Haemorrhoids

Haemorrhoids are swollen veins in the lower part of the rectum and around the anus that can cause pain, itching, and bleeding. This common condition affects about half of all people over age 50, but many cases can be managed at home with simple lifestyle changes and treatments.

Table of contents

• What are haemorrhoids?
• Types of haemorrhoids
• Symptoms of haemorrhoids
• What causes haemorrhoids?
• Who is more likely to get haemorrhoids?
• How are haemorrhoids diagnosed?
• Home treatments and lifestyle changes
• Medical and surgical treatments
• Possible complications
• Preventing haemorrhoids

hemorrhoids, piles

What are haemorrhoids?

Haemorrhoids are swollen and inflamed veins in the anus and lower rectum^[1]. In one sense, everyone has haemorrhoids, which are pillow-like clusters of veins that lie just beneath the mucous membranes lining the lowest part of the rectum and the anus^[12]. The condition most of us call haemorrhoids develops when those veins become swollen and distended, similar to varicose veins (swollen veins) in the legs^[1].

Haemorrhoids are among the most common causes of anal pathology and are responsible for a large portion of complaints related to the anal and rectal area^[5]. Despite their frequency, many patients are too embarrassed to seek treatment, so the true prevalence of the condition is not fully known^[5].

• Rectum
• Anus

Types of haemorrhoids

Haemorrhoids can develop inside or outside of your rectum, and the type depends on where the swollen vein forms^[2].

Internal haemorrhoids lie inside the rectum. You usually can’t see or feel them, and they rarely cause discomfort because there are few pain-sensing nerves in that area^[1]. They typically don’t hurt, but they tend to bleed. Many people with internal haemorrhoids don’t know they have them because they’re inside your rectum^[2]. If you have symptoms of internal haemorrhoids, you might see bright red blood on toilet paper, in your stool, or in the toilet^[2].

External haemorrhoids develop under the skin around the anus^[1]. These tend to be more noticeable because they happen outside your anus and are located where there are many more pain-sensing nerves^[2]. External haemorrhoids can be itchy and painful, and occasionally they bleed^[2]. You can usually see or feel external haemorrhoids^[2].

Prolapsed haemorrhoids occur when internal haemorrhoids stretch down and bulge outside of your anal opening^[2]. A haemorrhoid that pushes through the anal opening can result in pain and irritation^[1]. These haemorrhoids may bleed or cause pain, but they usually go back inside your body on their own. Even if they don’t, they can often be gently pushed back into place^[2].

Thrombosed haemorrhoids develop when a blood clot forms inside an external haemorrhoid^[1]. These types are usually painful and cause a purple or blue lump to form outside of your anus^[2]. A thrombosed haemorrhoid can result in severe pain, swelling, inflammation, and a hard, discolored lump near the anus^[1]. The clot only affects your anus and doesn’t move to other parts of your body^[2].

Symptoms of haemorrhoids

Symptoms of haemorrhoids usually depend on the type^[1]. Each person’s symptoms may vary^[4].

Internal haemorrhoids rarely cause pain and typically can’t be felt unless they prolapse^[2]. The most common symptom is painless bleeding during bowel movements. You might notice small amounts of bright red blood on your toilet tissue or in the toilet^[1].

External haemorrhoids are more noticeable and can cause several symptoms^[2]:

• Itching or irritation in the anal area^[1]
• Pain or discomfort, especially when sitting^[2]
• Swelling around the anus^[1]
• Hard lumps near your anus that feel sore or tender^[2]
• Bleeding when you wipe^[2]
• A feeling like you still need to have a bowel movement after going to the toilet^[6]
• Mucus in your underwear or on toilet paper after wiping^[6]

A thrombosed haemorrhoid causes similar symptoms like swelling, inflammation, and pain, but it’s typically much more severe and sudden^[2]. The pain can be sudden and severe when blood pools inside an external haemorrhoid^[1].

Non-thrombosed external haemorrhoids are usually the color of your skin and are soft to the touch. Thrombosed external haemorrhoids may appear blue, black, or purple and be firmer to touch, and they’re often more painful^[2].

What causes haemorrhoids?

Haemorrhoids develop when too much pressure builds up on the veins in your anus or rectum^[2]. This pressure and irritation lead to swelling and inflammation of your veins^[2]. Anything that puts pressure on the veins in your rectum and anus can lead to haemorrhoids^[4].

Traditionally, haemorrhoids are associated with chronic constipation, straining during bowel movements, and prolonged sitting on the toilet — all of which interfere with blood flow to and from the area, causing it to pool and enlarge the vessels^[12]. More recent studies show that patients with haemorrhoids tend to have a higher resting anal canal tone — that is, the smooth muscle of the anal canal tends to be tighter than average even when not straining^[12].

