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Hemorrhoids
Other namesHaemorrhoids, piles,[1] hemorrhoidal disease[2]
Diagram demonstrating the anatomy of both internal and external hemorrhoids
Pronunciation
  • UK: /ˈhɛmərɔɪdz/
SpecialtyGeneral surgery
SymptomsInternal: Painless, bright red rectal bleeding[3]
External: Pain and swelling around the anus[4]
Usual onset45–65 years of age[5]
DurationFew days[3]
CausesUnknown[4]
Risk factorsConstipation, diarrhea, sitting on the toilet for long periods, pregnancy[3]
Diagnostic methodExamination, rule out serious causes[2][3]
TreatmentIncreased fiber, drinking fluids, NSAIDs, rest, surgery, hemorrhoidal artery embolization[1][6]
Frequency50–66% at some time[1][3]

Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal.[7][8] In their normal state, they are cushions that help with stool control.[2] They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease.[8] The signs and symptoms of hemorrhoids depend on the type present.[4] Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating.[3][4] External hemorrhoids often result in pain and swelling in the area of the anus.[4] If bleeding occurs, it is usually darker.[4] Symptoms frequently get better after a few days.[3] A skin tag may remain after the healing of an external hemorrhoid.[4]

While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved.[4] This may include constipation, diarrhea, and sitting on the toilet for long periods.[3] Hemorrhoids are also more common during pregnancy.[3] Diagnosis is made by looking at the area.[3] Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should be ruled out.[2] Colonoscopy or sigmoidoscopy is reasonable to confirm the diagnosis and rule out more serious causes.[9]

Often, no specific treatment is needed and hemorrhoids that do not cause symptoms do not require treatment.[9][10] Initial measures consist of increasing fiber intake, drinking fluids to maintain hydration, NSAIDs to help with pain, and rest.[1] Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence.[9] A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management.[6] Hemorrhoidal artery embolization (HAE) is a safe and effective minimally invasive procedure that can be performed and is typically better tolerated than traditional therapies.[11][12][13] Surgery is reserved for those who fail to improve following these measures.[6]

Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives.[1][3] Males and females are both affected with about equal frequency.[1] Hemorrhoids affect people most often between 45 and 65 years of age,[5] and they are more common among the wealthy,[4] although this may reflect differences in healthcare access rather than true prevalence.[14] Outcomes are usually good.[3][9]

The first known mention of the disease is from a 1700 BC Egyptian papyrus.[15]

Signs and symptoms

[edit]
An external hemorrhoid

In about 40% of people with pathological hemorrhoids, there are no significant symptoms.[4] Internal and external hemorrhoids may present differently; however, many people may have a combination of the two.[10][8] Bleeding enough to cause anemia is rare,[5] and life-threatening bleeding is even more uncommon.[16] Many people feel embarrassed when facing the problem[5] and often seek medical care only when the case is advanced.[8]

External

[edit]

If not thrombosed, external hemorrhoids may cause few problems.[17] However, when thrombosed, hemorrhoids may be very painful.[1][8] Nevertheless, this pain typically resolves in two to three days.[5] The swelling may, however, take a few weeks to disappear.[5] A skin tag may remain after healing.[8] If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.[17]

Internal

[edit]

Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement.[8] The blood typically covers the stool, is on the toilet paper, or drips into the toilet bowl.[8] The stool itself is usually normally colored.[8] Blood mixed in with the stool is usually due to another cause of bleeding in the gut.[10] Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence.[16][18] Internal hemorrhoids are usually painful only if they become thrombosed or necrotic.[8]

Causes

[edit]

The exact cause of symptomatic hemorrhoids is unknown.[19] A number of factors are believed to play a role, including irregular bowel habits (constipation or diarrhea), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascites, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging.[1][5] Other factors believed to increase risk include obesity, a chronic cough, and pelvic floor dysfunction.[2][8] Squatting while defecating may also increase the risk of severe hemorrhoids.[20] Evidence for these associations, however, is poor.[2] Being a receptive partner in anal intercourse has been listed as a cause.[21]

During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures.[22] Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.[1] A personal history of hemorrhoids or anal fissures, constipation, prolonged straining during delivery, and delivering a larger baby (weighing over 3,800 grams) are risk factors for hemorrhoids during pregnancy and in the post-partum period.[10]

Pathophysiology

[edit]
Gross pathology of hemorrhoids, showing engorged blood vessels

Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes.[8] There are three main cushions present in the normal anal canal.[1] These are located classically at left lateral, right anterior, and right posterior positions.[5] They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle.[2]: 175  Sinusoids do not have muscle tissue in their walls, as veins do.[8] This set of blood vessels is known as the hemorrhoidal plexus.[2]

Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool.[8] When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure.[5] Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased.[16] Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms.[5] Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus.[5] The pectinate line divides the two regions, and is also used to divide internal from external hemorrhoids.[5][10]

Diagnosis

[edit]
Internal hemorrhoid grades
Grade Diagram Picture
1 Endoscopic view
2
3
4

Hemorrhoids are typically diagnosed by physical examination.[6] A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.[8] Visual confirmation of internal hemorrhoids, on the other hand, may require anoscopy, insertion of a hollow tube device with a light attached at one end.[5] A digital rectal exam (DRE) can also be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses.[8] If pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid.[5]

Internal

[edit]

Internal hemorrhoids originate above the pectinate line.[17] They are covered by columnar epithelium, which lacks pain receptors.[2] They were classified in 1985 into four grades based on the degree of prolapse:[1][2]

  • Grade I: No prolapse, just prominent blood vessels[6]
  • Grade II: Prolapse upon bearing down, but spontaneous reduction
  • Grade III: Prolapse upon bearing down requiring manual reduction
  • Grade IV: Prolapse with inability to be manually reduced.

External

[edit]
A thrombosed external hemorrhoid

External hemorrhoids occur below the dentate (or pectinate) line.[17] They are covered proximally by anoderm and distally by skin, both of which are sensitive to pain and temperature.[2]

Differential

[edit]

Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices, and itching have similar symptoms and may be incorrectly referred to as hemorrhoids.[1] Rectal bleeding may also occur owing to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia.[6] If anemia is present, other potential causes should be considered.[5] Rectal bleeding without bowel movements is unlikely to be due to hemorrhoids.[10]

Other conditions that produce an anal mass include skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae.[5] Anorectal varices due to portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition.[5] Portal hypertension does not increase the risk of hemorrhoids.[4]

Prevention

[edit]

A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements and getting sufficient exercise.[5][23] Spending less time attempting to defecate, avoiding reading while on the toilet,[1] and losing weight for overweight persons and avoiding heavy lifting are also recommended.[24]

Management

[edit]

Conservative

[edit]

Conservative treatment typically consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest.[1] Increased fiber intake has been shown to improve outcomes[25] and may be achieved by dietary alterations or the consumption of fiber supplements.[1][25] Evidence for benefits from sitz baths during any point in treatment, however, is lacking.[26] If they are used, they should be limited to 15 minutes at a time.[2]: 182  Decreasing time spent on the toilet and not straining is also recommended.[27]

While many topical agents and suppositories are available for the treatment of hemorrhoids, little evidence supports their use.[1] As such, they are not recommended by the American Society of Colon and Rectal Surgeons.[28] Steroid-containing agents should not be used for more than 14 days, as they may cause thinning of the skin.[1] Most agents include a combination of active ingredients.[2] These may include a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine.[2] Some contain Balsam of Peru to which certain people may be allergic.[29][30]

