Hemorrhoids - Causes, Symptoms and Treatment

This is a picture of a man holding a roll of toilet paper.

What are Hemorrhoids?

We have all heard about hemorrhoids at some point in our lives. This is because more than 4.4% of people in the world visit their doctors for this condition. Hemorrhoids are more commonly known as piles. It would be a shock for anyone going to the bathroom and finding fresh red blood on the toilet paper - the striking feature of hemorrhoids. But what is this condition? And why are they so common and often painful?

The anus and rectal canal is made up of a thick and highly complex plexus of veins. These veins are present to perform normal physiological functions. In their normal state, these veins are filled up with blood and help in maintaining continence, regulating the bowel movements, and controlling gas.

With age, the connective tissue above these veins becomes weak, and the walls of these vessels become thinner. Therefore, when these veins are filled up with blood, the thin walls cannot support the blood efficiently, and as a result, start to enlarge and bulge. This results in hemorrhoids.

Types of Hemorrhoids

There are mainly of two kinds of hemorrhoids; External and Internal.

Internal hemorrhoids are inside the rectum and cannot be seen with the naked eye. These cushions of engorged blood vessels are formed inside the rectum and cannot be seen or felt. This region of the anus has few pain-sensitive nerve endings, and thus internal hemorrhoids are not very painful.

However, internal hemorrhoids can cause bleeding from the rectum, and it is usually diagnosed when people find blood in their feces. The internal hemorrhoids can sometimes prolapse or bulge out on pooping or straining. These are known as prolapsed or protruding hemorrhoids. They look like small chunks of flesh that are slightly pinker than the surrounding area. They tend to go back inside once the pressure is released and can also be pushed back gently inside.

The other primary type is external hemorrhoids. As the name suggests, they can be seen by the naked eye. They are present beneath the skin surrounding the anal canal. There are many more nerve endings on the outer surface of the anus and rectum than on the inside, which makes external piles very painful.

Sometimes, external hemorrhoids can cause excruciating pain. This is usually due to a blood clot that has formed within the hemorrhoids. These are referred to as thrombosed hemorrhoids, and they can cause severe pain, bleeding, and itching. (1)

What Causes Hemorrhoids?

The question then arises; how are hemorrhoids caused by the disruption of normal anatomy and physiology? The answer is that the agitation of the veins in the lower rectum and anal canal weakens them.

Leading causes include excessive pressure in the lower part of the rectum and anus. Excessive pressure can result due to straining bowel movements, especially during constipation. The excess force used to push hard feces through the anal canal agitates the anal venous plexus which results in bleeding.

A diet deficient in fibers alters the stool consistency. Consequently, the gut transit time is prolonged, which is results in smaller, harder stools requiring more straining to expel. Long periods of sitting, especially on toilet seats for bowel movement, also play a significant role in developing piles. Hard stools, together with increased abdominal pressure in these situations, causes the veins to become engorged by blocking the venous return of the area. (2)(4)

Besides, pregnancy can also cause hemorrhoids. The uterus enlarges in pregnancy to accommodate the growing fetus, and this gravid uterus, in turn, exerts pressure on the venous plexus of the rectum, causing hemorrhoids or piles.

Aging can also make the connective tissue weaker around the veins that result in piles. A study was conducted on elderly patients. Out of 976 subjects, 39% suffered from hemorrhoids, whereas 72% had hemorrhoids of Grade 1 (3). Moreover, lifting heavyweight for a considerable period, obesity and genetics also play a role in developing hemorrhoids.

Symptoms of Hemorrhoids

The main symptom of having hemorrhoids is rectal bleeding.

The most common visit to a doctor occurs when a patient finds blood in their bowels. The characteristic feature of piles is a bright red, painless bleed from the rectum, mostly seen on the paper upon wiping or occasionally as a fresh splash in the toilet.

The second most common presentation is itching in the anal region. The pain associated with passing stool through disrupted anal cushions is severe and is commonly associated with intense itching. Some patients also report a mucus discharge in the stool along with blood.

This is also generally associated with anal irritation due to the mucus secretion from the displaced mucosa. If a patient with hemorrhoids experiences excruciating pain, a thrombosed mass would be the prime suspect. This pain is acute in character and peaks at 48 to 72 hours, with the pain subsiding on the fourth day.

The patient also experiences a hard time cleaning up after passing stool because the hemorrhoidal tissue is uneven, and it disrupts the consistency of the anal canal. Also, discomfort and soreness in the same area and leakage of feces are some usual symptoms. (5)

The Four Grades of Hemorrhoids

There are four grades of hemorrhoidal disease, which makes it easy for doctors to diagnose and treat them accordingly.

