Hemorrhoids

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
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What are hemorrhoids?

Hemorrhoids are a normal part of the anal canal. When veins inside the hemorrhoids swell or burst, hemorrhoid problems happen. Although uncomfortable at times, this common condition rarely poses a serious problem.

Normally, tissue surrounding the inside of the anus, sometimes called "anal cushions," fills with blood to help control bowel movements. Hemorrhoid problems happen when excessive pressure or other factors cause the veins within these cushions to swell and stretch.

Many people have hemorrhoid problems at some time. They can happen at any age, but the incidence increases after age 30. About half of people older than 50 have had hemorrhoid problems at some time in their life.¹

What causes hemorrhoid problems?

Excessive pressure on the veins in the pelvic and rectal area causes hemorrhoid problems. As pressure increases, blood pools in veins and causes them to swell, stretching the surrounding tissue. Increased pressure can come from rushing to complete a bowel movement or from constipation or persistent diarrhea, if either causes too much straining during bowel movements.

Being overweight also can contribute to hemorrhoid problems.

Pregnant women frequently develop hemorrhoids during the last 6 months of pregnancy because of increased pressure on the blood vessels in the pelvic area. Straining to push the baby out during labor can make hemorrhoid problems worse.

What are the types of hemorrhoids?

Hemorrhoids can develop inside the anal canal (internal hemorrhoids) or near the anal opening (external hemorrhoids). Both types can occur at the same time. The symptoms, progression, and treatment differ depending on where the hemorrhoids are.

Internal hemorrhoids have four degrees of severity . Bleeding may occur with any of these.

• First degree: The hemorrhoid does not stick out from the anus.
• Second degree: The hemorrhoid sticks out from the anus during a bowel movement but returns on its own to the anal canal afterward.
• Third degree: The hemorrhoid sticks out from the anus during a bowel movement and does not return to the anal canal on its own. In this case, you can push it inside the anus with your finger and then it will stay in.
• Fourth degree: The hemorrhoid is always outside the anus and cannot be pushed into the anal canal.

What are the symptoms?

• External hemorrhoids. External hemorrhoids can cause pain, itching, burning, and irritation. You might notice streaks of bright red blood on toilet paper after straining to have a bowel movement, and it may be difficult to clean the anal area.
• Internal hemorrhoids. Rectal bleeding is the most common symptom of internal hemorrhoids. You may notice bright red streaks of blood on toilet paper or bright red blood in the toilet bowl after having a normal bowel movement. You may see blood on the surface of the stool. Internal hemorrhoids can range from small, swollen veins in the wall of the anal canal to large, sagging veins and tissue that bulge out of the anus all the time. Internal hemorrhoids can be painful if they protrude all the time and are squeezed by the anal muscles or if they are clotted (thrombosed). You also may see mucus on the stool or toilet tissue, from hemorrhoids that stick out.

How are hemorrhoids diagnosed?

The diagnosis of hemorrhoids is based on a medical history and physical exam, which help a health professional identify the type of hemorrhoid—external or internal—and determine the appropriate treatment.

If you have rectal bleeding, it can be a sign of something more serious than hemorrhoids, like colon, rectal, or anal cancer. But you may not need many tests at first, especially if you are under 50 and your doctor thinks that hemorrhoids are the cause of rectal bleeding. Your doctor may only examine your rectum with a gloved finger (digital rectal exam). Or your doctor may use a short, lighted scope to look at the rectum (anoscopy).

If anoscopy does not provide a clear diagnosis, your health professional may use a flexible sigmoidoscope to look at the lower third of the colon or a colonoscope to examine the entire colon to check for other possible causes of bleeding.

How are hemorrhoids treated?

Home treatment is recommended for most external hemorrhoids. Treatment includes gradually increasing fiber and water in your diet, using creams to help stop itching, and occasional use of stool softeners.

Most internal hemorrhoids can be treated at home with the same measures used for external hemorrhoids. Generally, more severe hemorrhoids can be treated with nonsurgical procedures such as tying off hemorrhoids with rubber bands (rubber band ligation), scarring the tissue around them (coagulation therapy), injecting them with chemicals (injection sclerotherapy), or surgical removal (hemorrhoidectomy).