Flavonoids are of questionable benefit, with potential side effects.[2][31] Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.[32] Evidence does not support the use of traditional Chinese herbal treatment.[33]

The use of phlebotonics has been investigated in the treatment of low-grade hemorrhoids with a Cochrane review showing improvement in overall symptoms, including bleeding and itching. However there were no improvements in pain. The authors noted that more research was needed on the role of phlebotonics in the management of hemorrhoids.[28][34][35][36]

Procedures

[edit]

A number of office-based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur.[6] Office based procedures are associated with less pain and less risk of complications than surgical hemorrhoidectomy.[10]

  1. Rubber band ligation is typically recommended as the first-line treatment in those with grade I to III disease.[6] It is a procedure in which elastic bands are applied onto internal hemorrhoid at least 1 cm above the pectinate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. Scarring at the site is intended to prevent re-engorgement of the hemorrhoids.[10] If the band is placed too close to the pectinate line, intense pain results immediately afterwards.[1] The cure rate has been found to be about 87%, with a complication rate of up to 3% and the recurrence rate at 2 years was 15.5%.[6][1][10]
  2. Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is about 70%.[1] This modality is less effective for bleeding symptoms or prolapse as compared to rubber band ligation, but it is associated with less post-procedure pain.[10]
  3. A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually used only when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery,[1] or cryosurgery.[37] Infrared cauterization may be an option for grade I or II disease.[6] In those with grade III or IV disease, reoccurrence rates are high.[6] About 30% of patients who underwent cauterization needed additional interventions for relief of hemorrhoidal disease.[10]


Hemorrhoidal artery embolization (HAE) is a minimally invasive procedure performed by an interventional radiologist.[11] HAE involves the blockage of abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or microparticles to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding.[12] HAE is very effective at stopping bleeding related symptoms with success rate of approximately 90%.[13] Overall, the effectiveness of HAE is comparable to or better than surgery or transanal procedures.[38] The frequency and severity of any potential adverse events are also significantly lower in HAE compared to surgery or transanal procedures.[38]

Surgery

[edit]

A number of surgical techniques may be used if conservative management and office based procedures fail.[6] All surgical treatments are associated with some degree of complications, including bleeding, infection, anal strictures, and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder.[1] Also, a small risk of fecal incontinence occurs, particularly of liquid,[2][39] with rates reported between 0% and 28%.[40] Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis).[41] This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse.[41]

  1. Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid primarily indicated in grade 3-4 internal hemorrhoids or mixed disease that is not responsive to conservative and less invasive treatments.[10] It is associated with significant postoperative pain and usually requires two to four weeks for recovery.[1] However, the long-term benefit is greater in those with grade III hemorrhoids as compared to rubber band ligation.[42] It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours.[6][17] Evidence to support this is weak, however.[27] Glyceryl trinitrate ointment after the procedure helps both with pain and with healing.[43] Excisional hemorrhoidectomy is the preferred method of surgical hemorrhoid removal.[10] Open excisional hemorrhoidectomy (leaving the surgical excision site to heal on its own) and closed excisions (suturing the site of hemorrhoidectomy closed) have similar outcomes with regards to complications and relapse rates.[10] Hemorrhoid recurrence rates are about 6.5% at 2 years. Common complications in the post-surgery period include urinary retention, fecal incontinence (due to swelling and inflammation affecting the anal sphincter after surgery), bleeding, and pain. The risk of these complications is 3-6%, however fecal incontinence may be permanent in rare cases.[10]
  2. Doppler-guided transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy.[1]
  3. Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids.[1] However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy,[44] so it is typically recommended only for grade II or III disease.[6]

Epidemiology

[edit]

It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider.[16][19] However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time.[1] Both sexes experience about the same incidence of the condition,[1] with rates peaking between 45 and 65 years.[5] Some studies have found that they are common in people of higher socioeconomic status,[2] however this may reflect differences in healthcare access rather than true prevalence.[14]

Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes.[16] Only a small proportion of persons end up needing surgery.[2]

History

[edit]
An 11th-century English miniature. On the right is an operation to remove hemorrhoids.

The first known mention of this disease is from a 1700 BC Egyptian papyrus, which advises: "Thou shouldest give a recipe, an ointment of great protection; acacia leaves, ground, titurated and cooked together. Smear a strip of fine linen there-with and place in the anus, that he recovers immediately."[15] In 460 BC, the Hippocratic corpus discusses a treatment similar to modern rubber band ligation: "And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not foment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of Hellebore."[15] Hemorrhoids may have been described in the Bible, with earlier English translations using the now-obsolete spelling "emerods".[5]

Celsus (25 BC – 14 AD) described ligation and excision procedures and discussed the possible complications.[45] Galen advocated severing the connection of the arteries to veins, claiming it reduced both pain and the spread of gangrene.[45] The Susruta Samhita (4th–5th century BC) is similar to the words of Hippocrates, but emphasizes wound cleanliness.[15] In the 12th century, the Jewish physician and philosopher Maimonides also composed a streatise on hemorrhoids titled Fī al-Bawāsīr, part of his series of medical writings.[46] In the 13th century, European surgeons such as Lanfranc of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene made great progress and development of the surgical techniques.[45]

In medieval times, hemorrhoids were also known as Saint Fiacre's curse after a sixth-century saint who developed them following tilling the soil.[47] The first use of the word hemorrhoid in English occurs in 1398, derived from the Old French emorroides, from Latin hæmorrhoida,[48] in turn from the Greek αἱμορροΐς (haimorrhois), 'liable to discharge blood', from αἷμα (haima), 'blood'[49] and ῥόος (rhoos), 'stream, flow, current',[50] itself from ῥέω (rheo), 'to flow, to stream'.[51]

Notable cases

[edit]
  • Hall-of-Fame baseball player George Brett was removed from a game in the 1980 World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping, "My problems are all behind me".[52] Brett underwent further hemorrhoid surgery the following spring.[53]
  • Conservative political commentator Glenn Beck underwent surgery for hemorrhoids, subsequently describing his unpleasant experience in a widely viewed 2008 YouTube video.[54][55]
  • Former U.S. President Jimmy Carter had surgery for hemorrhoids in 1984.[56]
  • Cricketers Matthew Hayden and Viv Richards have suffered the condition.[57]
  • During World War II, US Army Lieutenant Colonel Harold Cohen was selected by General George S. Patton to organize a raid to rescue Patton's son-in-law from a German prison camp; Cohen was prevented from leading the raid due to hemorrhoids.[58] Patton personally examined Cohen and remarked, "that is some sorry ass".[59]

