes to diet and bowel habits. Most do not require surgery or other treatment unless the hemorrhoids are very large and painful.
The goal of nonsurgical procedures used to treat hemorrhoids, called fixative procedures, is to reduce the blood supply to the hemorrhoid so it shrinks or goes away. The scar tissue left in its place helps support the anal tissue and helps prevent new hemorrhoids.
Fixative procedures include tying off the hemorrhoids with a rubber band (rubber band ligation) or using heat, lasers, or electric current to create scar tissue (coagulation therapy). Fixative procedures can only be done on internal hemorrhoids.
Surgical removal of hemorrhoids (hemorrhoidectomy) can be used for large internal hemorrhoids, when several small hemorrhoids are present, or when other treatments have not controlled bleeding. Sometimes a combination of treatments (for example, a fixative procedure and a hemorrhoidectomy) is the most effective way to treat hemorrhoids. External hemorrhoids can only be removed surgically, if needed. If a blood clot develops in the external hemorrhoid, the clot may need to be removed to relieve pain.
Hemorrhoidectomy versus fixative procedures for internal hemorrhoids
- Fixative procedures are usually tried before surgery if hemorrhoids are small and stick out of the anus during a bowel movement but return to their normal position afterward (second-degree hemorrhoid).
- Hemorrhoidectomy may provide better long-term results than fixative procedures. But surgery is more expensive, requires a longer recovery time, is usually more painful, and has a greater risk of complications.
- Fixative procedures are the preferred treatment for people older than age 70 and for people in poor health.
Prevention
You can help prevent the irritating and painful symptoms of hemorrhoids.
Avoid constipation
- Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber.
- Drink plenty of fluids, enough so that your urine is light yellow or clear like water.
- Get some exercise every day. Try to do moderate activity at least 2½ hours a week. Or try to do vigorous activity at least 1¼ hours a week. It’s fine to be active in blocks of 10 minutes or more throughout your day and week.
- Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Read and follow all directions on the label.
Practice healthy bowel habits
- Go to the bathroom as soon as you have the urge.
- Avoid straining to pass stools. Relax and give yourself time to let things happen naturally.
- Avoid holding your breath while passing stools.
- Avoid reading while sitting on the toilet. Get off the toilet as soon as you have finished.
Modify your daily activities
- Avoid prolonged sitting or standing. Take frequent short walks.
- If possible, avoid lifting heavy objects frequently. If you must lift heavy objects, always exhale as you lift the object. Don’t hold your breath when you lift.
- If you are pregnant, sleeping on your side will lower pressure on the blood vessels in your pelvis. This can help keep hemorrhoids from becoming bigger.
Home Treatment
Home treatment, which mainly involves establishing healthy bowel habits, may keep your hemorrhoids from getting worse.
You can use the following suggestions to keep hemorrhoids from getting worse or to relieve your symptoms.
Avoid making hemorrhoids worse
- Blot the anus gently with white toilet paper moistened with water or a cleansing agent (such as Balneol) after bowel movements. Baby wipes or other premoistened towels (such as Tucks or Preparation H) are also useful for this purpose.
- Avoid rubbing the anal area. You can rinse off in the shower or on a bidet instead of wiping yourself with toilet paper. After cleansing, gently pat the anal area dry with a soft, absorbent towel or cloth.
- Use soaps that contain no perfumes or dyes.
Relieve pain and itching
- Take nonprescription pain relievers. Acetaminophen (Tylenol) can help with pain. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) and naproxen (Aleve) can help with pain and swelling. Be safe with medicines. Read and follow all instructions on the label.
- Apply ice several times a day for 10 minutes at a time. Follow this by placing a warm compress on the anal area for another 10 to 20 minutes.
- Take a sitz bath. Fill your bathtub with just enough warm water to cover the anal area. Do this several times a day, especially after you have had a bowel movement. Soak for about 15 minutes at a time. Be careful! If the water is too warm, it can burn you.
Use nonprescription medicines as recommended by your doctor or pharmacist. See Medications for information on nonprescription ointments, creams, and suppositories.
Other comfort measures
- You may need a day or more of bed rest to take pressure off inflamed, irritated veins. If you are pregnant, you may find it helpful to lie on your side. If you are not pregnant, sleeping on your stomach with a pillow under your hips will help reduce swelling of hemorrhoids.
- Try not to sit or stand for a long time when hemorrhoids are irritated. If you must sit for a long time, sit on a pillow. Avoid lifting heavy objects.
- Wear cotton underwear to prevent moisture buildup, which can irritate hemorrhoids. Wear loose clothing to allow freedom of movement and to reduce pressure on the anal area.
Medications
Medicines can help relieve symptoms of hemorrhoids. You might try one or more of the following nonprescription remedies.