You can often prevent hemorrhoids or keep them from becoming worse by maintaining a healthy lifestyle. Eat a fiber-rich diet of fruits, vegetables, and whole grains. Also, drink plenty of water and exercise regularly.

Frequently Asked Questions

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	Which treatment for hemorrhoids is right for me?

Hemorrhoids are usually caused by increased pressure on the veins in the pelvic and rectal area. As pressure increases, blood pools in veins and causes them to swell. Eventually, the swollen veins stretch the surrounding tissue, and hemorrhoids develop.

Bowel habits that can cause increased pressure and lead to the development of hemorrhoids include:

• Rushing to complete a bowel movement. Hurrying can lead to excessive straining and increase pressure on rectal veins.
• Persistent diarrhea or constipation, which may cause straining and increase pressure on veins in the anal canal.

Other factors that can lead to the development of hemorrhoids include:

• Being overweight. Excess weight, especially in the abdomen and pelvis, may increase pressure on pelvic veins.
• Pregnancy and labor. Hormonal changes during pregnancy increase blood flow to the pelvis and relax supportive tissues while the growing fetus causes increased pressure on blood vessels. During labor, hemorrhoids may develop because of the intense pressure on the anal area while pushing to deliver the baby.
• Medical conditions. For example, long-term heart and liver disease may cause blood to pool in the abdomen and pelvic area, enlarging the veins.
• Tumors in the pelvic area. These occur very rarely.

Bleeding during bowel movements, itching, and rectal pain are the most common hemorrhoid symptoms.

External hemorrhoids

Rectal pain occurs mainly with external hemorrhoids. Blood may pool under the skin, forming a hard, painful lump. This is called a thrombosed, or clotted, hemorrhoid. You might also notice streaks of blood on the toilet paper after straining to pass a stool.

Internal hemorrhoids

The most common symptom of internal hemorrhoids is rectal bleeding. You may find bright red streaks of blood on the toilet paper or bright red blood in the toilet bowl after having a normal bowel movement. Blood also may be visible on the surface of the stool.

Other symptoms of internal hemorrhoids may include:

• Itching. This is a frequent complaint, because internal hemorrhoids often seep mucus, which can irritate the anal skin and cause itching.
• Skin irritation. Large hemorrhoids that bulge from the anus may secrete mucus, causing mild irritation.
• Discomfort. You may still feel the urge to pass stool right after having a bowel movement. This uncomfortable feeling is caused by the bulging of the hemorrhoid in the end portion of the large intestine (anal canal). In general, the larger the hemorrhoid, the greater the discomfort.
• Pain. Most internal hemorrhoids are not painful. However, large hemorrhoids that bulge from the anus may become painful if they swell and are squeezed by the muscles that control the anus. Severe pain may be a sign that the blood supply to the hemorrhoid is being cut off (strangulated hemorrhoid). Emergency treatment is needed.

Rectal bleeding and pain and recent changes in bowel habits are also symptoms of colon, rectal, or anal cancer. People who have these symptoms, especially those age 50 or older or those with a family history of colon cancer, should talk to their health professional.

Other conditions with symptoms similar to hemorrhoids include anal fissures, anal fistulae, colon polyps, rectal prolapse, and inflammatory bowel disease (IBD).

Hemorrhoids form when increased pressure on the pelvic veins causes veins in the anal canal to swell and gradually stretch out of shape. Pressure increases can be caused by rushing to complete a bowel movement, persistent diarrhea or constipation, or other factors including being overweight or pregnant.

Persistent pressure also weakens tissues that support the veins in the anal canal. If those tissues become so weak that they can no longer hold the veins in place, the swollen veins and tissues bulge into the anal canal (internal hemorrhoids) or under the skin surrounding the anal opening (external hemorrhoids).

For some people, hemorrhoids may cause a little discomfort for a limited time. Other people have recurrent bouts of discomfort when hemorrhoids flare up. Some people struggle with hemorrhoid pain, discomfort, and itching much of their lives. The degree and duration of discomfort depend on where the hemorrhoids are.