References

[edit]
[edit]
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Hemorrhoid

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from Grokipedia
Hemorrhoids, also known as piles, are swollen and inflamed veins located in the and lower , similar to in other parts of the body. They are classified into two main types: internal hemorrhoids, which develop inside the and are often painless unless prolapsed, and external hemorrhoids, which form under the skin around the and can cause significant discomfort. This condition is highly prevalent, affecting an estimated 10 million people annually , with self-reported incidence rates around 4.4% of the , and global estimates suggesting up to 50-85% lifetime prevalence in some studies. The primary symptoms of hemorrhoids include painless during bowel movements, anal itching, pain or discomfort (particularly when sitting), and the presence of one or more hard, tender lumps near the . For internal hemorrhoids, bright red may appear on or in the bowl, while external ones often lead to swelling, , and occasional —a clot formation causing severe pain and inflammation. These symptoms can vary in severity but are typically exacerbated by straining or prolonged sitting. Hemorrhoids arise from increased pressure on the veins in the lower , often due to chronic , low-fiber diets, prolonged straining during bowel movements, or extended periods of sitting on the toilet. Other contributing factors include , (from the added pressure of the ), frequent heavy lifting, anal intercourse, and aging, which weakens the supporting tissues around the . and a can also play a role by promoting irritation or poor circulation in the area. Most cases of hemorrhoids can be effectively managed with conservative measures, such as increasing intake and using stool softeners to soften stools, using over-the-counter topical creams or ointments containing , , or local anesthetics such as lidocaine for relief from itching and pain, and taking warm sitz baths several times a day. Povidone-iodine (e.g., Betadine) is not recommended for direct application on bleeding hemorrhoids, as it can cause significant irritation, burning, and potential delay in healing. For more persistent or severe symptoms, minimally invasive procedures like (which cuts off blood supply to the hemorrhoid) or (injecting a chemical to shrink it) are common outpatient options. In rare, advanced cases involving large or thrombosed hemorrhoids, surgical interventions such as hemorrhoidectomy may be necessary to remove the affected tissue.

Definition and Classification

Definition

Hemorrhoids, also known as piles, are swollen vascular structures located in the and lower that consist of arteriovenous cushions. These cushions are normal anatomical components of the anorectum, formed by clusters of , , and connective tissue arranged in three principal columns along the . The supportive framework of these anal cushions includes and fibers, which help maintain their position and function in the healthy state. Unlike , which involve dilated and tortuous veins due to valve incompetence, hemorrhoids are not true varicosities but rather normal structures that become pathological when they engorge, , or cause symptoms through enlargement and distal displacement. This distinction corrects the longstanding misconception that hemorrhoids are simply varicose veins of the , as evidenced by histopathological studies showing their unique arteriovenous composition rather than venous dilation alone. Hemorrhoids represent a highly prevalent condition affecting the anorectal region, with estimates indicating that more than half of all adults experience them at some point in their lives. This widespread occurrence underscores their role as a common, often benign, alteration of normal when symptomatic.

Types and Classification

Hemorrhoids are primarily classified as internal or external based on their anatomical position relative to the dentate line, a in the . Internal hemorrhoids originate above the dentate line and are lined by insensate rectal mucosa, typically presenting without pain unless prolapsed. External hemorrhoids develop below the dentate line and are covered by somatically innervated anoderm and perianal skin, which can cause significant discomfort if inflamed or thrombosed. Mixed hemorrhoids, also termed interno-external, encompass vascular cushions that straddle both sides of the dentate line and may exhibit features of both internal and external types. For clinical assessment, internal hemorrhoids are graded according to the degree of prolapse using Goligher's classification system, established in 1975 and widely adopted for its prognostic value. Grade I hemorrhoids bleed but do not prolapse beyond the dentate line. Grade II hemorrhoids prolapse during straining or defecation but spontaneously reduce afterward. Grade III hemorrhoids prolapse and necessitate manual reduction by the patient. Grade IV hemorrhoids are irreducible, remaining prolapsed even with manual attempts, and often involve complications such as strangulation. Although widely used, Goligher's system has been criticized for its limitations, such as focusing primarily on prolapse and excluding external components, prompting proposals for revised classifications that incorporate additional anatomical and symptomatic factors. Thrombosed hemorrhoids represent a distinct variant where a blood clot forms within the dilated , predominantly affecting external hemorrhoids and leading to sudden, severe perianal along with a firm, bluish subcutaneous swelling. This acute thrombosis disrupts venous outflow, distinguishing it from non-thrombosed forms by its rapid onset and intensity of symptoms.

Signs and Symptoms

External Hemorrhoids

External hemorrhoids are classified as those located below the dentate line in the , distinguishing them from internal types by their position and innervation, which leads to somatic perception. The primary symptoms of external hemorrhoids include acute , swelling, itching, and perianal , often exacerbated by local trauma or of the dilated venous cushions. These manifestations arise from the sensitive anoderm covering, resulting in discomfort that can range from mild to significant tenderness upon touch or . A common complication is , where a blood clot forms within the external hemorrhoid, causing a sudden onset of severe due to the venous clot's pressure on surrounding tissues; this often presents as a firm, bluish-purple lump visible at the anal margin. The typically peaks within 48 to 72 hours and may subside over 7 to 14 days as the clot organizes, though the lump can persist. Upon resolution of the , a residual frequently develops at the site, consisting of excess perianal that may cause ongoing challenges or minor irritation. These symptoms significantly impact daily activities, with the associated and swelling leading to discomfort during prolonged sitting, bowel movements, or any activity involving anal , often limiting mobility and until resolution.

Internal Hemorrhoids

Internal hemorrhoids are vascular cushions located proximal to the dentate line within the . They are often but may present with primary symptoms including bright red , typically noticed on or in the toilet bowl after , and a sensation of or fullness in the rectal area. This bleeding results from trauma to the fragile mucosal lining during bowel movements and is usually painless. The lack of pain in internal hemorrhoids is attributed to their visceral innervation above the dentate line, which does not transmit somatic pain signals, unlike the sensitive somatic nerves below it. Patients may instead report discomfort as itching, burning, or a vague rather than acute . This innervation pattern contributes to the condition often going unnoticed until occurs. Internal hemorrhoids are classified into grades based on the degree of , which correlates with symptomatic progression. In grade I, there is no , and symptoms may be limited to occult blood; grade II involves that reduces spontaneously; grade III requires manual reduction; and grade IV features irreducible . Prolapsed internal hemorrhoids appear as enlarged venous nodes protruding outward, forming single or clustered lumps with radial (spoke-like) ridges; they may appear darker or purple, particularly with thrombosis (blood clot formation), which often causes stronger pain. This presentation helps distinguish them from rectal prolapse, which involves protrusion of the entire rectal wall (or just the mucosa), appearing as a larger, more symmetrical bulge with concentric (circular) ridges, often associated with less pain but mucus or stool leakage. As advances, symptoms escalate from isolated bleeding to include discharge, , and fecal soiling due to impaired anal closure. Irritation from prolapse stimulates increased mucus production by the mucous membrane, leading to leakage that can dry into white crusted spots in underwear, particularly with partial bulges. In severe cases, particularly with prolapsing internal hemorrhoids, patients may experience tenesmus, characterized by a persistent sensation of rectal fullness, incomplete evacuation, or an urgent need to defecate. This symptom arises from the mechanical effects of the prolapsed tissue on rectal function. Hemorrhoids do not cause upper back pain or mid back pain below the shoulder blades. Hemorrhoids cause localized symptoms in the anal and rectal area, such as pain, itching, swelling, and bleeding during bowel movements. Upper or mid back pain is typically due to musculoskeletal issues, posture, or other unrelated conditions and is not a symptom or complication of hemorrhoids. The symptoms described in this section may also signify recurrence of hemorrhoids after surgical treatment or other interventions. Recurrence may occur if underlying causes persist, and presents with similar signs, including bright red rectal bleeding during or after bowel movements, anal itching or irritation, pain or discomfort in the anal area, swelling or lumps near the anus, prolapse of hemorrhoidal tissue, sensation of rectal fullness, and mucus discharge or fecal seepage. Patients should consult a healthcare professional if symptoms return following treatment.

