Hemorrhoids: Causes, Symptoms, and Treatment Options
Hemorrhoids (also called piles) are swollen blood vessels in the anus and lower rectum. Everyone has hemorrhoidal tissue, which helps control bowel movements. It causes problems when it swells, stretches, or becomes irritated, leading to bleeding, itching, discomfort, or a bulge. About half of adults have hemorrhoid symptoms by age 50, and nearly all can be treated without surgery.
Types of hemorrhoids
- Internal hemorrhoids form inside the rectum, where there are few pain nerves. They usually cause painless bright red bleeding and may bulge out (prolapse) during bowel movements.
- External hemorrhoids form under the skin around the anus, where there are many pain nerves. They can itch, swell, and hurt, especially if a clot forms inside (a thrombosed hemorrhoid).
- Mixed hemorrhoids have both internal and external parts.
Internal hemorrhoids are graded by how far they prolapse:
- Grade I: bleed but do not bulge out
- Grade II: bulge out during a bowel movement and go back in on their own
- Grade III: bulge out and must be pushed back in
- Grade IV: stay out and cannot be pushed back in
Symptoms
- Bright red blood on toilet paper, on the stool, or in the toilet
- Itching or irritation around the anus
- A soft lump or bulge near the anus
- Discomfort or pain, especially when sitting
- Mucus leakage or trouble cleaning after a bowel movement
Causes and risk factors
Hemorrhoids develop when pressure in the lower rectum stretches the veins and the tissue that supports them. Common causes include:
- Straining during bowel movements and constipation
- Chronic diarrhea
- Sitting on the toilet for long periods (including scrolling on a phone)
- A low-fiber diet and not enough fluids
- Pregnancy and childbirth
- Obesity, heavy lifting, and long periods of sitting
- Aging, which weakens the supporting tissue
When to see a doctor
See us for any rectal bleeding. Bleeding can also come from anal fissures, polyps, inflammatory bowel disease, or colorectal cancer, so don't assume it is hemorrhoids. See rectal bleeding.
Get care right away for heavy bleeding, dizziness, severe anal pain, fever, or black or maroon stools.
Diagnosis
- History and exam, including a gentle look at the anus and a finger exam of the rectum
- Anoscopy: a short, lighted tube that lets the doctor see internal hemorrhoids in the office
- Colonoscopy or sigmoidoscopy if you are 45 or older, have a family history of colon cancer, have a change in bowel habits, have anemia, or if the bleeding doesn't fit hemorrhoids
Treatment options
1. Home care (the first step for everyone)
- Fiber: 25 to 35 grams a day from fruit, vegetables, beans, and whole grains, or a supplement such as psyllium (Metamucil). Fiber reduces bleeding and straining.
- Fluids: drink enough water to keep stools soft.
- Bathroom habits: go when you feel the urge, don't strain or hold your breath, and limit toilet time to a few minutes. A footstool that raises your knees can help.
- Warm sitz baths: soak in a few inches of warm water for 10 to 15 minutes, two or three times a day.
- Cold packs to ease swelling of external hemorrhoids.
- Treat constipation or diarrhea, stay active, and avoid heavy lifting during flare-ups.
2. Over-the-counter creams and suppositories
Witch hazel pads, numbing creams (lidocaine), protective ointments, and hydrocortisone can ease itching and pain. They relieve symptoms but do not shrink the hemorrhoid. Use steroid creams for no more than about a week, because long-term use thins the skin.
3. Office treatments for internal hemorrhoids
- Rubber band ligation (banding): the most effective office treatment for grade I to III internal hemorrhoids that keep bleeding or prolapsing. A tiny band cuts off the blood supply, and the hemorrhoid shrinks and falls off. We offer non-surgical hemorrhoid treatment with the CRH O'Regan System in our Temple City office. Read the details in hemorrhoid banding: how it works.
- Infrared coagulation: heat seals off the blood supply of small bleeding hemorrhoids.
- Sclerotherapy: an injection that shrinks small hemorrhoids; sometimes used for people on blood thinners.
4. Treatment for a thrombosed external hemorrhoid
If seen within about 72 hours of the pain starting, a doctor can remove the clot through a small cut under local numbing for fast relief. After that, it usually heals on its own over 2 to 3 weeks with sitz baths, pain relievers, and stool softeners.
5. Surgery
Large grade III to IV hemorrhoids, large external or mixed hemorrhoids, and hemorrhoids that don't respond to office treatment may need surgery by a colorectal or general surgeon. Options include hemorrhoidectomy (removal), stapled hemorrhoidopexy, and Doppler-guided hemorrhoid artery ligation. Surgery is the most durable treatment but needs anesthesia and has a painful recovery of a few weeks.
Hemorrhoids during pregnancy
Hemorrhoids are common in pregnancy and after delivery because of pressure from the uterus, constipation, and pushing during labor. Fiber, fluids, sitz baths, and a stool softener usually help, and most hemorrhoids improve after the baby is born. Talk with your obstetrician before using medicated creams.
Complications
- Anemia from long-term bleeding (rare; other causes of anemia should be checked)
- Thrombosis: a painful clot in an external hemorrhoid
- Strangulation: a prolapsed internal hemorrhoid whose blood supply is cut off, causing severe pain
- Skin tags: extra skin left after an external hemorrhoid heals
Preventing hemorrhoids
- Eat high-fiber foods every day and drink plenty of fluids.
- Don't strain, and don't linger on the toilet.
- Stay active and keep a healthy weight.
- Treat constipation early. See constipation.
Make an appointment
Our gastroenterologists in Temple City care for patients from Arcadia, San Gabriel, Pasadena, Monrovia, Monterey Park, and across the San Gabriel Valley. We accept most PPO plans (see accepted insurances), and our doctors speak English, Vietnamese, and Mandarin. Schedule an appointment or call 626-898-4560.
This article is for general education and is not a substitute for medical advice. Talk with your doctor about your own health.
Quick Answers
What are hemorrhoids?
Swollen blood vessels in and around the anus and lower rectum. Everyone has hemorrhoidal tissue; it causes symptoms when it becomes swollen, stretched, or irritated.
Do hemorrhoids go away on their own?
Mild flare-ups often settle within a week or two with fiber, fluids, warm baths, and less straining. Hemorrhoids that keep bleeding or bulging usually need an office treatment.
Is rectal bleeding always from hemorrhoids?
No. Bleeding can also come from anal fissures, polyps, inflammatory bowel disease, or colorectal cancer. See a doctor for any rectal bleeding; a colonoscopy is often recommended if you are 45 or older or have other symptoms.
What is the best treatment for hemorrhoids?
It depends on the type and size. Most start with fiber and good bathroom habits. Internal hemorrhoids that keep bleeding or prolapsing are best treated with rubber band ligation in the office. Large or external hemorrhoids may need surgery.
What is a thrombosed hemorrhoid?
A blood clot in an external hemorrhoid that causes sudden pain and a hard, bluish lump. If seen within about 72 hours, removing the clot gives quick relief; otherwise it heals on its own over 2 to 3 weeks.
Are hemorrhoids common during pregnancy?
Yes. Pressure from the growing uterus, constipation, and straining during delivery make hemorrhoids common in pregnancy and after childbirth. Most improve after delivery with fiber, fluids, and warm baths.
How long can I use hemorrhoid cream?
Steroid creams such as hydrocortisone should be used for no more than about a week unless your doctor says otherwise, because long-term use can thin the skin.
