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Hemorrhoids

Overview

Hemorrhoids (HEM-uh-roids), also called piles, are swollen veins in your anus and lower rectum, similar to varicose veins. Hemorrhoids have a number of causes, although often the cause is unknown. They may result from straining during bowel movements or from the increased pressure on these veins during pregnancy. Hemorrhoids may be located inside the rectum (internal hemorrhoids), or they may develop under the skin around the anus (external hemorrhoids).

Hemorrhoids are very common. Nearly three out of four adults will have hemorrhoids from time to time. Sometimes they don't cause symptoms but at other times they cause itching, discomfort and bleeding.

Occasionally, a clot may form in a hemorrhoid (thrombosed hemorrhoid). These are not dangerous but can be extremely painful and sometimes need to be lanced and drained.

Fortunately, many effective options are available to treat hemorrhoids. Many people can get relief from symptoms with home treatments and lifestyle changes.

Hemorrhoids

Hemorrhoids are swollen veins in your lower rectum. Internal hemorrhoids are usually painless, but tend to bleed. External hemorrhoids may cause pain.

Symptoms

Signs and symptoms of hemorrhoids may include:

  • Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet
  • Itching or irritation in your anal region
  • Pain or discomfort
  • Swelling around your anus
  • A lump near your anus, which may be sensitive or painful (may be a thrombosed hemorrhoid)

Hemorrhoid symptoms usually depend on the location.

Internal hemorrhoids. These lie inside the rectum. You usually can't see or feel these hemorrhoids, and they rarely cause discomfort. But straining or irritation when passing stool can damage a hemorrhoid's surface and cause it to bleed.

Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids. These are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed.

Thrombosed hemorrhoids. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus) that can result in severe pain, swelling, inflammation and a hard lump near your anus.

When to see a doctor

Bleeding during bowel movements is the most common sign of hemorrhoids. Your doctor can do a physical examination and perform other tests to confirm hemorrhoids and rule out more-serious conditions or diseases.

Also talk to your doctor if you know you have hemorrhoids and they cause pain, bleed frequently or excessively, or don't improve with home remedies.

Don't assume rectal bleeding is due to hemorrhoids, especially if you are over 40 years old. Rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer. If you have bleeding along with a marked change in bowel habits or if your stools change in color or consistency, consult your doctor. These types of stools can signal more extensive bleeding elsewhere in your digestive tract.

Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness or faintness.

Causes

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop from increased pressure in the lower rectum due to:

  • Straining during bowel movements
  • Sitting for long periods of time on the toilet
  • Chronic diarrhea or constipation
  • Obesity
  • Pregnancy
  • Anal intercourse
  • Low-fiber diet

Hemorrhoids are more likely with aging because the tissues that support the veins in your rectum and anus can weaken and stretch.

Complications

Complications of hemorrhoids are very rare but include:

  • Anemia. Rarely, chronic blood loss from hemorrhoids may cause anemia, in which you don't have enough healthy red blood cells to carry oxygen to your cells.
  • Strangulated hemorrhoid. If the blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be "strangulated," another cause of extreme pain.

Prevention

The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
  • Consider fiber supplements. Most people don't get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular.

    If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.

  • Don't strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
  • Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
  • Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
  • Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.

Diagnosis

Your doctor may be able to see if you have external hemorrhoids simply by looking. Tests and procedures to diagnose internal hemorrhoids may include examination of your anal canal and rectum:

  • Digital examination. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as growths. The exam can suggest to your doctor whether further testing is needed.
  • Visual inspection. Because internal hemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope.

Your doctor may want to examine your entire colon using colonoscopy if:

  • Your signs and symptoms suggest you might have another digestive system disease
  • You have risk factors for colorectal cancer
  • You're middle-aged and haven't had a recent colonoscopy

Treatment

Home remedies

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.
  • Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.
  • Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Avoid alcohol-based or perfumed wipes. Gently pat the area dry or use a hair dryer.
  • Don't use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn't contain perfume or alcohol.
  • Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.
  • Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don't get relief in a week, or sooner if you have severe pain or bleeding.

