Hemorrhoids: Symptoms, Causes & Treatment Options

What Are Hemorrhoids?

Hemorrhoids (also called piles) are swollen blood vessels in the rectum and anus that can cause bleeding, itching, pain, and a feeling of fullness. They occur when the supportive tissues in the anal canal weaken and the blood vessels enlarge, either remaining inside the rectum (internal hemorrhoids) or protruding outside (external hemorrhoids).

Hemorrhoids develop when the blood vessels and surrounding supportive tissue in the lower rectum and anus become swollen and inflamed. This occurs because the veins in this area are under constant pressure from standing, sitting, and during bowel movements. When this pressure becomes excessive or prolonged, the vessel walls stretch and the supporting connective tissue weakens, leading to hemorrhoid formation.

The condition is extremely common, affecting approximately 50% of adults over age 50 at some point in their lives. However, hemorrhoids can occur at any age and are increasingly seen in younger adults due to sedentary lifestyles and dietary factors. While hemorrhoids can cause significant discomfort, they are rarely dangerous and typically respond well to conservative treatment.

Understanding the anatomy helps explain why hemorrhoids occur. The anal canal contains two types of blood vessel cushions: internal hemorrhoidal plexuses located above the dentate line (where the rectum meets the anus), and external hemorrhoidal plexuses below this line. When these cushions become enlarged, they cause the symptoms we associate with hemorrhoids.

Internal vs. External Hemorrhoids

Hemorrhoids are classified based on their location relative to the dentate line, the anatomical boundary between the rectum and anus. This distinction is important because it affects both symptoms and treatment approaches.

Internal hemorrhoids develop inside the rectum, above the dentate line. Because this area has few pain-sensing nerves, internal hemorrhoids are typically painless even when bleeding. They are classified into four grades based on severity:

• Grade I: Hemorrhoids that bleed but do not prolapse (protrude outside the anus)
• Grade II: Hemorrhoids that prolapse during bowel movements but return on their own
• Grade III: Hemorrhoids that prolapse and require manual repositioning
• Grade IV: Hemorrhoids that are permanently prolapsed and cannot be pushed back in

External hemorrhoids develop under the skin around the anus, below the dentate line. This area is rich in pain-sensing nerves, so external hemorrhoids can be quite painful, especially if a blood clot forms within them (thrombosed hemorrhoid). They appear as lumps near the anal opening and may cause itching, burning, and discomfort.

Many people have both internal and external hemorrhoids simultaneously, a condition known as mixed hemorrhoids. This combination can make symptoms more complex and may require a comprehensive treatment approach addressing both types.

What Are the Symptoms of Hemorrhoids?

The most common symptoms of hemorrhoids include painless bleeding during bowel movements (bright red blood on toilet paper or in the bowl), itching or irritation around the anus, pain or discomfort, swelling near the anus, and a lump or bulge that may be felt during cleaning. Symptoms vary depending on whether hemorrhoids are internal or external.

Hemorrhoid symptoms can range from barely noticeable to significantly impacting quality of life. The most characteristic symptom is painless bleeding during bowel movements, typically noticed as bright red blood on toilet paper, in the toilet bowl, or coating the stool. This bleeding occurs because the swollen blood vessels are easily damaged during the passage of stool.

Beyond bleeding, hemorrhoids can cause a constellation of symptoms that affect daily comfort and hygiene. The specific symptoms experienced depend largely on the type and severity of hemorrhoids present. Understanding these symptoms helps distinguish hemorrhoids from other conditions and guides appropriate treatment.

It's important to note that symptoms can fluctuate over time. Many people experience periods of improvement followed by flare-ups, often triggered by changes in diet, activity level, or bowel habits. This cyclical pattern is characteristic of hemorrhoidal disease and responds well to consistent preventive measures.

Common Symptoms by Type

The symptoms you experience depend largely on whether you have internal or external hemorrhoids:

When Symptoms Indicate Something More Serious

While hemorrhoids are common and usually benign, certain symptoms warrant prompt medical attention. Rectal bleeding, though often caused by hemorrhoids, can also indicate other conditions including colorectal cancer, inflammatory bowel disease, or anal fissures. You should seek medical evaluation if:

• You experience rectal bleeding for the first time, regardless of amount
• Bleeding is heavy, persistent, or accompanied by dizziness
• You notice changes in bowel habits lasting more than a few weeks
• Pain is severe or doesn't improve with home treatment
• You're over 50 and haven't had a recent colonoscopy

What Causes Hemorrhoids?