Hemorrhoids frequently develop during pregnancy because of extra pressure on veins (from the enlarged uterus).

During labor, hemorrhoids may start or get worse because of the intense straining and pressure on the anal area while pushing to deliver the baby. For more information, see the topic Pregnancy.

External hemorrhoids

Because external hemorrhoids may not cause any symptoms, you may not be aware that you have hemorrhoids.

When a vein within an external hemorrhoid breaks open and bleeds, blood may pool under the skin, forming a hard, bluish lump. This is known as a thrombosed, or clotted, hemorrhoid. Thrombosed hemorrhoids can be very painful.

Internal hemorrhoids

Small internal hemorrhoids may not grow larger if bowel habits or other factors change to lower pressure on the veins in the bowel.

Large internal hemorrhoids may bulge from the anus. After bowel movements, you may have to push them back through the anus. At worst, large internal hemorrhoids stick out all the time.

In rare cases, hemorrhoids may bulge through the anus and swell. Muscles that control the opening and closing of the anus may cut off a hemorrhoid's blood supply (strangulated hemorrhoid). This may cause the hemorrhoid tissues to die. If this happens, you will feel severe rectal pain and may see blood and pus at the anus. You will need urgent surgery to prevent further complications, such as death of the affected tissue and infection.

Bowel habits, physical stresses, and other conditions can raise the risk of developing hemorrhoids or make existing hemorrhoids worse. Some of these factors can be prevented.

Factors that increase your risk

• Persistent constipation or diarrhea. These conditions may lead to straining with bowel movements.
• Being overweight.
• A family history of hemorrhoids. You may inherit the tendency to get them.
• Being age 50 or older. Half of people who are older than 50 seek treatment for hemorrhoids.
• Pregnancy and labor and delivery. As the fetus grows during the last 6 months of pregnancy, blood volume and pressure on pelvic blood vessels increase. The strain of labor also can cause hemorrhoids to start or get worse.
• Liver, heart disease, or both. These conditions may cause blood to back up in the pelvis and abdomen.

Factors that may make hemorrhoids worse

Hemorrhoids may be made worse by:

• Prolonged sitting or standing. This may cause blood to pool in the anal area and increase pressure on the veins.
• Frequent heavy lifting or holding your breath when lifting heavy objects. This can cause a sudden increase of pressure in blood vessels.

Common symptoms of hemorrhoids may be a sign of other serious health problems. Colon or rectal cancer and other conditions have many of the same symptoms as hemorrhoids. You should call your health professional if:

• Rectal bleeding occurs that is not associated with trying to pass stools.
• Stools become more narrow than usual (may be no wider than a pencil).
• You cannot pass stools, or you have diarrhea with abdominal bloating.
• Stools are black or tarry.
• Any unusual material seeps from the anus.
• You have a fever along with bloody stools or what you think may be hemorrhoids.
• A lump or bulge that is not tender and does not go away develops at the anal opening.

If you have hemorrhoids, call your health professional if:

• Moderate rectal pain lasts longer than 1 week after home treatment.
• Pain or swelling is severe.
• Tissue from inside the body bulges from the anus and does not return to normal after 3 to 7 days of home treatment.
• A lump inside the anus becomes bigger or more painful.

If rectal bleeding becomes heavy or changes color (such as from bright red to dark red), or if stools change color (from brown to maroon or black), you should be evaluated by your health professional.

Watchful Waiting

If you are younger than age 50 and occasionally have minimal rectal bleeding (bright red blood seen mainly on toilet paper) from hemorrhoids, you may try home treatment for a week or two if you are reasonably certain that the bleeding is caused by one of the following:

• Straining to pass stools
• A known injury to the anus

See the Home Treatment section of this topic for more information.

In most cases, bleeding caused by hemorrhoids should stop after 2 to 3 days. Continue home treatment to prevent bleeding from starting again. Call your health professional if bleeding:

• Persists for more than 1 week without improvement.
• Starts again.
• Occurs when there is no reason to expect it.