Causes and

Causes

Hemorrhoids develop primarily due to increased intra-abdominal pressure, which exerts force on the veins in the rectal and anal area. This pressure commonly arises from straining during bowel movements, often linked to chronic constipation, as well as from prolonged sitting on the or regularly lifting heavy objects. A low-fiber diet contributes by promoting the formation of hard stools, which necessitate greater straining and thereby elevate intra-abdominal pressure. Vascular factors, such as the weakening of connective tissues that support the hemorrhoidal cushions, play a significant role, particularly with advancing age or during when hormonal changes and uterine pressure further compromise venous support. Portal hypertension associated with liver disease leads to rectal varices, which are dilated submucosal veins that can mimic hemorrhoids but are pathophysiologically distinct. These etiological factors ultimately lead to the engorgement and of vascular structures in the .

Pathophysiology

Hemorrhoids arise from pathological changes in the anal cushions, which are normal vascular structures composed of arteriovenous sinusoids and that contribute to anal continence by providing a watertight seal during . These cushions, located above the dentate line, normally engorge to prevent fecal leakage but become symptomatic when they enlarge, , or undergo due to disrupted vascular dynamics. The engorgement process begins with arterial hyperperfusion into the venous , often resulting from impaired in the arteriovenous shunts and lax internal support, leading to sinusoidal congestion and dilation. This overflow is exacerbated by increased intra-abdominal pressure from factors such as straining, which impairs venous return and promotes vascular engorgement. Tissue degeneration plays a central role in progression, involving the loss of supportive and within the anal cushions, which weakens their attachment to the underlying structures like Treitz's muscle and Park's ligament. Overexpression of matrix metalloproteinase-9 (MMP-9) contributes to this breakdown by degrading elastic fibers, resulting in cushion , , and eventual as the tissues lose elasticity with age or . Shear forces from repeated straining further accelerate deterioration, allowing the cushions to displace downward and become fixed in a prolapsed position. Inflammation and emerge as consequences of these vascular and structural alterations, with chronic causing venous wall dilation, blood stagnation, and hypercoagulability that fosters clot formation within the congested sinusoids. Inflammatory responses, including mucosal ulceration and erosion of arteriolar walls, intensify with , leading to ischemia and potential in severe cases. When displaced, the anal cushions shift from their physiological role in continence to a pathological state, where engorged and inflamed tissues cause ongoing vascular distortion and symptomatic disease.

Diagnosis

Physical Examination

The physical examination for hemorrhoids begins with a thorough external inspection of the perianal region, where the healthcare provider visually assesses for signs of swelling, , or skin tags. This involves gently spreading the to examine the anoderm for lumps, prolapsed tissue, bluish tender masses indicative of , or other abnormalities such as irritation or fissures. External hemorrhoids or prolapsed internal ones may be immediately apparent during this step, particularly if the patient bears down to simulate straining. Following external inspection, a digital rectal examination (DRE) is performed to evaluate internal structures. The provider inserts a gloved, lubricated finger into the to assess for tenderness, masses, tone, or the presence of and . This maneuver can detect enlarged or thrombosed internal hemorrhoids if they are palpable, though softer ones may not be felt. Topical anesthetics, such as lidocaine ointment, may be applied to minimize discomfort during the procedure. Optimal patient positioning enhances visualization and access during the examination, with common options including the left lateral decubitus position with knees flexed toward the chest, , or prone jackknife. The left lateral position is often preferred for the DRE to allow relaxation of the anal sphincter. Despite its utility, the has limitations, particularly in detecting higher or non-prolapsed internal hemorrhoids, which may require additional for confirmation. The DRE is less effective for soft vascular lesions unless they are significantly enlarged or thrombosed.

Anoscopy and Imaging

Anoscopy is a diagnostic procedure that employs a short, rigid, lighted tube called an anoscope to directly visualize the anal canal and distal rectum, enabling the identification and characterization of internal hemorrhoids, particularly grades I through III, which do not prolapse beyond the anal verge. The procedure begins with a digital rectal examination to assess for any obstructions or tenderness, followed by lubrication of the anoscope with a topical anesthetic such as 2% lidocaine jelly applied 10 minutes prior to insertion. The patient is positioned in the left lateral decubitus or knee-chest stance, and the anoscope is gently inserted through the anus with the obturator in place to ease entry; once fully inserted, the obturator is removed, allowing illumination and inspection of the mucosal lining for vascular cushions indicative of hemorrhoidal enlargement. Patients may be asked to bear down to simulate defecation, which can reveal prolapse in grade II or III hemorrhoids, and the exam typically lasts 5 to 10 minutes without the need for sedation due to the visceral innervation above the dentate line minimizing discomfort. This technique offers higher sensitivity for detecting anorectal pathology compared to flexible sigmoidoscopy alone. For evaluation of potential higher-grade lesions or when biopsy is required, proctoscopy or sigmoidoscopy may be performed as adjunctive procedures to extend visualization beyond the distal rectum. Proctoscopy, also known as rigid sigmoidoscopy, utilizes a straight, hollow proctoscope approximately 10 inches long to examine the rectum and lower sigmoid colon, identifying sources of bleeding or inflammation associated with hemorrhoids while allowing for tissue sampling if suspicious areas are noted. The procedure involves insufflation of air to expand the rectal walls for better views and is conducted in an office setting without anesthesia, taking 5 to 15 minutes. Flexible sigmoidoscopy, in contrast, employs a bendable endoscope to assess the rectum and sigmoid colon up to about 60 cm, useful for confirming hemorrhoidal involvement in cases of persistent symptoms or to rule out proximal pathology, with the capability to perform biopsies via forceps passed through the scope. These methods are particularly indicated when anoscopy alone is insufficient for assessing grade IV hemorrhoids or associated complications. Imaging modalities such as endoanal and (MRI) are rarely employed for routine hemorrhoid diagnosis but play a role in complex cases involving integrity or extensive anorectal involvement. Endoanal provides high-resolution, real-time of the anal cushions and using a transrectal or transperineal probe, detecting hemodynamic abnormalities like mosaic patterns of blood flow in grades III and IV hemorrhoids that correlate with arteriovenous shunts, thereby aiding in preoperative planning without direct disruption. It is valuable for evaluating involvement in recurrent or complicated hemorrhoidal , offering morphological and functional insights through three-dimensional reconstruction. MRI of the anal region, utilizing T2-weighted and gadolinium-enhanced sequences, is reserved for intricate scenarios such as suspected fistulas or abscesses coexisting with hemorrhoids, providing multiplanar soft-tissue contrast to delineate extent and guide surgical intervention. Preparation for these procedures emphasizes bowel clearance to optimize visualization, typically involving a single administered 1 to 2 hours prior to the exam to evacuate the without requiring full colonic purgation. For and , this minimal preparation suffices, as no or extensive is needed, though patients are advised to empty their bowels naturally if possible. In , more thorough prep with clear and laxatives may be recommended to ensure the lower colon is accessible. Adjustments to medications like anticoagulants should be discussed in advance to minimize risks during instrumentation.