Medications

If your hemorrhoids produce only mild discomfort, your doctor may suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel, or hydrocortisone and lidocaine, that can relieve pain and itching, at least temporarily.

Don't use an over-the-counter steroid cream for more than a week unless directed by your doctor because it may cause your skin to thin.

External hemorrhoid thrombectomy

If a painful blood clot (thrombosis) has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision and drainage, which may provide prompt relief. This procedure is most effective if done within 72 hours of developing a clot.

Minimally invasive procedures

For persistent bleeding or painful hemorrhoids, your doctor may recommend one of the other minimally invasive procedures available. These treatments can be done in your doctor's office or other outpatient setting and do not usually require anesthesia.

  • Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week. This procedure is effective for many people.

    Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four days after the procedure but is rarely severe. Occasionally, more-serious complications can occur.

  • Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
  • Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel.

    While coagulation has few side effects and may cause little immediate discomfort, it's associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Surgical procedures

If other procedures haven't been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Your surgery may be done as an outpatient or may require an overnight hospital stay.

  • Hemorrhoid removal. In this procedure, called hemorrhoidectomy, your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic.

    Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids. Complications may include temporary difficulty emptying your bladder and resulting urinary tract infections.

    Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a warm bath also may help.

  • Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. It is typically used only for internal hemorrhoids.

    Stapling generally involves less pain than hemorrhoidectomy and allows for earlier return to regular activities. Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Complications can also include bleeding, urinary retention and pain, as well as, rarely, a life-threatening blood infection (sepsis). Talk with your doctor about the best option for you.

Rubber band ligation of hemorrhoid

To remove a hemorrhoid using rubber band ligation, your doctor inserts a small tool called a ligator through a lighted tube (scope) in the anal canal and grasps the hemorrhoid with forceps. Sliding the ligator's cylinder upward releases rubber bands around the base of the hemorrhoid. Rubber bands cut off the hemorrhoid's blood supply, causing it to wither and drop off.

Lifestyle and home remedies

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.
  • Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.
  • Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Avoid alcohol-based or perfumed wipes. Gently pat the area dry or use a hair dryer.
  • Don't use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn't contain perfume or alcohol.
  • Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.
  • Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don't get relief in a week, or sooner if you have severe pain or bleeding.

Preparing for an appointment

If you have signs and symptoms of hemorrhoids, make an appointment with your regular doctor. Depending on your signs and symptoms, your doctor may refer you to one or more specialists — including a doctor with expertise in the digestive system (gastroenterologist) or a colon and rectal surgeon — for evaluation and treatment.

You can help your doctor by being prepared with as much information as possible. Here are some suggestions to help you get ready for your appointment.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance.
  • Write down any symptoms you're experiencing and how long you've noticed them.
  • Write down key personal information, including typical bowel habits and diet, especially your fiber intake.
  • Make a list of all medications, vitamins or supplements that you're taking.
  • Write down questions to ask your doctor.

For hemorrhoids, some questions you might want to ask your doctor include:

  • What's the likely cause of my symptoms?
  • Is my condition likely to be temporary or permanent?
  • Am I at risk of complications related to this condition?
  • What treatment approach do you recommend?
  • If treatments we try first don't work, what will you recommend next?
  • Am I a candidate for surgery? Why or why not?
  • Are there any additional self-care steps that might help?
  • I have other medical problems. How can I manage these along with hemorrhoids?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

  • When did your symptoms first occur?
  • How uncomfortable are your symptoms?
  • What are your typical bowel habits?
  • How much fiber does your diet contain?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • Has anyone in your family ever had hemorrhoids or cancer of the colon, rectum or anus?
  • Have you had a change in your bowel habits?
  • During bowel movements, have you noticed blood on your toilet paper, dripping into the toilet or mixed into your stools?

What you can do in the meantime

In the time before your appointment, take steps to soften your stools. Eat more high-fiber foods, such as fruits, vegetables and whole grains, and consider trying an over-the-counter fiber supplement, such as Metamucil and Citrucel. Drinking six to eight glasses of water a day also may help soften your stools and relieve your symptoms.

Last updated: April 27th, 2017

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