If you are older than age 50 or have a family history of colon cancer, it is a good idea to consult your health professional any time you have new rectal bleeding, notice blood on your stools, have changes in bowel habits, or have anal pain. These symptoms may be signs of colon cancer or other conditions. Your health professional may recommend screening tests to see if you have a more serious problem. See the Exams and Tests section of this topic.

Who To See

The following professionals can evaluate and treat hemorrhoids:

• Family medicine doctor
• Internist
• Nurse practitioner
• Physician assistant
• Obstetrician
• Gastroenterologist
• Gynecologist
• General surgeon

If medical treatment or surgery is necessary, you may be referred to a:

• Gastroenterologist.
• General or colorectal surgeon.
• Doctor who specializes in problems affecting the rectum and anus (proctologist).

To prepare for your appointment, see the topic Making the Most of Your Appointment

A health professional can evaluate symptoms of hemorrhoids to rule out other, more serious problems. A number of conditions that affect the anus and colon (large intestine) can cause bleeding, mucus drainage, itching, and discomfort. Most people who have these symptoms think they have hemorrhoids, but often they do not.

If hemorrhoids are present, the health professional will evaluate their location and size and develop a treatment plan based on the hemorrhoids' degree of severity .

The diagnosis of hemorrhoids is based on a medical history and physical exam. A digital rectal exam and an anoscopy may be the only tests needed at first. Your doctor will decide which tests to use. If hemorrhoids are the obvious cause of rectal bleeding, you are younger than age 50, and you do not have risk factors for colon cancer, you may not need more tests.

To make sure nothing else (like colon cancer) is causing your symptoms, you may need other tests, such as:

• Flexible sigmoidoscopy. This test allows a health professional to look inside the anus, rectum, and lower part of the large intestine (colon) for abnormal growths or other signs of disease.
• Barium enema.
• Colonoscopy.

These tests are not used routinely to diagnose hemorrhoids.

Most hemorrhoids can be treated with simple changes to diet and bowel habits. Most do not require surgery or other treatment unless the hemorrhoids are very large and painful. For home care and prevention tips, see the Home Treatment and Prevention sections of this topic.

The goal of nonsurgical procedures used to treat hemorrhoids, called fixative procedures, is to reduce the blood supply to the hemorrhoid so it shrinks or goes away. The scar tissue left in its place helps support the anal tissue and helps prevent more hemorrhoids from developing.

Fixative procedures include tying off the hemorrhoids with a rubber band (rubber band ligation) or injecting chemicals to shrink the tissue (injection sclerotherapy). One other fixative procedure uses heat, laser, or electric current to create scar tissue (coagulation therapy).

Surgical removal of hemorrhoids (hemorrhoidectomy) can be used for large internal hemorrhoids, when several small hemorrhoids are present, or when other treatments have not controlled bleeding. Sometimes a combination of treatments (for example, a fixative procedure and a hemorrhoidectomy) is the most effective way to treat hemorrhoids.

Hemorrhoidectomy versus fixative procedures for internal hemorrhoids

• Fixative procedures are usually tried before surgery if hemorrhoids are small and stick out of the anus during a bowel movement but return to their normal position afterward (second-degree hemorrhoid ). For more information about fixative procedures, see the Other Treatment section of this topic.
• Hemorrhoidectomy may provide better long-term results than fixative procedures. However, surgery is more expensive, requires longer recovery times, is usually more painful, and has a greater risk of complications.
• Fixative procedures are the preferred treatment for people older than age 70 and those in poor health.

Which treatment for hemorrhoids is right for me?

You can help prevent the irritating and painful symptoms of hemorrhoids.

Avoid constipation

• Eat more fiber. Include foods such as whole-grain breads and cereals, raw vegetables, raw and dried fruits, and beans. Limit your intake of low- or no-fiber foods, such as ice cream, soft drinks, cheese, white bread, and red meat.
• Drink 8 to 10 glasses of water each day. Fruit juices are another good choice. Avoid liquids that contain caffeine (such as coffee and tea) or alcohol. These liquids may cause dehydration, which can lead to constipation.
• Stool softeners containing bran or psyllium can be helpful. You can save money by buying bran or psyllium (available in bulk at most health food stores) and sprinkling it on foods or stirring it into fruit juice. Avoid laxatives, another type of medicine that affects the bowels, because they may cause diarrhea, which can irritate hemorrhoids.
• Avoid foods and beverages that seem to make your symptoms worse. These may include nuts, spicy foods, coffee, and alcohol.
• Regular, moderate exercise, along with a high-fiber diet, promotes smooth, regular bowel movements.