Differential Diagnosis

Hemorrhoids often present with symptoms such as , pain, or protrusion that can mimic other anorectal disorders, necessitating careful clinical differentiation. Common mimics include anal fissures, which are linear tears in the anal mucosa causing severe, sharp pain during and bright red , in contrast to the often painless bleeding associated with internal hemorrhoids. Perianal abscesses present with localized swelling, tenderness, and possible fever or drainage, distinguishing them from the vascular cushions of hemorrhoids through palpable induration and systemic signs of . More serious differential diagnoses must be excluded, particularly in atypical presentations. may manifest with persistent , unexplained weight loss, or changes in bowel habits, unlike the intermittent symptoms typical of hemorrhoids. , such as or , can cause accompanied by chronic , , and systemic symptoms like , setting it apart from isolated anorectal complaints. Other conditions like must be distinguished from prolapsed hemorrhoids. Prolapsed hemorrhoids are enlarged venous nodes that protrude outward, appearing as single or clustered lumps with radial (spoke-like) ridges; they may be darker or purple, with pain often stronger if thrombosed (clotted). In contrast, rectal prolapse involves protrusion of the entire rectal wall (or just the mucosa), presenting as a larger, more symmetrical bulge with concentric (circular) ridges; it is often less painful but associated with mucus or stool leakage. Fistulas feature chronic drainage from recurrent abscesses. Distinguishing these conditions relies on history and physical examination findings, with colonoscopy recommended for persistent or unexplained bleeding to rule out polyps, tumors, or other malignancies. Red flags prompting further investigation include new-onset symptoms in patients over 50 years of age, anemia, or involuntary weight loss, as these increase the likelihood of underlying colorectal pathology.

Prevention

Dietary Measures

Dietary measures play a crucial role in preventing hemorrhoids by promoting regular bowel movements and reducing the need for straining during . Increasing intake to 25-30 grams per day is recommended, primarily from sources such as fruits, , and whole grains, which help bulk up stool and facilitate easier passage through the intestines. Adequate hydration complements consumption by softening stools and preventing , a key for hemorrhoid development. experts advise consuming 8-10 glasses of daily to support this process, adjusting intake based on individual factors like activity level and climate. Specific high- foods can be incorporated to achieve these goals, including prunes for their effect due to content, from whole grains to add bulk, and supplements like husk, which absorbs to form a gel-like substance that eases bowel movements. Clinical evidence supports the efficacy of these measures; for instance, supplementation has been shown to reduce the recurrence of associated with hemorrhoids by approximately 50%, thereby aiding in prevention when adopted consistently.

Lifestyle Modifications

Lifestyle modifications play a crucial role in preventing and managing internal hemorrhoids by reducing intra-abdominal pressure and promoting anorectal health. These changes focus on daily habits that alleviate strain on rectal veins, which can otherwise lead to swelling and . Adopting such practices is particularly important for individuals at risk, as they help maintain regular bowel function without exacerbating underlying related to venous congestion. To avoid straining during , individuals should avoid prolonged sitting on the , as this increases on the anal cushions and contributes to hemorrhoid formation. Using a to elevate the feet into a can straighten the anorectal angle, facilitating easier passage of stool and reducing the need for excessive force. These measures minimize the Valsalva maneuver's impact, which temporarily elevates intra-abdominal and strains hemorrhoidal veins. Weight management is essential, as significantly elevates the risk of hemorrhoids through increased intra-abdominal pressure and chronic . Studies indicate a causal association between higher (BMI) and hemorrhoidal disease, with each unit increase in BMI raising risk by approximately 3.5%. Maintaining a healthy weight via balanced habits reduces pelvic strain, thereby supporting anorectal integrity and preventing symptom progression. Regular exercise promotes prevention by enhancing bowel motility and circulation, which helps avert —a key contributor to straining. Moderate activities such as walking or for 20–60 minutes, 3–5 days per week, are recommended to support digestive regularity without undue pressure. However, heavy lifting and exercises involving the , like weightlifting or intense squats, should be avoided, as they acutely increase intra-abdominal pressure and can provoke or worsen hemorrhoids. Proper practices prevent irritation and secondary complications by maintaining a clean perianal area. Gentle cleaning after bowel movements using lukewarm and fragrance-free wipes or mild avoids harsh rubbing, which can inflame sensitive tissues. Pat dry softly and wear breathable underwear to keep the area dry, reducing the risk of bacterial overgrowth and discomfort associated with hemorrhoids. Sitz baths in warm for 10–15 minutes several times daily can further soothe the region without aggressive scrubbing.

Management

Conservative Treatments

Conservative treatments represent the first-line approach for managing mild to moderate hemorrhoids, focusing on symptom relief through non-invasive measures that address itching, , swelling, and without procedural interventions. These therapies are particularly effective for grades I and II hemorrhoids, where symptoms can often be alleviated by improving bowel habits and reducing local irritation. Topical agents are commonly used to soothe external symptoms, particularly for bleeding hemorrhoids. Safe over-the-counter options include hydrocortisone (1%) creams to reduce inflammation and itching, witch hazel-based products (e.g., Tucks pads) for soothing, local anesthetics like lidocaine or pramoxine for pain relief, and combination products like Preparation H or Anusol. Hydrocortisone creams reduce itching and inflammation by suppressing local immune responses, while , an found in over-the-counter preparations like , provides temporary relief from discomfort and swelling through its vasoconstrictive and properties. Povidone-iodine (e.g., Betadine) is not recommended or considered safe for direct application on bleeding hemorrhoids, as it can cause significant irritation, burning, stinging, and potential delay in healing of the sensitive anal tissue. It is not a standard treatment according to medical authorities. Patients should always consult a healthcare provider before using any product on bleeding areas. In the UK, stronger prescription-only steroid-anesthetic combinations, such as Proctosedyl or Scheriproct, are available for treating hemorrhoids and offer more potent relief compared to over-the-counter options. These should be applied as directed, typically for up to one week to avoid side effects such as thinning or dryness. For bleeding hemorrhoids specifically, priority should be given to a high-fiber diet, stool softeners, sitz baths, and avoiding straining. Oral medications target underlying contributors to hemorrhoid exacerbation, such as . Fiber supplements, including husk, increase stool bulk and softness, moderately improving overall symptoms and reducing as supported by meta-analyses; a daily intake of 25-30 grams is often recommended alongside adequate fluid consumption. Stool softeners like docusate sodium facilitate easier passage of stool by drawing water into it, minimizing straining during and thereby decreasing pressure on hemorrhoidal veins. These are typically used for 1-2 weeks or until bowel regularity is achieved. For temporary relief of symptoms associated with prolapsed hemorrhoids, promoting soft stools through increased dietary fiber intake, plenty of fluids, and mild stool softeners after consulting a pharmacist is particularly emphasized, along with encouraging rest and avoiding lying on the back for extended periods to reduce rectal pressure. Sitz baths involve soaking the perianal area in lukewarm for 10-15 minutes, 2-3 times daily, to promote blood flow, reduce swelling, and alleviate pain and itching through relaxation of the anal sphincter. For prolapsed hemorrhoids, the water can optionally be infused with chamomile for added soothing effects. No additives are necessary, and this simple measure can be performed at home using a or specialized basin. For pain management, particularly in thrombosed hemorrhoids, over-the-counter nonsteroidal anti-inflammatory drugs such as ibuprofen are recommended to reduce inflammation and provide pain relief, at a dosage of 400-600 mg every 8 hours with food to minimize gastrointestinal irritation. If unable to take ibuprofen due to contraindications, paracetamol (acetaminophen) may be used instead, at 500-1000 mg every 6-8 hours. Doses should be followed strictly, and a doctor consulted for personal suitability. Acetaminophen provides effective relief from discomfort without anti-inflammatory effects that might irritate the . Topical lidocaine gels or ointments numb the area locally to ease acute pain and itching, often combined with other topicals for short-term use of 1-2 weeks. Patients are advised to consult a healthcare provider if symptoms persist beyond this period or worsen. Medical attention should be sought urgently for hemorrhoid-related bleeding if it persists beyond 3-7 days, was initially profuse, or is accompanied by new symptoms such as severe pain, fever, extreme weakness, black stool, or mucus in stool; prompt evaluation is recommended even if bleeding has decreased to rule out complications or other conditions. Additionally, seek care if symptoms do not improve after one week of conservative treatment, heavy bleeding, changes in bowel habits, presence of a hard lump, intense pain, or abnormal stool color, as these may indicate other serious conditions such as colorectal cancer. Consultation with a colorectal or gastroenterology specialist is recommended, which may involve a digital rectal examination, anoscopy, or colonoscopy. With consistent conservative management, including dietary fiber, stool softeners, sitz baths, and other supportive measures, symptoms in mild cases often resolve in a few days to 1-2 weeks. During this period, gradual resumption of light exercise is generally possible while avoiding straining or heavy lifting to support healing and prevent exacerbation.

