Facts about hemorrhoids
Hemorrhoids are enlarged and swollen blood vessels located in the lower part
of the rectum and the anus. The blood vessels become swollen due to increased
pressure within them.
- Hemorrhoids usually are caused by
increased pressure within the lower abdomen. Some potential causes include
- straining at the time of bowel movement (this may be due to
constipation or profuse
hemorrhoids are located on the inside lining of the rectum and
cannot be felt unless they prolapse and push through the anus opening
causing pain and itching.
- External hemorrhoids are located beneath the skin on the outer aspect of the anus.
bleeding with a bowel movement and a mass or fullness that can be felt at
the anal opening.
- A thrombosed external hemorrhoid occurs when blood within the blood vessel clots, and may cause
- External and internal hemorrhoids are
diagnosed by a physical exam and history by a health-care professional.
Sigmoidoscopy or colonoscopy may be ordered to look for other causes of blood in
- Several treatments are available for
hemorrhoids, and include home remedies, for example, over-the-counter (OTC) medicine like
stool softeners and creams or suppositories to shrink and decrease inflammation
of the hemorrhoid tissue); changes in the diet; Sitz baths; exercise; or
- Hemorrhoids can be prevented by keeping
the stools soft, by regular exercise, eating a high fiber diet, drinking plenty
of fluids; avoiding straining with bowel movements, and trying to avoid sitting
for long periods of time, especially on the toilet.
How do you know if you have a hemorrhoid?
The most common signs and symptom is painless bleeding. There may be
bright red blood on the outside of the stools, on the toilet paper, or dripping
into the toilet. The bleeding usually is self-limiting.
What are the signs and symptoms of an internal or prolapsed hemorrhoid?
Most often, internal hemorrhoids have no symptoms but are only found if there is bleeding with a bowel movement or if the hemorrhoid prolapses so that it can be felt outside of the anus. This may lead to itching and pain as well as the bleeding.
Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell and extend from their
location in the rectum through the anus. A prolapsed internal hemorrhoid:
- Can be felt as a lump outside the anus
- Can be gently pushed back through the anus, this may resolve the
location of the hemorrhoid, but does not fix the hemorrhoid itself
- May enlarge and swell even more if it cannot be pushed back
- May become entrapped, which requires more urgent medical attention
Hemorrhoids may also cause
anal itching (pruritus ani), and
a constant feeling of needing to have a bowel movement (tenesmus).
Internal hemorrhoid severity can be graded:
- Grade I: Prominent blood vessels with no prolapse
- Grade II: Prolapse with bearing down but with spontaneous reduction
- Grade III: Prolapse with bearing down but requiring manual reduction
- Grade IV: Prolapse with inability to manual reduction
What are the signs and symptoms of an external or thrombosed hemorrhoid?
Thrombosed external hemorrhoids are a painful condition. These occurs when a
blood clot develops in a hemorrhoidal
blood vessel causing swelling and inflammation.
- When a blood clot occurs in a hemorrhoid, the hemorrhoid will become even
more swollen. This swelling leads to increased pain.
- The pain is usually worse with bowel movements and may increase with
A thrombosed external hemorrhoid may resolve on its own; however, this
condition often needs medical care. Bleeding with a bowel movement is never normal and should prompt a visit to a
health-care professional. While hemorrhoids are the most common cause of
bleeding with a bowel movement, there may be other
reasons for bleeding including
inflammatory bowel disease, infection, and
Common Causes of Rectal Pain
The four common causes of the symptom of rectal pain, pressure, or discomfort are
- anal fissures,
- fleeting anal spasms (Proctalgia fugax), and
- other more constant muscle spasms (Levator ani syndrome).
What is the difference between an internal, external, or thrombosed hemorrhoid?
- An internal hemorrhoid is a swollen blood vessel that arises from within the rectum above the pectinate line. It causes no
symptoms unless there is bleeding with a bowel movement, or if it prolapses and can be felt
externally after if protrudes through the anus.
- An external hemorrhoid arises from blood vessels that surround the anus beyond the pectinate line. They do not cause many
problems unless they rapidly expand and clot. Usually this clot resolves spontaneously leaving residual skin.
- A thrombosed external hemorrhoid occurs when the blood clot that forms in an
external hemorrhoid does not resolve causing increased swelling and pain within the hemorrhoidal tissue.
What causes hemorrhoids?
Hemorrhoids are not arteries or veins, but instead are normal blood vessels called sinusoids that are located in the walls that surround the rectum and anus. When the venous pressure within these blood vessels increases, the
hemorrhoids swell and dilate, because it is more difficult for blood to empty from them. This leads to the most common symptoms of bleeding and swelling.
