Overview of Hemorrhoids

Internal hemorrhoids (also called piles) are a common condition in which venous structures inside the rectum and anus become swollen due to increased pressure. Problematic hemorrhoids can be treated with over-the-counter (OTC) remedies, but in more severe cases, surgery may be required to alleviate discomfort—this is especially the case if a blood clot has formed, or the hemorrhoids have become a chronic issue.

The term "hemorrhoid" refers to engorged or thrombosed veins inside and outside the anus, within and beyond the anal verge. Hemorrhoidal veins are normal veins that everyone has, and they cushion the tissue. Hemorrhoids, on the other hand, are the abnormal growths that occur.

Sometimes hemorrhoids are both internal and external (mixed). In some cases, hemorrhoids that were inside the rectum can protrude out of the anus and become externally visible. (These are called prolapsed hemorrhoids and they are still considered internal hemorrhoids.)

While hemorrhoids have sometimes been described as varicose veins, the conditions are different, so the terms should not be used interchangeably. (Anorectal varicose veins can develop due to certain conditions, such as portal hypertension, and should be evaluated independently of hemorrhoids.)

Hemorrhoids that have become swollen or inflamed may not cause any symptoms at all. However, when symptoms are present, they can range from mild to severe. Symptoms can also depend on whether the hemorrhoids are internal, external, or mixed. Common symptoms of hemorrhoids include:

• Internal: Painless rectal bleeding (blood is bright red and may drip into the toilet bowl or be present on toilet paper when wiping)
• External: A feeling of fullness or discomfort in the rectum
• Both: The sensation of needing to defecate even when the bowel is empty
• External: Pain in the rectum (which may be sharp, sudden, and severe if a blood clot has formed)
• External: Anal pain and discomfort (more noticeable if hemorrhoids have prolapsed)
• Both: Itching and/or mucous discharge from the anus
• Both: In some cases, other anorectal conditions such as anal fissures

It is important to note that internal hemorrhoids usually can't be felt, while external ones often can be. Painless bleeding is usually an indicator of internal hemorrhoids.

Hemorrhoids are not a dangerous condition and rarely lead to any serious health complications. However, because there are other more serious anorectal disorders that can cause similar symptoms, including cancer, it's important to have the problem evaluated by a health provider if symptoms are persistent and do not respond to treatment at home.

Many people are too embarrassed about having hemorrhoids to seek care, but the condition is extremely common all over the world and can be easily treated in most cases.

Hemorrhoids seem to affect men and women equally and typically occur during middle age, though younger people can develop them as well. Hemorrhoids affect people worldwide, but the exact incidence isn't known.

Many people never mention hemorrhoids to their doctor; they might be embarrassed or are able to manage the condition without additional medical intervention. Some people may not even know they have hemorrhoids because they never have symptoms.

People get hemorrhoids for a variety of reasons. There are most likely multiple factors that contribute to hemorrhoidal development throughout a person's life. Experts believe some factors make a person more likely to develop hemorrhoids, including:

• A family history of hemorrhoids
• Straining to have a bowel movement
• Staying on the toilet for long periods of time
• Inflammatory Bowel Disease (IBD)
• Obesity
• Constipation
• Diarrhea
• Laxative or enema overuse
• Prolonged sitting (such as in an office setting)

Several conditions related to other body systems can also predispose a person to hemorrhoids. Some of these risk factors are temporary, such as pregnancy, and hemorrhoids that develop due to these causes often resolve with the condition.

Other conditions that can lead to hemorrhoids include chronic coughing, pelvic floor dysfunction, and connective tissue disorders.

A health care provider will usually be able to diagnose hemorrhoids based on a history of symptoms and a physical exam. A doctor may want to rule out other more serious conditions that can have similar symptoms as hemorrhoids.

External hemorrhoids can be diagnosed upon visual inspection, whereas internal hemorrhoids are diagnosed with an anoscopy, sigmoidoscopy, and/or colonoscopy.

The tests are not so much to confirm a diagnosis of hemorrhoids, but to exclude other diagnoses such as cancer or inflammatory bowel disease. (It's also possible for a person to have hemorrhoids and other conditions at the same time.)

Tests that a doctor may order when evaluating hemorrhoids and other anorectal conditions include:

• Colonoscopy
• Blood tests
• Flexible sigmoidoscopy
• Exam with an anoscope or proctoscope
• Stool sample tests to look for blood, infection, and/or inflammation

When a diagnosis of hemorrhoids is made, a doctor will indicate what type they are (internal, external, or mixed) and may assign them a grade based on the degree of prolapse (external visibility). The grading system for internal hemorrhoids has four stages:

• Grade I. No prolapse
• Grade II. Prolapse only when bearing down. These reduce on their own.
• Grade III. Prolapse when bearing down. These can be manually reduced.
• Grade IV. Prolapsed, do not reduce on their own, and cannot be reduced manually.