Minimally Invasive Procedures

Minimally invasive procedures represent a cornerstone in the management of symptomatic grade II and III internal hemorrhoids, providing effective symptom relief through outpatient interventions that target vascular supply or tissue shrinkage while minimizing recovery time and complications compared to traditional surgery. These techniques are particularly suited for patients with bleeding or prolapse who do not respond to conservative measures, achieving durable results in the majority of cases with minimal anesthesia requirements. Rubber band ligation involves placing small rubber bands around the base of an internal hemorrhoid using an anoscope, which cuts off the blood supply and leads to and sloughing of the banded tissue within 5-7 days. This procedure is performed in an office setting and can treat multiple hemorrhoids in a single session, with reported success rates ranging from 69% to 97% depending on the grade and follow-up duration. Recurrence may occur in up to 30% of cases over long-term follow-up, often manageable with repeat banding. Sclerotherapy entails injecting a chemical sclerosant, such as or phenol in oil, directly into the hemorrhoid base to induce and , thereby shrinking the vascular cushions. Administered via an anoscope without , it is quick and well-tolerated, with clinical success rates of 80-90% for grade II and III hemorrhoids, particularly in controlling . Multiple injections may be needed for optimal results, and it is less effective for prolapsing hemorrhoids compared to ligation methods. Infrared coagulation applies targeted infrared light energy through a probe inserted via anoscope, generating heat that coagulates tissue proteins and induces scarring to reduce hemorrhoid size. This non-contact method penetrates about 2.5 mm and requires 3-4 applications per hemorrhoid, yielding success rates of 67-96% in alleviating symptoms like bleeding for low-grade internal hemorrhoids. It is favored for its simplicity and low pain profile, though recurrence rates can reach 20-30% over 1-2 years. Laser hemorrhoidoplasty (LHP) is an emerging minimally invasive technique that uses to ablate and shrink hemorrhoidal tissue, often performed under in an outpatient setting. It is suitable for grades II-IV hemorrhoids, offering reduced postoperative , minimal , and quick recovery, with clinical rates of 80-95% in symptom control as per 2024 recommendations. Hemorrhoidal artery ligation, often Doppler-guided (DG-HAL), uses a specialized proctoscope with an integrated Doppler probe to identify and suture-ligate the terminal branches of the superior rectal , reducing arterial inflow to the hemorrhoidal and promoting shrinkage. Performed under , it addresses multiple arterial sites (typically 6-8) and may include mucopexy for , with overall rates exceeding 90% and recurrence below 10% at 1-year follow-up. This technique is emerging as a less painful option for grade II-IV hemorrhoids, preserving anal function. Hemorrhoidal artery embolization (HAE), also known as emborrhoid technique, is a catheter-based procedure where embolic agents like particles or coils are deployed via femoral access to occlude the superior rectal supplying the hemorrhoids. Suitable for severe or recurrent cases, it achieves technical success in 98-100% of procedures and clinical improvement in 79-94% of patients, particularly for control, with minimal post-procedural . Long-term data remain limited, but it offers a non-surgical alternative for patients unfit for other interventions. Recovery after minimally invasive procedures (e.g., rubber band ligation, sclerotherapy, infrared coagulation, laser hemorrhoidoplasty, hemorrhoidal artery ligation, and embolization) typically allows return to normal activities within days, though heavy exercise or strenuous activities should be avoided initially to support healing.

Surgical Options

Surgical options are reserved for advanced hemorrhoids, particularly grades III and IV, that do not respond to conservative or minimally invasive treatments, as well as cases involving or other complications such as strangulation. These procedures typically require general or regional and involve a stay, contrasting with outpatient interventions. Common indications include persistent , refractory , or mixed internal-external hemorrhoids with significant external components. Hemorrhoidectomy remains the gold standard for severe, grade III and IV hemorrhoids, involving the excision of hemorrhoidal cushions using open (Milligan-Morgan) or closed (Ferguson) techniques, often with electrocautery or energy devices like LigaSure for . This procedure achieves excellent long-term symptom control with a success rate of approximately 95% and low recurrence, making it particularly effective for incarcerated or thrombosed hemorrhoids. However, it is associated with significant postoperative pain that typically subsides within about 2 weeks and requires multimodal analgesia including opioids and nonsteroidal anti-inflammatory drugs. Recovery generally takes 2-4 weeks, with resumption of strenuous exercise or manual labor recommended after 6-8 weeks to ensure proper healing. To support recovery and prevent constipation, which can exacerbate pain and delay healing, patients are encouraged to follow a high-fiber diet, gradually increasing fiber intake. Recommended foods include fruits such as prunes, green leafy vegetables, whole grains, and plenty of fluids—at least 8 glasses of water daily. Prune juice or unfiltered apple juice can provide natural laxative effects. Foods to avoid include spicy foods (which can cause irritation during bowel movements), low-fiber foods, dairy products, red meat, processed foods, sugary items, and caffeine (which can contribute to constipation). Stool softeners and adequate hydration are typically recommended to avoid straining. Stapled hemorrhoidopexy, also known as procedure for and hemorrhoids (PPH), addresses prolapsing internal hemorrhoids by using a circular stapling device to resect redundant rectal mucosa approximately 4 cm above the dentate line, thereby elevating the hemorrhoidal cushions and interrupting blood supply. It is indicated for grade III and IV hemorrhoids with circumferential that have failed nonoperative , offering advantages such as reduced postoperative pain and faster recovery compared to traditional excision, with patients returning to work in about 6-8 days. Despite these benefits, it carries risks of (known as post-stapling syndrome in 1.6-15% of cases), bleeding (up to 9%), and rare but serious complications like pelvic or . Doppler-guided hemorrhoidal artery ligation with rectoanal repair (HAL-RAR) combines selective ligation of terminal hemorrhoidal arteries identified via Doppler with a mucopexy (rectoanal repair) using absorbable sutures to lift prolapsed mucosa, typically performed under regional . This technique is suitable for grade II-IV hemorrhoids unresponsive to prior therapies, particularly those with and , and provides symptom relief in about 94% of grade IV cases with minimal disruption to anal function. It results in low morbidity, with operating times of 20-35 minutes and quick resumption of activities, though recurrence rates for can reach 9-28%. Across these surgical approaches, potential risks include (2-36%), postoperative bleeding (0.03-6%), anal stenosis (0-6%), and (2-12%), with the choice of procedure guided by hemorrhoid grade, patient comorbidities, and surgeon expertise to balance efficacy and recovery. Postoperative care universally emphasizes pain control, stool softeners, and sitz baths to mitigate complications like or delayed .