Common situations that increase pressure within the hemorrhoidal blood vessels
and lead to abnormalities include the following.
- Straining to have a bowel movement. This may be due to constipation or diarrhea.
- Prolonged sitting, including on the toilet
- Lack of exercise
- Low fiber diet
- Colon cancers
- Liver disease
- Inflammatory bowel disease
- Anal intercourse
- Spinal cord injury
an internal, external, prolapsed, and thrombosed hemorrhoids
When to seek medical care for hemorrhoids
When to call the doctor
- Bleeding from the rectum or anus is never normal and although hemorrhoids
are the most common reason to have blood in the stool, it should be discussed
with your primary health-care professional. Other causes of
rectal bleeding exist and can
be serious. Inflammatory bowel disease and
cancers of the colon can present with
rectal bleeding. Blood in the stool should never be ignored.
- Medical care should be sought urgently if a person is taking anticoagulation medications such as warfarin (Coumadin), dabigatran (Pradaxa), rivaroxiban (Xarelto), apixaban (Eliquis), clopidogrel (Plavix), prasugrel (Effient) or enoxaparin (Lovenox).
- Individuals who have associated symptoms such as lightheadedness and weakness may
have significant blood loss and may require more urgent care.
- Hemorrhoids do not cause abdominal pain; should this
pain be present with
bleeding, medical care should be sought immediately.
- Prolapsed hemorrhoids that cannot be pushed back through the anus require
- Thrombosed external hemorrhoids may cause significant pain and medical care
may be necessary to remove the clot.
Which specialties of doctors treat hemorrhoids?
Hemorrhoids are a common problem and most often may be treated by a primary care provider, internist, emergency or urgent care provider. Surgeons may need to operate to remove enlarged or inflamed hemorrhoids.
How are hemorrhoids diagnosed?
Diagnosis of hemorrhoids is usually made by history and physical examination
by the health-care professional. Inspection of the anus and a digital rectal
examination are often performed. Depending upon the situation, past medical
history, medications and stability of the patient, treatment may follow with no
- Internal hemorrhoids may not be diagnosed by physical exam; they may not be able
to be felt, even by digital rectal exam.
- Prolapsed internal and external
hemorrhoids may be visualized when the health-care professional examines the anus.
thrombosed external hemorrhoid can be diagnosed just by looking at it.
If there is concern that significant bleeding has occurred, a
complete blood count
(CBC) to measure
blood hemoglobin and
and platelet count is obtained. If the patient is on warfarin (Coumadin), a prothrombin time (PT) or INR may be done to measure the blood clotting levels.
How do you get rid of hemorrhoids?
There are several natural home remedies, for example warm Sitz baths, dietary changes, stool
to treat hemorrhoids. OTC or prescription medicine or surgery may be required to repair the hemorrhoids,
for example, rubber band ligation, sclerotherapy, laser therapy, hemorrhoidectomy, and
What natural home remedies soothe or cure hemorrhoids?
Hemorrhoid symptoms of pain and itching can be treated at home by doing the
Warm Sitz Baths
- Sitting in a few inches of warm water three times a day for 15 to 20 minutes
may help decrease the inflammation of the hemorrhoids.
- It is important to dry off the anal area completely after each Sitz bath to
minimize irritation of the skin surrounding the anus.
- Increased fluid intake and dietary fiber (roughage) will decrease the potential for
constipation and lessen the pressure on the rectum and anus during a bowel
movement, minimizing further swelling, discomfort, and bleeding. Dietary
fiber supplements also
may help bulk up the stools
- Stool softeners may help. A health-care professional or a pharmacist are good resources to discuss their use.
- Individuals with hemorrhoids should not sit for long periods of time and may
benefit from sitting on an air or rubber donut available at most local
- Exercise is helpful in relieving constipation and in decreasing pressure on
the hemorrhoidal veins. Individuals should be encouraged to have a bowel movement
as soon as possible after the urge arises and not sit on the toilet for long
periods of time. Once that urge passes, stools can
become constipated and straining with a bowel movement may occur.
What is the medical treatment for hemorrhoids?
Over-the-Counter (OTC) Medications
- Many creams, ointments, and suppositories are available for symptom relief
and may be used for comfort. However, they do not "cure" hemorrhoids. Often
they contain a numbing medication or a corticosteroid to decrease inflammation
Prolapsed Internal Hemorrhoids Treatment
- Most prolapsed internal hemorrhoids can be pushed back into the anus, but
occasionally your health-care professional may need to reduce them by gently pushing them
with constant pressure.