Practice healthy bowel habits

• Go to the bathroom as soon as you have the urge.
• Avoid straining to pass stools. Relax and give yourself time to let things happen naturally.
• Avoid holding your breath while passing stools.
• Avoid reading while sitting on the toilet. Get off the toilet as soon as you have finished.

Modify your daily activities

• Avoid prolonged sitting or standing. Take frequent short walks.
• If possible, avoid lifting heavy objects frequently. If you must lift heavy objects, always exhale as you lift the object. Don't hold your breath when you lift.
• If you are pregnant, sleeping on your side will lower pressure on the blood vessels in your pelvis. This can help keep hemorrhoids from becoming bigger.

Home treatment, which mainly involves establishing healthy bowel habits, may keep your hemorrhoids from getting worse. See the Prevention section of this topic for more on healthy bowel habits.

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketoprofen, can cause hemorrhoids to bleed more. If you need to use a nonprescription pain reliever, choose one that is not an NSAID, such as acetaminophen (for example, Tylenol).

You can use the following suggestions to keep hemorrhoids from getting worse or to relieve your symptoms.

Avoid making hemorrhoids worse

• Blot the anus gently with white toilet paper moistened with water or a cleansing agent (such as Balneol) after bowel movements. Baby wipes or other premoistened towels (such as Tucks) are also useful for this purpose.
• Avoid rubbing the anal area. You can rinse off in the shower or on a bidet instead of wiping yourself with toilet paper. After cleansing, gently pat the anal area dry with a soft, absorbent towel or cloth.
• Use soaps that contain no perfumes or dyes.

Relieve pain and itching

• Apply ice several times a day for 10 minutes at a time. Follow this by placing a warm compress on the anal area for another 10 to 20 minutes.
• Apply moist heat (such as warm, damp towels) several times a day.
• Take a sitz bath. Fill your bathtub with just enough warm water to cover the anal area. Do this several times a day, especially after you have had a bowel movement. Soak for about 15 minutes at a time. Be careful! If the water is too warm, it could burn you.

Use nonprescription medicines as recommended by your health professional or pharmacist. See the Medications section of this topic for information on nonprescription ointments, creams, and suppositories.

Other comfort measures

• You may need a day or more of bed rest to take pressure off inflamed, irritated veins. If you are 3 to 6 months pregnant, you may find it helpful to lie on your side. If you are not pregnant, sleeping on your stomach with a pillow under your hips will help decrease swelling of hemorrhoids.
• Try not to sit or stand for a long time when hemorrhoids are irritated. If you must sit for a long time, sit on a pillow. Avoid lifting heavy objects.
• Wear cotton underwear to prevent moisture buildup, which can irritate hemorrhoids. Wear loose clothing to allow freedom of movement and to reduce pressure on the anal area.
• Do not use a ring ("doughnut") cushion. It will restrict blood flow and may make your symptoms worse.

Medicines can help relieve symptoms of hemorrhoids. You might try one or more of the following nonprescription remedies.

• Ointments that protect the skin, such as zinc oxide or petroleum jelly, are the best nonprescription remedies for hemorrhoids. Ointments can prevent further injury and reduce itching by forming a barrier over hemorrhoids.
• Use suppositories like those made by Preparation H or Tucks (formerly Anusol) for 7 to 10 days to relieve irritation and lubricate the anal canal during bowel movements. Some of these products contain substances that can harm anal tissues if they are used for too long.
• Apply an ointment that contains 1% hydrocortisone, a type of steroid medicine that may relieve inflammation and itching. Your health professional may prescribe 2.5% hydrocortisone. However, these products should not be used for more than 2 weeks because they can thin the skin.
• Apply products that contain medicine to numb an area (local anesthetic). These products often have the suffix "-caine" in the name or the ingredients. Although these products help some people, especially those who have painful external hemorrhoids, some people become allergic to them. Ask your health professional before using these products.