Common activities or conditions that cause pressure and lead to or worsen haemorrhoids include^[2]:

• Straining during bowel movements — this is a major cause^[4]
• Sitting on the toilet for long periods^[3]
• Having chronic constipation or diarrhea^[3]
• Straining when lifting heavy objects^[2]
• Obesity or being overweight^[4]
• Pregnancy, when the growing baby puts pressure on the veins in the lower abdomen and pelvis^[4]. Hormonal changes during pregnancy can also contribute^[4]
• A low-fiber diet^[4]
• Repeatedly lifting heavy items^[4]
• Anal sex^[7]

Constipation adds to these troubles because straining during a bowel movement increases pressure in the anal canal and pushes the haemorrhoids against the muscle^[12]. Finally, the connective tissues that support and hold haemorrhoids in place can weaken with age, causing haemorrhoids to bulge and prolapse^[12].

Who is more likely to get haemorrhoids?

Haemorrhoids are very common. An estimated 1 in 20 Americans have haemorrhoids that are bothersome^[2]. They affect people of all ages, races, and ethnicities, and are common in both men and women^[2][3].

Haemorrhoids are more common as you age, affecting more than half of people over age 50^[2][3]. About half of adults older than age 50 have experienced one or more of the classic symptoms^[12].

You are more likely to get haemorrhoids if you^[3]:

• Strain during bowel movements
• Sit on the toilet for long periods of time
• Have chronic constipation or diarrhea
• Eat foods that are low in fiber
• Are older than age 50
• Are pregnant
• Often lift heavy objects

Some people may also be predisposed to developing haemorrhoids due to genetics^[4].

How are haemorrhoids diagnosed?

Haemorrhoids can usually be diagnosed from a simple medical history and physical exam^[12]. A healthcare professional might be able to see external haemorrhoids during a physical examination^[8]. External haemorrhoids are generally apparent, especially if a blood clot has formed^[12].

Diagnosing internal haemorrhoids might include an exam of your anal canal and rectum^[8]:

Digital rectal exam: A healthcare professional places a gloved, lubricated finger into your rectum. This allows your health professional to check for anything that’s not usual, such as growths^[8].

Visual exam: Internal haemorrhoids are often too soft for a healthcare professional to feel during a rectal exam. The health professional might look at the lower part of your colon and rectum with a tool such as an anoscope (a short tube inserted into the rectum with light), a proctoscope, or a sigmoidoscope^[8].

A healthcare professional might want to look at your entire colon using colonoscopy (a procedure to view the inside of the large bowel) if^[8]:

• Your symptoms suggest that you might have another digestive system disease
• You have risk factors for colorectal cancer
• You are middle-aged and haven’t had a recent colonoscopy

If there’s evidence of rectal bleeding or microscopic blood in the stool, flexible sigmoidoscopy or colonoscopy may be performed to rule out other causes of bleeding^[12].

Home treatments and lifestyle changes

Many people get relief from haemorrhoids with home treatments and lifestyle changes^[1]. You can often lessen the mild pain, swelling, and inflammation of haemorrhoids with these approaches^[8].

Dietary changes: Eat more foods that are high in fiber, such as fruits, vegetables, and whole grains. This helps soften the stool and increases its bulk, which can help you avoid straining^[8]. Fiber can also reduce the chance of straining during bowel movements^[18]. You may also want to take a fiber supplement such as psyllium or methylcellulose^[10]. Add fiber to your diet slowly to avoid problems with gas^[8].

Stay hydrated: Drink water or other nonalcoholic liquids each day as recommended by your health care professional^[10]. Drinking plenty of fluid helps keep stools soft^[6].

Good bathroom habits: When you feel the urge to have a bowel movement, go to the bathroom immediately — don’t wait for a more convenient time^[14]. Putting off bowel movements can worsen constipation, which then aggravates haemorrhoids^[14]. Don’t strain during bowel movements and don’t push too hard when going to the toilet^[6]. Don’t sit on the toilet for long periods of time^[10]. Spend no more than five minutes on the toilet^[17].

Try elevation: Elevating your feet a bit with a step stool as you sit on the toilet changes the position of the rectum in a way that may allow for easier passage of stools^[4].

Soak in warm water: Soak your anal area in plain warm water for 10 to 15 minutes two or three times a day^[8]. A sitz bath is a shallow tub designed to soak just the area around the anus. You can fill a sitz bath with warm water or use your regular tub. Adding half a cup of Epsom salts can provide added relief^[18]. After soaking, pat — don’t rub — the affected area with a soft cloth until dry^[18].

Use topical treatments: Apply a haemorrhoid cream or suppository containing hydrocortisone that you can buy without a prescription^[8]. You also can use pads containing witch hazel or a numbing medicine^[8]. Applying over-the-counter haemorrhoid creams or ointments or using suppositories may relieve mild pain, swelling, and itching of external haemorrhoids^[10]. Most often, doctors recommend using over-the-counter products for 1 week^[10].