Hemorrhoids are caused by increased pressure on the blood vessels in the rectal area. The most common causes include chronic constipation and straining during bowel movements, prolonged sitting (especially on the toilet), pregnancy, obesity, heavy lifting, low-fiber diet, and aging. These factors weaken the supportive tissue and cause blood vessels to swell.

The fundamental cause of hemorrhoids is increased pressure within the hemorrhoidal blood vessels. This pressure causes the vessel walls to stretch, the supporting connective tissue to weaken, and eventually the hemorrhoidal cushions to prolapse. Understanding what creates this excessive pressure is key to both treating existing hemorrhoids and preventing future occurrences.

The anal canal is designed to maintain continence while allowing the passage of stool. The hemorrhoidal cushions play a crucial role in this function, acting as vascular pillows that help seal the anal canal. When these cushions are subjected to repeated or sustained pressure, they become enlarged and symptomatic. The underlying mechanism involves both vascular engorgement (increased blood filling the vessels) and deterioration of the supporting connective tissue.

Multiple factors typically combine to cause hemorrhoids. While a single episode of straining rarely causes permanent hemorrhoids, repeated strain over time progressively weakens the supporting structures. This is why lifestyle modifications targeting multiple risk factors are so effective in both treatment and prevention.

Primary Risk Factors

Chronic constipation is the leading cause of hemorrhoids. When stool is hard and difficult to pass, straining increases intra-abdominal pressure, which is transmitted directly to the hemorrhoidal vessels. This straining also prolongs time spent on the toilet, further increasing pressure. Studies show that people with chronic constipation are significantly more likely to develop hemorrhoids compared to those with regular bowel habits.

Prolonged sitting, particularly on the toilet, contributes to hemorrhoid development in two ways. First, the seated position increases pressure on the anal cushions. Second, the shape of the toilet seat creates a "squatting gap" that allows the hemorrhoidal tissues to bulge downward. Spending more than 10-15 minutes on the toilet significantly increases hemorrhoid risk. Reading or using phones on the toilet extends sitting time and should be avoided.

Pregnancy is a major risk factor for hemorrhoids, affecting up to 35% of pregnant women. Several factors contribute: the growing uterus puts pressure on pelvic blood vessels, increased blood volume causes vessel expansion, progesterone relaxes vessel walls, and constipation is common during pregnancy. The straining of labor and delivery can also cause or worsen hemorrhoids. Fortunately, pregnancy-related hemorrhoids often improve within a month after delivery.

Diet low in fiber leads to harder stools that require more straining to pass. The typical Western diet provides only about half the recommended 25-35 grams of daily fiber. Without adequate fiber, stool moves slowly through the colon, becoming harder and more difficult to evacuate. Insufficient fluid intake compounds this problem by further hardening stool.

Contributing Factors

Obesity increases intra-abdominal pressure, which is transmitted to the pelvic floor and hemorrhoidal vessels. Excess weight also often correlates with reduced physical activity and poorer dietary choices, both of which contribute to constipation. Weight loss, when indicated, can significantly reduce hemorrhoid symptoms.

Age is an important factor because the supporting tissues in the anal canal naturally weaken over time. By age 50, the connective tissue that helps anchor hemorrhoidal cushions has lost much of its elasticity and strength. This explains why hemorrhoids become increasingly common with advancing age, even in people without other risk factors.

Heavy lifting and physical exertion that involves straining can contribute to hemorrhoid development. Activities that require holding the breath while bearing down (Valsalva maneuver) increase abdominal pressure dramatically. Proper lifting technique and breathing during exertion can help minimize this risk.

Certain medications can contribute to constipation and thereby increase hemorrhoid risk. Common culprits include:

• Iron supplements
• Certain pain medications, particularly opioids
• Some antidepressants and psychiatric medications
• Certain blood pressure medications
• Antacids containing aluminum or calcium

When Should You See a Doctor for Hemorrhoids?

See a doctor if you experience rectal bleeding (especially for the first time), symptoms that don't improve after one week of home treatment, severe pain, large external lumps, or if you're over 50 and haven't had a recent colorectal screening. Seek immediate care for heavy bleeding, signs of infection (fever, increasing pain), or feeling faint.

While hemorrhoids are common and often manageable at home, professional medical evaluation is important in several circumstances. The primary concern with rectal bleeding is ensuring it's actually from hemorrhoids and not a more serious condition. Colorectal cancer, inflammatory bowel disease, and other conditions can cause similar symptoms.