Complications and Prognosis

Common Complications

One of the most frequent complications of hemorrhoids is , particularly from internal hemorrhoids, which can lead to chronic blood loss and, in rare cases, due to recurrent internal hemorrhage. from hemorrhoidal bleeding has an incidence of approximately 0.5 patients per 100,000 population per year, often affecting individuals with grade 2 or 3 internal hemorrhoids, and typically resolves rapidly after treatment such as hemorrhoidectomy, with hemoglobin levels improving from a mean of 9.4 g/dL pre-treatment to 14.1 g/dL at six months post-treatment. Thrombosis, or the formation of a clot within an external hemorrhoid, commonly results in acute , swelling, and , presenting as a hard, discolored lump near the . This complication is particularly prevalent in external hemorrhoids and can cause severe discomfort, often requiring prompt intervention like excision within 2-3 days to alleviate symptoms. Infection represents another common issue, potentially leading to perianal or , especially arising from associated anal fissures or following procedures. Perianal occur frequently after surgical interventions for hemorrhoids and can manifest as localized if not addressed. Strangulation occurs when prolapsed internal hemorrhoids (typically grades III or IV) become irreducible, compromising the blood supply and leading to ulceration, , and extreme pain. This situation demands urgent evaluation and may necessitate surgical intervention to restore circulation. Post-treatment complications, particularly after procedures like hemorrhoidectomy, often include pain and . Pain is the most common issue following , affecting a significant portion of patients, while arises in up to 15-39% of cases depending on type and technique, with lower rates observed in stapled hemorrhoidectomy compared to conventional methods.

Prognosis

The prognosis for hemorrhoidal disease is generally favorable, with most cases achieving symptom resolution and improved quality of life following appropriate treatment, though recurrence remains a common concern influenced by multiple factors. Conservative and procedural interventions effectively manage symptoms in the majority of patients, allowing return to normal activities within days to weeks, depending on the severity and treatment modality. Recurrence rates after treatment typically range from 10% to 20% for surgical and minimally invasive procedures, based on long-term follow-up studies, but can reach up to 56% in without sustained lifestyle interventions. Higher recurrence is observed with non-surgical approaches alone, often exceeding 50% if predisposing habits like straining persist. Adherence to post-treatment preventive strategies significantly lowers these rates by addressing underlying venous pressures. Key factors affecting recovery and recurrence include the initial grade of hemorrhoids, where advanced grades (III and IV) correlate with poorer long-term outcomes and higher risk due to greater and tissue damage. Patient compliance with preventive measures, such as increased intake and regular exercise, is essential for sustained remission, as non-compliance doubles the likelihood of symptom return. Comorbidities like and chronic exacerbate recurrence by promoting sustained intra-abdominal pressure and impaired venous return. Most patients report substantial enhancements in after treatment, with resolution of and enabling better daily functioning; however, chronic or recurrent hemorrhoids can result in persistent discomfort, anxiety, and limitations in . Surgical success rates exceed 90% in alleviating symptoms long-term for suitable candidates, though individual variability persists. Direct mortality from hemorrhoids is negligible, as the condition is benign; prolapsed hemorrhoids accompanied by fibrous anal polyps typically represent a benign, chronic issue and are not dangerous absent other pathological changes. Indirect risks arise from chronic bleeding causing , which can lead to severe complications like if unmanaged. Additionally, symptom similarity may delay diagnosis, indirectly contributing to worse cancer prognosis in misattributed cases.

Epidemiology

Prevalence and Distribution

Hemorrhoids are a ubiquitous condition, with lifetime prevalence estimates indicating that approximately 50% of adults experience them by age 50, with prevalence increasing to over 50% in adults older than 50 years, based on recent studies. Globally, the condition affects individuals across all ages and genders, though many cases remain undiagnosed due to their often nature. Recent studies from the 2020s report a wide symptomatic range of 4-86%, reflecting variations in diagnostic criteria and population screening methods. appears higher in Western and developed countries, where low-fiber diets contribute to increased risk through chronic and straining. In contrast, lower rates are observed in regions with higher intake, underscoring the role of lifestyle factors in distribution. As of 2024, global lifetime estimates range from 50-70% in various populations. Incidence peaks between ages 45 and 65 for both men and women, showing overall in the general population. However, women face elevated risk during due to increased intra-abdominal pressure and hormonal changes. A significant proportion of cases may be or self-managed without medical consultation, leading to skewed epidemiological data.

Demographic Variations

Hemorrhoids are uncommon in individuals under 20 years of age, with development before this age occurring in about 4.3% of cases, primarily due to the resilience of supporting tissues in younger populations. Prevalence increases with age, becoming more common after age 30, with a peak incidence between 45 and 65 years and affecting more than half of people over age 50 (although some studies indicate a decrease in prevalence after age 65), as the connective tissues supporting the rectal veins weaken and stretch, facilitating venous dilation and . Overall is similar between genders, affecting both men and women comparably in the general . However, women experience a higher incidence during , with estimates indicating that 25% to 35% of pregnant individuals develop symptomatic hemorrhoids due to increased pelvic pressure and hormonal changes that relax vascular walls. Geographically, hemorrhoids are more in industrialized nations, where dietary habits often include lower intake, leading to harder stools and greater straining during . Ethnically, Caucasians exhibit higher rates than , with among whites approximately 1.5 times greater across all age groups, potentially linked to differences in diet, socioeconomic factors, and bowel habits. Certain comorbidities elevate the risk of hemorrhoids. In patients with and associated , prevalence is heightened, ranging from 21% to 36%, as elevated venous pressure contributes to anorectal vascular engorgement. Similarly, individuals with (IBD) face an increased likelihood, with symptomatic hemorrhoids occurring in 3.3% to 20.7% of cases, often exacerbated by chronic inflammation, , and straining.

History

Etymology and Early Descriptions

The term "hemorrhoid" originates from the word haimorrhois, a compound of haima (blood) and rhein (to flow), literally meaning "that which flows with blood." This nomenclature was first applied by (c. 460–370 BCE), the "Father of ," to describe the bleeding condition arising from dilated rectal veins.00017-7/fulltext) The earliest systematic medical descriptions appear in the , a compilation of texts from the 5th–4th centuries BCE attributed to and his school. These works detail symptoms such as , pain, and , attributing the condition to imbalances in bodily humors like or heating the rectal veins. Treatments emphasized non-surgical interventions, including herbal suppositories composed of astringent substances like myrtle or to staunch bleeding and reduce swelling. By the CE, the Roman encyclopedist expanded on these ideas in De Medicina, advocating surgical excision for severe cases, often preceded by ligation with threads to control bleeding. Biblical texts also reference the affliction, using the archaic English term "emerods" (from Hebrew teḥorim, denoting tumors or swellings) in Deuteronomy 28:27 as one of the curses for covenant disobedience, likely alluding to painful, bleeding rectal growths. In medieval Islamic medicine, Avicenna (Ibn Sina, 980–1037 CE) provided comprehensive accounts in his Canon of Medicine, classifying hemorrhoids by type and severity while prioritizing conservative herbal remedies. He recommended topical applications and internal decoctions of plants such as oak galls, sumac, and rose for their astringent, anti-inflammatory, and hemostatic effects to alleviate symptoms without surgery.