Use cold packs: Use an ice pack wrapped in a towel to ease discomfort^[6]. Putting a small cold pack on the troubled areas a few times a day can provide temporary relief^[13].

Keep clean and dry: Wipe your bottom with damp toilet paper after bowel movements^[6]. Use plain, unscented wipes, wet tissue, cotton balls, or a bidet to clean yourself^[17]. Don’t wipe your bottom too hard^[6].

Take pain relievers: Take over-the-counter pain relievers such as paracetamol if haemorrhoids hurt^[6]. Don’t take painkillers that contain codeine, as they can cause constipation. Don’t take ibuprofen if your haemorrhoids are bleeding^[6].

Exercise regularly and avoid prolonged sitting: Keep active to help optimize the digestive system and prevent haemorrhoids^[13]. If you sit for too many hours without taking a break, it can place too much pressure on the veins, which can make haemorrhoids worse^[18]. Try to stand up and move around at least once an hour^[18]. Regular exercise can help you manage haemorrhoids by helping combat constipation, preventing prolonged sitting, and helping you manage your weight^[18].

Cut down on alcohol and caffeine: Reducing alcohol and caffeine intake, like tea, coffee, and cola, can help avoid constipation^[6].

Medical and surgical treatments

If home treatments don’t provide relief, you may need medical treatment. If there’s no improvement to your haemorrhoids after home treatments, you may need hospital treatment^[6].

Office-based treatments include procedures that can be performed during a doctor’s visit^[10]:

Rubber band ligation: A doctor places a special rubber band around the base of the haemorrhoid. The band cuts off the blood supply. The banded part of the haemorrhoid shrivels and falls off, most often within a week^[10]. Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III haemorrhoids because of its effectiveness compared with other office-based procedures^[11].

Sclerotherapy: A doctor injects a solution into an internal haemorrhoid, which causes scar tissue to form. The scar tissue cuts off the blood supply, often shrinking the haemorrhoid^[10]. This minimally invasive treatment involves injecting a chemical that causes the haemorrhoid to scar and shrink, resulting in the elimination of bleeding and other symptoms^[13].

Infrared photocoagulation: A doctor uses a tool that directs infrared light at an internal haemorrhoid. Heat created by the infrared light causes scar tissue to form, which cuts off the blood supply, often shrinking the haemorrhoid^[10].

Electrocoagulation: A doctor uses a tool that sends an electric current into an internal haemorrhoid. The electric current causes scar tissue to form, which cuts off the blood supply, often shrinking the haemorrhoid^[10].

Surgical treatments may be needed for recurrent or higher-grade disease^[11]. You’ll usually need to be asleep for this type of treatment and may need to stay in hospital for more than 1 day^[6]:

Haemorrhoidectomy: This involves cutting out the haemorrhoids^[6]. This is effective for the treatment of grade III or IV, recurrent, or highly symptomatic haemorrhoids^[11]. Excisional haemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures^[11].

Stapled haemorrhoidopexy: This procedure involves stapling the haemorrhoids back inside your anus^[6]. Stapled haemorrhoidopexy elevates grade III or IV haemorrhoids to their normal position by removing a band of tissue^[11].

Haemorrhoidal artery ligation: Stitches are used to cut the blood supply to your haemorrhoids to make them shrink^[6]. This may be useful in grade II or III haemorrhoids because patients may experience less pain and recover more quickly^[11].

Excision of thrombosed external haemorrhoids: Excision of thrombosed external haemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms^[11].

Possible complications

Although haemorrhoids are rarely dangerous, they can be a recurrent and painful intrusion^[12]. Complications of haemorrhoids can include^[3]:

• Blood clots in an external haemorrhoid
• Skin tags — extra skin left behind when a blood clot in an external haemorrhoid dissolves
• Infection of a sore on an external haemorrhoid
• Strangulated haemorrhoid — when the muscles around your anus cut off the blood supply to an internal haemorrhoid that has fallen through your anal opening
• Anemia — a condition where you don’t have enough healthy red blood cells

Preventing haemorrhoids

The best way to prevent haemorrhoids is to keep your stools soft so they pass easily and to avoid straining^[1]. Many of the lifestyle changes used to treat haemorrhoids can also help prevent them^[2]:

• Eat foods high in fiber
• Drink plenty of fluids
• Avoid straining during bowel movements
• Don’t ignore the urge to have a bowel movement
• Exercise regularly
• Avoid prolonged sitting
• Maintain a healthy weight
• Don’t sit on the toilet for long periods

Eating more fiber and avoiding straining can help prevent haemorrhoids^[2].