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.
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.
The most common symptoms of both internal and external hemorrhoids include:
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 can get irritated and clot under the skin, causing a hard painful lump. This is called a thrombosed, or clotted, hemorrhoid.
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.
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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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:
Other things that can lead to the development of hemorrhoids include:
Bleeding during bowel movements, itching, and rectal pain are the most common hemorrhoid symptoms.
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.
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:
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:
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.
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.
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.
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.
Hemorrhoids may be made worse by:
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:
If you have hemorrhoids, call your doctor if:
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:
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:
These tests are not used routinely to diagnose hemorrhoids.
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.
You can help prevent the irritating and painful symptoms of hemorrhoids.
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.
Use nonprescription medicines as recommended by your doctor or pharmacist. See Medications for information on nonprescription ointments, creams, and suppositories.
Medicines can help relieve symptoms of hemorrhoids. You might try one or more of the following nonprescription remedies.
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 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.
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.
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.
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.
Fixative procedures include:
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.
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.
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