- If the hemorrhoids remain swollen and trapped outside the anus and they
are not treated, the hemorrhoid tissue may not receive enough blood and can
become infected. In such situations, surgery may be required to resolve the
Thrombosed Hemorrhoids Treatment
- Thrombosed external hemorrhoids can be painful and are associated with a
hard lump that is felt at the anus and cannot be pushed back inside. Most often
the clot within the hemorrhoid will need to be removed with a small incision.
- After local anesthetic is placed under the skin surrounding the hemorrhoid,
a scalpel is used to cut into the area and the clot is removed. There is almost
instant relief of the sharp pain but a dull ache may continue.
- There may be some mild bleeding from the hemorrhoid for a couple of days.
Sitz baths and over-the-counter pain medications may be recommended.
- The use of a rubber or air rubber donut may help with the pain, and preventing constipation is a priority.
Internal Hemorrhoid Treatments
Unless there is bleeding an internal hemorrhoid may have no symptoms. Once there is bleeding and/or prolapse and the diagnosis is made, home remedies are most often used to control symptoms. If bleeding increases or there is
difficulty in reducing prolapsed hemorrhoids, referral to a surgeon is often made to discuss more aggressive treatment options.
External Hemorrhoid Treatment
Treatment of external hemorrhoids usually addresses the hygiene issue, where excess skin tags makes it difficult to properly clean the anus area after a bowel movement. If this becomes a significant issue, surgery can be considered to remove the hemorrhoid.
external hemorrhoids may require the clot removed acutely in an office or emergency/urgent care department procedure.
What surgery options are available to treat and cure hemorrhoids?
A variety of surgical options exist for persistent pain or bleeding.
Rubber band ligation:
Rubber band ligation of internal hemorrhoids can be performed in the doctor's office. The surgeon places a couple of tight rubber bands around the base of the hemorrhoidal vein,
which causes it to lose its blood supply. There may be some fullness or discomfort for 1
to 2 days after the procedure, and a minor amount of bleeding may be experienced.
Sclerotherapy: Sclerotherapy describes a procedure when a chemical is injected into the hemorrhoid,
which causes it to scar and decrease in size.
Laser therapy: Laser therapy can be used to scar and harden internal hemorrhoids.
Hemorrhoidectomy: Hemorrhoidectomy is a surgical procedure performed in the operating room with an anesthetic agent (general, spinal or local with sedation) where the whole hemorrhoid is removed (ectomy=removal).
This is the most aggressive approach and there is a markedly decreased chance of
the hemorrhoids returning. There is a potential for complications with this
procedure; however, these occur less than 5% of the time. Complications include
infection, bleeding, and stenosis where scarring causes the anus to narrow.
Stapled hemorrhoidectomy: Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for severe hemorrhoid disease. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids, but instead tightens the abnormally lax hemorrhoidal supporting tissue to prevent the hemorrhoid to prolapse downward. Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return to normal activities and work sooner.
Regardless of the surgery, Sitz baths and dietary suggestions for increased roughage are usually recommended.
What is stapled hemrroidectomy (pictures)?
The following are pictures of the stapled hemorrhoidectomy procedure.
Picture of Internal Hemorrhoids in Anal Canal
Picture of Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids
Picture of Suturing the Anal Canal through the Hollow Tube
Picture of Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by pulling On Suture
Picture of Hemorrhoids Pulled Back Above Anal Canal after Stapling and Removal of Hemorrhoidal Supporting Tissue
Do I need to follow-up with my doctor after being treated for hemorrhoids?
Warm Sitz baths, plenty of fluids and increased roughage are usually recommended. Hemorrhoidal pain is usually managed with over-the-counter pain relievers.
Stool softeners may be recommended by your health-care professional. The person should contact their
health-care professional if they develop increased
rectal pain, bleeding, fever, abdominal pain, or
vomiting after hemorrhoid treatment.
Can hemorrhoids be prevented?
The risk of hemorrhoids can be decreased by preventing constipation by eating a
high fiber diet, staying well hydrated, getting regular exercise, and trying to have a bowel movement as soon as possible after the urge arises.
What's the prognosis for a person with hemorrhoids?
Most people with hemorrhoids have an excellent prognosis. While symptoms of bleeding or discomfort may flare
up from time to time, they don't last long and can be relieved with symptomatic care at home.
Reviewed on 11/20/2017
Rakel RE, Rakel D. "Textbook of Family Medicine." 9th edition. 2015 Saunders.