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Hemorrhoids are swollen
veins in the
anal canal. This common problem can be painful, but
it's usually not serious.
Veins can swell inside the anal canal to
form internal hemorrhoids. Or they can swell near the opening of the anus to
form external hemorrhoids. You can have both types at the same time. The
symptoms and treatment depend on which type you have.
Many people have
hemorrhoids at some time.
Too much pressure on the
veins in the pelvic and rectal area causes hemorrhoids.
tissue inside the anus fills with blood to help control bowel movements. If you
strain or sit on the toilet a long time to move stool, the increased pressure causes the veins in this tissue to
swell and stretch. This can cause hemorrhoids.
constipation also may lead to straining and can increase pressure on veins in
the anal canal.
Pregnant women can get hemorrhoids during the
last 6 months of pregnancy. This is because of increased pressure on the blood
vessels in the pelvic area. Straining to push the baby out during labor can
make hemorrhoids worse.
Being overweight can also lead to
The most common symptoms of
both internal and external hemorrhoids include:
With internal hemorrhoids, you may see bright red streaks of blood on toilet
paper or bright red blood in the toilet bowl after you have a normal bowel
movement. You may see blood on the surface of the stool.
hemorrhoids often are small, swollen veins in the wall of the anal canal. But
they can be large, sagging veins that bulge out of the anus all the time. They
can be painful if they bulge out and are squeezed by the anal muscles. They may
be very painful if the blood supply to the hemorrhoid is cut off. If
hemorrhoids bulge out, you also may see mucus on the toilet paper or
External hemorrhoids can get irritated and clot under the skin, causing a hard
painful lump. This is called a thrombosed, or clotted, hemorrhoid.
Your doctor can
tell if you have hemorrhoids by asking about your past health and doing a
You may not need many tests at first, especially
if you are younger than 50 and your doctor thinks that your rectal bleeding is
caused by hemorrhoids. Your doctor may just
examine your rectum with a gloved finger. Or your doctor may use a short,
lighted scope to look inside the rectum.
Rectal bleeding can be a
sign of a more serious problem, such as colon, rectal, or anal cancer. So if
the first exam does not show a clear cause of your problems, your doctor may
use a lighted scope (sigmoidoscope) to look at the lower
third of your colon. Or your doctor may use another kind of scope (colonoscope) to
look at the entire colon to check for other causes of bleeding.
For most external
hemorrhoids, home treatment is all you need. This includes slowly adding
fiber to your meals, drinking more water, and using
over-the-counter ointments for a limited time to stop itching. You also may use
stool softeners. The same home treatment can be used for most internal
If your internal hemorrhoids are severe, you may
need other treatment. The doctor may tie off the hemorrhoids with rubber bands
or scar the tissue around the hemorrhoids. These treatments reduce the blood
supply to the hemorrhoids so that they shrink or go away.
to remove hemorrhoids may be done if other treatments don't work.
Healthy habits can help you prevent hemorrhoids or keep them from getting
worse. Eat foods that have lots of fiber, such as fruits, vegetables, and whole
grains. Also, drink plenty of water, and get plenty of exercise.
Learning about hemorrhoids:
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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
Bowel habits that can cause increased pressure and lead
to hemorrhoids include:
Other things that can lead to the development of
Bleeding during bowel movements, itching,
and rectal pain are the most common
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.
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
Other symptoms of internal hemorrhoids may include:
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, need to talk to their doctors.
Other conditions with symptoms similar to hemorrhoids include:
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
Because external hemorrhoids
may not cause any symptoms, you may not be aware that you have
When a vein within an external hemorrhoid gets irritated, blood may clot under the skin, forming a hard, bluish lump. This is
known as a thrombosed, or clotted, hemorrhoid. Thrombosed hemorrhoids can be
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.
Hemorrhoids may be made worse by:
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. Call your doctor if you have symptoms like these:
If you have hemorrhoids, call your doctor
If rectal bleeding becomes heavy or changes color (such as
from bright red to dark red), or if stools change size, shape, or color (from brown to maroon
or black), be sure to see your doctor.