Grade 1 hemorrhoids bleed, but they do not protrude out from the anal canal. Grade 2 hemorrhoids protrude out, but they go back inside simultaneously. Grade 3 hemorrhoids also protrude, but they require manual help to push them back in. Grade 4 disease protrudes and bleeds, and the manual reduction does not help in this grade.

The hemorrhoidal disease has been thoroughly researched to date, and effective treatments are available for every stage of the disease, both through medication or surgery. Unfortunately, most people do not seek medical advice because of privacy concerns and a fear of being ridiculed, resulting in the disease progressing to a higher grade when they finally seek medical intervention. This stigma concerning piles should be progressively dealt with and reduced.

Different methods and tests are present to diagnose hemorrhoids. The first-line test is a digital rectal examination where the doctor inserts a well-lubricated finger inside the patient's anus to check for any mucosa abnormalities. Other more advanced tests include proctoscopy, sigmoidoscopy, and colonoscopy.

How to Treat Hemorrhoids?

In treating hemorrhoids, it is essential to assess the clinical presentation and grade of the lesion. In less severe cases, the doctor prescribes ice packs for swelling, suppositories, and hemorrhoidal creams.

However, in more advanced, prolapsed, and thrombosed disease, hemorrhoidectomy, which refers to the removal of the hemorrhoidal tissue, is performed. (6) In this standard surgical procedure, the abnormal hemorrhoidal mass is removed, and the connective tissue cushions in the anal region are repositioned.

Hemorrhoidal tissue can also be burned using the surgical infrared laser or by electrical coagulation procedure. Nowadays, sclerotherapy, commonly known as rubber band ligation, is used to treat hemorrhoids.

How to Prevent Hemorrhoids?

The most emphasized topic regarding hemorrhoids is its prevention (7). It's high prevalence worldwide has become a significant concern, and various guidelines have been made to prevent its occurrence.

Dietary improvement is the best preventive strategy for this condition. Eating fiber-rich foods such as beans, vegetables, and fruits help to soften the feces. Fiber supplements are also a great alternative. Another critical and often neglected point is not to restrain bowel movement. One should not delay an urge to defecate.

If you place a step stool in front of the toilet seat and prop your feet up a bit while defecating, it helps you pass stools with ease and with minimum straining. Also, drinking 6 to eight glasses of water daily is a solution to softening the stool.

Refrain from straining and holding breath during defecation as this creates an increased force in the veins of the lower rectal canal and increases the chance of hemorrhoidal changes. Exercising regularly helps to prevent constipation, and in turn, the chances of developing hemorrhoids. Sitting for long periods is not healthy for overall body health and especially for hemorrhoids.

If you still develop constipation or suffer from long-standing constipation, take laxatives prescribed by your doctor, as constipation is a leading cause of hemorrhoidal disease. It is noteworthy to know that hemorrhoids are not cancerous, and they will not progress into cancers.

However, having symptoms like those of hemorrhoids does not cancel out the chances of other anal diseases and cancers. So it is imperative to see a doctor on the first symptom or suspicion and get a thorough physical examination.


(1) Sun, Z., & Migaly, J. (2016). Review of Hemorrhoid Disease: Presentation and Management. Clinics in colon and rectal surgery, 29(1), 22–29. https://doi.org/10.1055/s-0035-1568144

(2) Lohsiriwat V. (2012). Hemorrhoids: from basic pathophysiology to clinical management. World journal of gastroenterology, 18(17), 2009–2017. https://doi.org/10.3748/wjg.v18.i17.2009

(3)Riss, Stefan & Weiser, Friedrich & Schwameis, Katrin & Riss, Thomas & Mittlboeck, Martina & Steiner, Gottfried & Stift, Anton. (2011). The prevalence of hemorrhoids in adults. International journal of colorectal disease. 27. 215-20. 10.1007/s00384-011-1316-3.

(4)Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician. 2018;97(3):172-179.

(5)Hemorrhoidal Disease: A comprehensive review. Journal of the American College of Surgeons

(6)Yeo, D., & Tan, K. Y. (2014). Hemorrhoidectomy - making sense of the surgical options. World journal of gastroenterology, 20(45), 16976–16983. https://doi.org/10.3748/wjg.v20.i45.16976

(7), Diseases of the Colon & Rectum: October 1988 - Volume 31 - Issue 10 - p 832

doi: 10.1007/BF02560124

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