Hemorrhoids that are grade IV may also become strangled, form clots (thrombosis), or become ulcerated, which can lead to severe pain.

Several conditions can cause symptoms similar to hemorrhoids, such as discomfort, bleeding, and anorectal lumps, and may need to be ruled out. Some of these conditions are benign, but others may be quite serious.

Other conditions a doctor may want to rule out when diagnosing hemorrhoids include warts, skin tags, proctitis, anal fissure, abscesses, rectal prolapse, and enlarged, dilated veins (varices) of the rectum and anus due to a condition such as increased portal vein blood pressure.

In some people, especially those who are over the age of 45 and have a family history of colorectal cancers, a doctor may want to rule out cancer as a cause for symptoms.

Hemorrhoids often don't cause any problems and people may not even realize they have them. If a person has hemorrhoids but no symptoms, no treatment is needed. If hemorrhoids cause pain or recur frequently, more definitive treatment may be necessary.

Luckily, there are many different options for managing hemorrhoids ranging from at-home and over-the-counter treatments to surgical procedures. There are also many steps a person can take to reduce their risk of developing hemorrhoids and help prevent them from coming back.

The easiest and most affordable treatments for symptoms associated with hemorrhoids can be made or performed at home or purchased over-the-counter. These include:

• Topical creams, ointments, or wipes (such as Tucks)
• Warm sitz baths (20 minutes in the tub after having a bowel movement)
• Using ice packs to help reduce swelling
• Maintaining proper anal and perianal hygiene
• Avoiding prolonged sitting when possible or using a cushion to ease pain and discomfort
• Having a bowel movement as soon as you feel the urge rather than holding it
• Not spending prolonged periods of time on the toilet and avoiding straining
• Avoiding heavy lifting or other activities that strain the abdominal muscles

Some people find it helpful to establish a bowel routine. This may include setting a specific time of day (such as after breakfast) to give themselves time to go to the bathroom and attempt to have a bowel movement.

Several lifestyle changes and adjustments can be made to not just relieve the symptoms of hemorrhoids, but help prevent them from returning after treatment—or, these tips may even lessen someone's chance of getting hemorrhoids in the first place.

While certain factors (such as heredity) can't be changed, there are other risk factors for hemorrhoids that a person can change by proactively developing healthier habits.

Getting more exercise, standing when possible, or otherwise avoiding prolonged sitting is ideal. Note, however, that not all exercise is beneficial—extreme exercise with a lot of straining or Valsalva maneuvers (which involves forceful exhalation) and weightlifting can even worsen hemorrhoids.

Especially if overweight or obese, making changes to your diet and activity level to promote healthy weight loss also helps with the management of hemorrhoids. Be sure to drink plenty of water, too, as dehydration can cause constipation (leading to hemorrhoids).

Stool softeners may be helpful for preventing constipation (which can lead to hemorrhoids), but stimulate laxatives and enemas should not be overused, as they can lead to or even worsen hemorrhoids.

If chronic or frequent diarrhea is causing hemorrhoids, finding out the cause of the bowel changes (such as a food allergy or a condition such as Crohn's Disease) and treating it will help treat the hemorrhoids as well.

There are several procedures that can be used to surgically treat hemorrhoids, and a doctor will help a patient decide which option is best.

Rubber Band Ligation

Also called "banding," this procedure cuts off the blood supply to the tissue. After about a week, the tissue withers and the hemorrhoid falls off. Some medical professionals can perform the procedure in the office, while others will prefer to do it in an operating room.

There is minimal recovery involved, and patients usually can go home and resume normal activity on the same day.

Cautery Procedures

Using infrared radiation technology, cryotherapy, electrocautery, and lasers are also sometimes used to treat hemorrhoids that have not responded to home remedies and banding procedures.

Sclerotherapy

Sclerotherapy injects chemicals into the tissue to make the vein shrink. While it's a quick procedure that can be done in the doctor's office, it isn't always a permanent fix.

Hemorrhoidectomy

This definitively treats severe hemorrhoids by surgically removing them completely. Recovery from the procedure can be very painful and there are potential complications, including damage to the muscles that control the bowel.

There are several other surgical techniques that can potentially be used to treat hemorrhoids. If a medical professional believes a person's hemorrhoids need surgical treatment, they will work with the patient to review the available treatment options and pick the one that is best-suited to the individual's case.

Internal hemorrhoids (also called piles) are a common condition affecting men and women of all ages around the world. While most cases of hemorrhoids can be treated at home with over-the-counter remedies, severe cases may require surgery. If you believe you may have hemorrhoids, it is best to speak with your doctor. Even if you do not have hemorrhoids, you may have another medical condition with similar symptoms.