Watchful waiting is a wait-and-see approach. And 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 doctor if bleeding:
If you are older than age 50 or have a family history of
colon cancer, it is a good idea to tell your doctor 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 doctor may recommend screening tests to see
if you have a more serious problem. See Exams and Tests.
The following professionals can evaluate and treat
If medical treatment or surgery is needed, you may be
referred to a:
To prepare for your appointment, see the topic Making the Most of Your Appointment.
A doctor can evaluate
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 doctor 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:
These tests are not used routinely to diagnose
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.
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 new hemorrhoids.
procedures include tying off the hemorrhoids with a rubber band (rubber band
ligation) or using heat, lasers, or electric current to create scar tissue
(coagulation therapy). Fixative procedures can only be done on internal hemorrhoids.
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. External hemorrhoids can only be removed surgically, if needed. If a blood clot develops in the external hemorrhoid, the clot may need to be removed to relieve pain.
You can help prevent the irritating and
painful symptoms of
Home treatment, which mainly involves
establishing healthy bowel habits, may keep your
hemorrhoids from getting worse.
You can use the following suggestions to keep
hemorrhoids from getting worse or to relieve your symptoms.
Use nonprescription medicines as recommended by your
doctor or pharmacist. See Medications for information on nonprescription ointments, creams, and suppositories.
Medicines can help relieve symptoms of
hemorrhoids. You might try one or more of the
following nonprescription remedies.
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 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). If a blood clot develops in the external hemorrhoid, the clot may need to be removed to relieve pain.
Surgical removal of
hemorrhoids (hemorrhoidectomy) is a last resort for treating small internal
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.
Sometimes, increased pressure on external
hemorrhoids causes them to get irritated and to clot. This
causes a lump (thrombosed, or clotted, hemorrhoid) to form. You may suffer from
severe pain at the site of a clotted hemorrhoid.
A procedure to
relieve the pain can be done in a doctor's office or
outpatient clinic. The doctor 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 soon after the clot has formed.
If the pain is
tolerable, you may choose to wait to see a doctor. 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. If medical treatment is
needed, fixative procedures are the most widely used nonsurgical treatments.
Fixative procedures include:
Not all doctors have the
experience or the equipment to do 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
The American College of Gastroenterology is an organization of digestive disease specialists. The website contains information about common gastrointestinal problems.
The American Gastroenterological Association is a
society of doctors who specialize in the digestive system
(gastroenterologists). This Web site can help you find a gastroenterologist in
your area. They also have patient information on many gastrointestinal diseases
The American Society of Colon and Rectal Surgeons is the leading
professional society representing more than 1,000 board-certified colon and
rectal surgeons and other surgeons dedicated to treating people with diseases
and disorders affecting the colon, rectum, and anus.
This clearinghouse is a service of the U.S. National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the
U.S. National Institutes of Health. The clearinghouse answers questions;
develops, reviews, and sends out publications; and coordinates information
resources about digestive diseases. Publications produced by the clearinghouse
are reviewed carefully for scientific accuracy, content, and readability.
Other Works Consulted
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
Madoff RD (2012). Diseases of the rectum and anus. In L Goldman, A Shafer, eds., Goldman’s Cecil Medicine, 24th ed., pp. 945–949. Philadelphia: Saunders.
Marcello PW (2010). Diseases of the anorectum. In M Feldman et al., eds., Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th ed., vol. 2, pp. 2257–2274. Philadelphia: Saunders.
Rivadeneira DE, et al. (2011). Practice parameters for the management of
hemorrhoids. Diseases of the Colon and Rectum, 549(9): 1059–1064. Available online: http://www.fascrs.org/physicians/practice_parameters.
March 16, 2012
Anne C. Poinier, MD - Internal Medicine & Kenneth Bark, MD - Surgery,
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