Hemorrhoids (Piles)

What hemorrhoids are

Everyone has hemorrhoidal tissue: cushions of blood vessels, muscle and connective tissue that help seal the anus and control continence. They become "hemorrhoids" in the medical sense when they swell, stretch, bleed or slip down.

Grades of internal hemorrhoids

Thrombosed external hemorrhoid

A blood clot forms in an external hemorrhoid, causing a sudden, very painful, hard, bluish lump. Pain peaks in the first 48 to 72 hours and then gradually improves over 1 to 2 weeks. It may leave a small skin tag.

Symptoms

• bright red blood on toilet paper, dripping into the bowl or streaking the stool
• itching or irritation around the anus
• a lump or swelling near the anus
• a feeling of incomplete emptying
• mucus discharge
• discomfort, especially when sitting
• sudden severe pain with a thrombosed external hemorrhoid

Internal hemorrhoids usually do not hurt. Sharp pain during bowel movements, often with a small amount of blood, suggests an anal fissure instead.

Causes and risk factors

• straining during bowel movements
• chronic constipation or chronic diarrhea
• sitting on the toilet for long periods, including scrolling on a phone
• low-fiber diet
• pregnancy: pressure from the uterus and hormonal changes; very common in the third trimester and after birth
• aging, as supporting tissues weaken
• obesity
• heavy lifting
• chronic cough

Diagnosis

A doctor will ask about your symptoms and bowel habits and examine the anal area. Tests may include:

• digital rectal exam: a gloved finger checks for lumps or tenderness
• anoscopy: a short tube with a light to view internal hemorrhoids
• colonoscopy or sigmoidoscopy: recommended for rectal bleeding in people 45 or older, those with a family history of colorectal cancer, or those with warning signs such as anemia, weight loss or a change in bowel habits. This rules out colorectal cancer, polyps and inflammatory bowel disease

Do not assume rectal bleeding is from hemorrhoids without an assessment.

How to get rid of hemorrhoids: home treatment

Most hemorrhoids improve within a week or two with these steps:

• Increase fiber gradually to 25 to 35 g a day through fruits, vegetables, beans, whole grains, or a supplement such as psyllium. This softens stools and reduces straining and bleeding.
• Drink plenty of water.
• Do not strain or delay going when you feel the urge.
• Limit toilet time to a few minutes. Leave your phone outside.
• Sitz baths: sit in a few inches of warm water for 10 to 15 minutes, 2 to 3 times a day and after bowel movements.
• Keep the area clean with water or unscented wipes; pat dry gently. Avoid harsh soaps and scented products.
• Over-the-counter treatments: hemorrhoid creams with hydrocortisone (no more than 1 week, as longer use thins the skin), witch hazel pads, and topical anesthetics for short-term relief.
• Pain relief: acetaminophen (paracetamol) or ibuprofen at label doses. Opioid pain medicines worsen constipation.
• Stool softeners if needed.
• Use a cold pack wrapped in a cloth for swelling.

Medical procedures

For persistent or bleeding internal hemorrhoids:

• Rubber band ligation: a small band placed at the base cuts off blood supply, and the hemorrhoid falls off in about a week. It is the most common office procedure for grade I to III hemorrhoids.
• Sclerotherapy: an injection that shrinks the hemorrhoid.
• Infrared coagulation: heat to scar and shrink the tissue.
• Hemorrhoid artery ligation: tying off the arteries feeding the hemorrhoid.
• Hemorrhoidectomy: surgical removal for large grade III or IV hemorrhoids, mixed internal and external disease, or failed procedures. It is the most effective long-term option but causes significant pain for 1 to 2 weeks.
• Stapled hemorrhoidopexy: repositions prolapsing tissue.

For a thrombosed external hemorrhoid seen within about 72 hours, a doctor can remove the clot under local anesthetic for faster relief. After that, home care is usually best as it starts to heal.

Hemorrhoids in pregnancy

Hemorrhoids are common in late pregnancy and after delivery. Fiber, fluids, sitz baths and short-term creams are safe first steps. Check with your provider before using medicated products. They often improve within weeks after birth.

Prevention

• eat a high-fiber diet and drink enough fluid
• respond promptly to the urge to go, and avoid straining
• limit time on the toilet
• stay active and maintain a healthy weight
• consider a footstool to raise your knees on the toilet, which may make passing stool easier

Frequently asked questions

What are the symptoms of hemorrhoids?

Common symptoms are bright red blood on toilet paper or in the bowl, itching around the anus, a lump or swelling, mucus discharge and discomfort. Internal hemorrhoids are usually painless. External hemorrhoids with a clot cause sudden severe pain.

How do I get rid of hemorrhoids fast?

Soften your stools with fiber and water, avoid straining and long toilet sessions, take warm sitz baths several times a day, and use an over-the-counter cream or witch hazel pads for short-term relief. Most improve within a week. Persistent ones may need banding.

Do hemorrhoids go away on their own?

Small hemorrhoids often settle within a few days to 2 weeks with home care. Thrombosed hemorrhoids improve over 1 to 2 weeks. Larger or prolapsing internal hemorrhoids may keep recurring and need a procedure.

Is rectal bleeding always hemorrhoids?

No. Hemorrhoids are the most common cause of bright red rectal bleeding, but anal fissures, polyps, inflammatory bowel disease and colorectal cancer can also cause it. Bleeding should be checked, especially if you are over 45 or have other symptoms.

What is the difference between internal and external hemorrhoids?

Internal hemorrhoids are inside the rectum, usually painless, and mainly cause bleeding or prolapse. External hemorrhoids are under the skin around the anus, can itch and hurt, and may form a painful clot.