For most people with known hemorrhoids and typical symptoms, home treatment is appropriate as the first approach. However, medical evaluation becomes necessary when symptoms are new, severe, persistent, or accompanied by warning signs. Healthcare providers can confirm the diagnosis, rule out other conditions, and recommend appropriate treatment based on the type and grade of hemorrhoids.

Don't let embarrassment prevent you from seeking care. Healthcare providers see hemorrhoid patients regularly, and delaying evaluation of concerning symptoms can lead to missed diagnoses or prolonged discomfort.

Routine Medical Evaluation Is Recommended For:

• First-time rectal bleeding – Even if you suspect hemorrhoids, bleeding should be evaluated to confirm the diagnosis
• Symptoms lasting more than one week despite home treatment
• Recurrent symptoms that keep coming back after initial improvement
• Prolapsing hemorrhoids that protrude during bowel movements
• Changes in stool appearance or bowel habits
• People over age 50 who haven't had recent colorectal cancer screening
• Family history of colorectal cancer or polyps

How Can You Treat Hemorrhoids at Home?

Effective home treatments for hemorrhoids include increasing dietary fiber to 25-35 grams daily, drinking 8-10 glasses of water, taking warm sitz baths for 10-15 minutes several times daily, using over-the-counter creams containing hydrocortisone or witch hazel, avoiding straining, and not sitting on the toilet longer than necessary. Most hemorrhoids improve within 1-2 weeks with consistent self-care.

The majority of hemorrhoids respond well to conservative home treatment, with approximately 90% of cases improving without the need for procedures or surgery. The key to successful home treatment is addressing both immediate symptom relief and the underlying causes that led to hemorrhoid development. A comprehensive approach targeting diet, bowel habits, and local symptom management produces the best results.

Consistency is crucial for home treatment success. Following recommendations for a few days isn't sufficient – most experts recommend maintaining lifestyle changes for at least six weeks to allow hemorrhoidal tissues to heal and to establish new habits that prevent recurrence. The good news is that these same measures that treat hemorrhoids also prevent them from returning.

Dietary Changes

Increase fiber intake gradually to 25-35 grams daily. Fiber softens stool and adds bulk, making bowel movements easier and reducing strain. Good fiber sources include:

• Fruits: apples, pears, berries, prunes, figs
• Vegetables: broccoli, carrots, leafy greens, Brussels sprouts
• Whole grains: oatmeal, brown rice, whole wheat bread
• Legumes: beans, lentils, chickpeas
• Fiber supplements: psyllium husk, methylcellulose

Increase fiber gradually over 2-3 weeks to minimize bloating and gas. Each increase in fiber should be accompanied by additional water intake.

Drink adequate fluids – aim for 8-10 glasses of water daily. Adequate hydration works with fiber to keep stools soft. Without enough fluid, added fiber can actually worsen constipation. Coffee and alcohol don't count toward fluid goals as they can have dehydrating effects.

Limit constipating foods including white bread, pasta, rice, processed foods, red meat (in excess), and dairy products if they affect your bowel habits. These foods tend to slow transit time and produce harder stools.

Sitz Baths

A sitz bath involves soaking the anal area in warm water for 10-15 minutes. This simple treatment is remarkably effective for symptom relief:

• Warm water relaxes the anal sphincter, reducing pain and spasm
• Increased blood flow promotes healing
• Soaking cleanses the area gently without irritation
• Provides immediate relief from itching and discomfort

Use plain warm (not hot) water. While some people add Epsom salts or baking soda, plain water is equally effective. Take sitz baths 2-3 times daily and after each bowel movement during flare-ups. Gently pat dry afterward – never rub.

Over-the-Counter Treatments

Several types of non-prescription medications can provide symptom relief:

Topical creams and ointments containing hydrocortisone reduce inflammation and itching. These should be used for no more than 2-3 weeks continuously, as prolonged use can thin the skin. Products combining hydrocortisone with lidocaine provide both anti-inflammatory and numbing effects.

Witch hazel pads or wipes provide cooling relief and have mild astringent properties that can reduce swelling. These are particularly useful for external hemorrhoids and can be applied after bowel movements.

Lidocaine preparations temporarily numb the area and are helpful when pain makes bowel movements particularly difficult. These are available as creams, ointments, and suppositories.

Suppositories are particularly useful for internal hemorrhoids, delivering medication directly to the affected area. They work best when inserted after bowel movements and are often used at bedtime.