Most hemorrhoids do not require surgery. It is usually considered only for severe hemorrhoids.

Surgery may be done if other treatments (including home treatment) have failed. Surgery is also considered when symptoms become so bothersome that your lifestyle is affected or when hemorrhoids create a medical emergency, such as uncontrolled bleeding or blood and pus at the anus along with severe rectal pain.

External hemorrhoids

External hemorrhoids usually are not removed with surgery (hemorrhoidectomy) except if they are very large and uncomfortable or if you are having surgery on the anal area for another reason, such as internal hemorrhoids or a tear (anal fissure).

Internal hemorrhoids

Surgical removal of hemorrhoids (hemorrhoidectomy) is a last resort for treating small internal hemorrhoids.

Hemorrhoidectomy is considered the most successful way to treat large internal hemorrhoids, especially those that are still a problem after treatments that cut off blood flow to hemorrhoids (fixative procedures) have been tried.

Surgery

The surgical option for hemorrhoids is a hemorrhoidectomy, used mostly for large internal hemorrhoids.

What To Think About

Which treatment for hemorrhoids is right for me?

Occasionally, increased pressure on externalhemorrhoids causes them to break and bleed. This causes a lump (thrombosed, or clotted, hemorrhoid) to form. You may suffer from severe pain at the site of the clotted hemorrhoid.

A procedure to relieve the pain can be performed in a health professional's office or outpatient clinic. The health professional applies local anesthesia and then makes a small incision where the lump has occurred to remove the clot and reduce pressure and pain. The procedure works best if it is done less than 4 or 5 days after the clot has formed.

If the pain is tolerable, you may choose to wait to see a health professional. The pain usually goes away in a few days. After 4 or 5 days, the pain from cutting and draining the hemorrhoid is usually worse than the pain from the clot.

Many people who have hemorrhoids find relief from symptoms through home treatment. See the Home Treatment section of this topic for more information. If medical treatment is necessary, fixative procedures are the most widely used nonsurgical treatments. These procedures are most successful if you have small hemorrhoids.

Other Treatment Choices

Fixative procedures include:

• Rubber band ligation, a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow so that the hemorrhoid shrinks and dies and, in about a week, falls off.
• Coagulation with light (infrared photocoagulation), lasers, or electricity, which creates scar tissue, cutting off the blood supply to the hemorrhoid so that it shrinks and dies.

Rarely used procedures include:

• Injection sclerotherapy.
• Cryotherapy.
• Anal dilation.

What To Think About

Not all doctors have the experience or the equipment to perform all types of fixative procedures. This may help you decide which procedure to choose. Ask your doctor which procedure he or she does the most and how satisfied people have been with the outcomes of that procedure.

See the Home Treatment section of this topic for tips on keeping hemorrhoids from becoming worse or recurring after treatment.

Which treatment for hemorrhoids is right for me?

Organizations

• Constipation, Age 12 and Older
• Rectal Problems

Citations

1. Stelzner M (2001). Hemorrhoids section of Anorectal problems. In DC Lynge et al., eds., 20 Common Problems: Surgical Problems and Procedures in Primary Care, pp. 112–127. New York: McGraw-Hill.

Other Works Consulted

• American Gastroenterological Association (2004). American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. Gastroenterology, 126(5): 1461–2.

• Dozois EJ, Pemberton JH (2006). Hemorrhoids and other anorectal disorders. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 945–958. Philadelphia: Saunders Elsevier.

• Mehigan BJ, et al. (2000). Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: Randomised controlled trial. Lancet, 355(9206): 782–785.

• Rowsell M, et al. (2000). Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: Randomised controlled trial. Lancet, 355(9206): 779–781.

Author:	Monica Rhodes	Last Updated October 10, 2006
Medical Review:	Adam Husney, MD - Family Medicine Brent Shoji, MD - General Surgery
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