- Ointments that protect the skin, such as zinc oxide or petroleum jelly, are the best nonprescription remedies for hemorrhoids. Ointments can prevent further injury and reduce itching by forming a barrier over hemorrhoids.
- Use suppositories, such as those made by Preparation H or Tucks (formerly Anusol), for 7 to 10 days to relieve irritation and to lubricate the anal canal during bowel movements. Some of these products contain substances that can harm anal tissues if they are used for too long.
- Apply an ointment that contains 1% hydrocortisone, a type of steroid medicine that may relieve inflammation and itching. Your doctor may prescribe 2.5% hydrocortisone. But these products should not be used for more than 2 weeks, because they can thin the skin.
- Apply products that contain medicine to numb an area (local anesthetic). These products often have the suffix “-caine” in the name or the ingredients. Although these products help some people, especially those who have painful external hemorrhoids, some people become allergic to them. Ask your doctor before using these products.
- Take nonprescription pain relievers. Acetaminophen (Tylenol) can help with pain. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) and naproxen (Aleve) can help with pain and swelling. Be safe with medicines. Read and follow all instructions on the label.
Surgery
Most hemorrhoids do not require surgery. It is usually considered only for severe hemorrhoids.
Surgery may be done if other treatments (including home treatment) have failed. Surgery is also considered when symptoms become so bothersome that your lifestyle is affected or when hemorrhoids create a medical emergency, such as uncontrolled bleeding or blood and pus at the anus along with severe rectal pain.
External hemorrhoids
External hemorrhoids usually are not removed with surgery (hemorrhoidectomy) except if they are very large and uncomfortable or if you are having surgery on the anal area for another reason, such as internal hemorrhoids or a tear (anal fissure). If a blood clot develops in the external hemorrhoid, the clot may need to be removed to relieve pain.
Internal hemorrhoids
Surgical removal of hemorrhoids (hemorrhoidectomy) is a last resort for treating small internal hemorrhoids.
Hemorrhoidectomy is considered the most successful way to treat large internal hemorrhoids, especially those that are still a problem after treatments that cut off blood flow to hemorrhoids (fixative procedures) have been tried.
What to think about
Sometimes, increased pressure on external hemorrhoids causes them to get irritated and to clot. This causes a lump (thrombosed, or clotted, hemorrhoid) to form. You may suffer from severe pain at the site of a clotted hemorrhoid.
A procedure to relieve the pain can be done in a doctor’s office or outpatient clinic. The doctor applies local anesthesia and then makes a small incision where the lump has occurred to remove the clot and reduce pressure and pain. The procedure works best if it is done soon after the clot has formed.
If the pain is tolerable, you may choose to wait to see a doctor. The pain usually goes away in a few days. After 4 or 5 days, the pain from cutting and draining the hemorrhoid is usually worse than the pain from the clot.
Other Treatment
Many people who have hemorrhoids find relief from symptoms through home treatment. If medical treatment is needed, fixative procedures are the most widely used nonsurgical treatments. Fixative procedures are only for internal hemorrhoids.
Other treatment choices
Fixative procedures include:
- Rubber band ligation, a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow so that the hemorrhoid shrinks and dies and, in about a week, falls off.
- Coagulation with light (infrared photocoagulation), lasers, or electricity, which creates scar tissue, cutting off the blood supply to the hemorrhoid so that it shrinks and dies.
What to think about
Not all doctors have the experience or the equipment to do all types of fixative procedures. This may help you decide which procedure to choose. Ask your doctor which procedure he or she does the most and how satisfied people have been with the outcomes of that procedure.
References
Other Works Consulted
- Dozois EJ, Pemberton JH (2006). Hemorrhoids and other anorectal disorders. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 945–958. Philadelphia: Saunders Elsevier.
- Madoff RD (2016). Diseases of the rectum and anus. In L Goldman, A Schafer, eds., Goldman-Cecil Medicine, 25th ed., vol.1, pp. 967–973. Philadelphia: Saunders.
- Marcello PW (2010). Diseases of the anorectum. In M Feldman et al., eds., Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th ed., vol. 2, pp. 2257–2274. Philadelphia: Saunders.
- Rivadeneira DE, et al. (2011). Practice parameters for the management of hemorrhoids. Diseases of the Colon and Rectum, 549(9): 1059–1064. Available online: http://www.fascrs.org/physicians/practice_parameters.
Current as of: November 7, 2018
Author: Healthwise Staff
Medical Review:Anne C. Poinier, MD – Internal Medicine & Adam Husney, MD – Family Medicine & E. Gregory Thompson, MD – Internal Medicine & Kenneth Bark, MD – General Surgery, Colon and Rectal Surgery
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