What Medical Treatments Are Available for Hemorrhoids?

Medical treatments for hemorrhoids include rubber band ligation (most common and effective non-surgical treatment with 70-80% success), sclerotherapy (injection to shrink hemorrhoids), infrared coagulation, and surgical hemorrhoidectomy for severe cases. Treatment choice depends on hemorrhoid type, grade, and symptoms. Most people respond to non-surgical treatments.

When home treatments don't provide adequate relief or hemorrhoids are too advanced for conservative management, medical procedures offer effective solutions. The good news is that modern hemorrhoid treatments are generally well-tolerated, often performed in an office setting, and have high success rates.

Treatment selection depends on several factors: whether hemorrhoids are internal or external, the grade of internal hemorrhoids, severity of symptoms, patient preferences, and any previous treatments tried. Your healthcare provider will recommend the most appropriate option based on your specific situation.

Office-Based Procedures

Rubber band ligation is the most widely used and effective non-surgical treatment for internal hemorrhoids grades I-III. During this procedure, a small rubber band is placed around the base of the hemorrhoid, cutting off its blood supply. The hemorrhoid shrinks and falls off within a week or two, usually without the patient noticing.

The procedure takes just a few minutes, is performed without anesthesia, and most people return to normal activities the same day. Success rates range from 70-80%, though some patients may need repeat treatments. Temporary discomfort and minor bleeding are common after the procedure.

Sclerotherapy involves injecting a chemical solution directly into the hemorrhoid, causing it to shrink. It's typically used for smaller internal hemorrhoids (grades I-II) and is particularly useful for patients taking blood thinners who can't undergo other procedures. The injection causes minimal discomfort, and multiple hemorrhoids can be treated in one session.

Infrared coagulation uses infrared light to create scar tissue, which cuts off blood supply to the hemorrhoid. It's effective for grade I-II hemorrhoids and causes less pain than rubber band ligation, though it may be slightly less effective for larger hemorrhoids.

Surgical Options

Hemorrhoidectomy is surgical removal of hemorrhoid tissue. It's the most effective treatment for severe (grade III-IV) or recurring hemorrhoids but is reserved for cases that don't respond to less invasive treatments. The procedure is performed under anesthesia and requires 2-4 weeks of recovery.

While hemorrhoidectomy has a high success rate, it also has more significant recovery discomfort than office procedures. Modern techniques, including stapled hemorrhoidopexy and Doppler-guided procedures, offer alternatives with potentially faster recovery.

Thrombosed hemorrhoid treatment: When an external hemorrhoid develops a blood clot (thrombosis), it can cause severe pain. If treated within 72 hours, a simple office procedure can remove the clot and provide immediate relief. After 72 hours, the clot begins to absorb on its own, and conservative treatment is usually recommended.

How Can You Prevent Hemorrhoids?

Prevent hemorrhoids by eating 25-35 grams of fiber daily, drinking 8-10 glasses of water, exercising regularly, avoiding prolonged sitting, going to the bathroom when you feel the urge, not straining during bowel movements, limiting toilet time to under 10 minutes, and maintaining a healthy weight. These same measures prevent hemorrhoid recurrence after treatment.

Prevention is fundamentally about reducing pressure on the hemorrhoidal blood vessels and maintaining soft, easy-to-pass stools. The lifestyle measures that prevent hemorrhoids are the same ones that treat them – and they benefit overall digestive and cardiovascular health as well.

Consistency is key to prevention. Hemorrhoids develop over time from repeated strain and pressure, so preventive measures need to become permanent habits rather than temporary fixes. People who successfully prevent hemorrhoid recurrence typically make these behaviors part of their daily routine.

Lifestyle Recommendations for Prevention

• Maintain a high-fiber diet: Aim for 25-35 grams daily from fruits, vegetables, whole grains, and legumes
• Stay hydrated: Drink 8-10 glasses of water daily, more if you're physically active
• Exercise regularly: Physical activity promotes bowel regularity and helps maintain healthy weight
• Don't delay bowel movements: Go when you feel the urge to prevent stool from hardening
• Limit toilet time: Stay less than 10 minutes; don't read or use your phone
• Don't strain: If stools are difficult to pass, increase fiber and fluids rather than pushing harder
• Take breaks from sitting: If you have a desk job, stand and move every hour
• Maintain healthy weight: Excess weight increases pressure on pelvic blood vessels