Evolution of Treatments

The treatment of hemorrhoids has evolved significantly from rudimentary ancient methods to sophisticated minimally invasive techniques, reflecting advances in medical understanding and technology. In ancient times, Hippocrates (460–375 BC), often regarded as the father of medicine, described the first surgical interventions, including cauterization using red-hot irons to burn the hemorrhoidal tissue, ligation with thread to tie off the veins, and excision to remove the swollen tissue. These procedures, detailed in the Hippocratic Corpus, aimed to control bleeding and prolapse but were painful and carried risks of infection. During the Middle Ages, conservative approaches dominated due to limited surgical capabilities, with herbal poultices made from plants like aloe and myrrh applied topically to soothe inflammation and promote healing, as documented in medieval Persian medical texts. The 19th century marked the advent of more systematic surgical excision, with British surgeon Frederick Salmon introducing anal stretching in 1835 and later refining open hemorrhoidectomy techniques that influenced modern practices. In 1882, Walter Whitehead advanced the field by developing a radical excision method for circumferential hemorrhoids, involving complete removal of the affected tissue, though it was later modified due to high complication rates like anal . also emerged around this time, pioneered by James Morgan in , who injected iron to shrink veins, offering a less invasive alternative to . The 20th century brought refinements in both surgical and non-surgical options. In 1937, Edward Milligan and Morgan standardized the open hemorrhoidectomy, emphasizing preservation of sensitive anal skin bridges to minimize pain and incontinence, a technique that remains a gold standard. Rubber band ligation, introduced by Paul Blaisdell in the 1950s and popularized by Lawrence Barron in 1963, represented a major shift toward office-based procedures by strangulating the hemorrhoid base with a rubber band to induce necrosis and sloughing. By the 1990s, stapled hemorrhoidopexy, first described by Antonio Longo in 1998, utilized circular staplers to resect redundant rectal mucosa and elevate prolapsed hemorrhoids, reducing postoperative pain compared to traditional excision while promoting faster recovery. In the , the focus has shifted to minimally invasive outpatient treatments, exemplified by hemorrhoidal artery embolization (HAE), which gained traction in the as a non-surgical option involving catheter-based occlusion of feeding arteries to shrink hemorrhoids, with initial reports dating back to and showing high efficacy for grades I-III disease. This procedure, performed under , aligns with broader trends toward reduced invasiveness and quicker return to daily activities. Culturally, treatments transitioned from a subject shrouded in stigma to routine medical care, spurred by the 1970s dietary fiber hypothesis advanced by Denis Burkitt, which linked low-fiber diets to and hemorrhoids, promoting preventive high-fiber intake and destigmatizing discussions of anorectal health.

References

  1. https://www.mayoclinic.org/diseases-conditions/hemorrhoids/symptoms-causes/syc-20360268
  2. https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids
  3. https://pmc.ncbi.nlm.nih.gov/articles/PMC4755769/
  4. https://pmc.ncbi.nlm.nih.gov/articles/PMC10840063/
  5. https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/symptoms-causes
  6. https://medlineplus.gov/hemorrhoids.html
  7. https://www.mayoclinic.org/diseases-conditions/hemorrhoids/diagnosis-treatment/drc-20360280
  8. https://www.ncbi.nlm.nih.gov/books/NBK537182/
  9. https://pmc.ncbi.nlm.nih.gov/articles/PMC7075634/
  10. https://pmc.ncbi.nlm.nih.gov/articles/PMC6479658/
  11. https://pmc.ncbi.nlm.nih.gov/articles/PMC3342598/
  12. https://www.ncbi.nlm.nih.gov/books/NBK279467/
  13. https://pmc.ncbi.nlm.nih.gov/articles/PMC9246490/
  14. https://www.aafp.org/pubs/afp/issues/2011/0715/p204.html
  15. https://pmc.ncbi.nlm.nih.gov/articles/PMC10603225/
  16. https://pmc.ncbi.nlm.nih.gov/articles/PMC6478596/
  17. https://www.ncbi.nlm.nih.gov/books/NBK500009/
  18. https://my.clevelandclinic.org/health/diseases/15120-hemorrhoids
  19. https://my.clevelandclinic.org/health/diseases/thrombosed-hemorrhoids
  20. https://arksurgicalpractice.com.sg/anal-rectal-conditions-singapore/rectal-prolapse-vs-hemorrhoids-key-differences-explained/
  21. https://pmc.ncbi.nlm.nih.gov/articles/PMC5012736/
  22. https://my.clevelandclinic.org/health/diseases/prolapsed-hemorrhoids
  23. https://my.clevelandclinic.org/health/diseases/14615-rectal-prolapse
  24. https://www.webmd.com/digestive-disorders/understanding-hemorrhoids-basics
  25. https://www.sciencedirect.com/science/article/pii/S0140673689917248
  26. https://emedicine.medscape.com/article/775407-overview
  27. https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/diagnosis
  28. https://emedicine.medscape.com/article/775407-clinical
  29. https://www.aafp.org/pubs/afp/issues/2018/0201/p172.html
  30. https://www.ncbi.nlm.nih.gov/books/NBK459324/
  31. https://my.clevelandclinic.org/health/procedures/10749-proctoscopy
  32. https://www.mayoclinic.org/tests-procedures/flexible-sigmoidoscopy/about/pac-20394189
  33. https://pmc.ncbi.nlm.nih.gov/articles/PMC7708963/
  34. https://pmc.ncbi.nlm.nih.gov/articles/PMC5449423/
  35. https://pmc.ncbi.nlm.nih.gov/articles/PMC5467076/
  36. https://my.clevelandclinic.org/health/treatments/24993-anoscopy
  37. https://emedicine.medscape.com/article/775407-differential
  38. https://www.uptodate.com/contents/hemorrhoids-clinical-manifestations-and-diagnosis
  39. https://pmc.ncbi.nlm.nih.gov/articles/PMC3140328/
  40. https://www.webmd.com/digestive-disorders/best-worst-foods-hemorrhoids
  41. https://www.healthline.com/nutrition/food-for-piles
  42. https://www.ernestcastromd.com/blog/preventing-hemorrhoids-through-diet
  43. https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/eating-diet-nutrition
  44. https://www.medicalnewstoday.com/articles/hemorrhoids-high-fiber-diet
  45. https://pmc.ncbi.nlm.nih.gov/articles/PMC8416428/
  46. https://health.clevelandclinic.org/5-simple-ways-you-can-prevent-hemorrhoids
  47. https://pmc.ncbi.nlm.nih.gov/articles/PMC10587414/
  48. https://www.healthline.com/health/exercises-for-hemorrhoids
  49. https://www.health.harvard.edu/blog/natural-remedies-for-hemorrhoid-2021022321942
  50. https://pmc.ncbi.nlm.nih.gov/articles/PMC2244760/
  51. https://www.mayoclinic.org/drugs-supplements/povidone-iodine-topical-route/side-effects/drg-20068745
  52. https://www.pharmacyplanet.com/proctosedyl-ointment.html
  53. https://www.prescriptiondoctor.com/haemorrhoids/scheriproct
  54. https://www.mayoclinic.org/medical-professionals/digestive-diseases/news/hemorrhoidal-disease-diagnosis-and-management/mac-20430067
  55. https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/treatment
  56. https://pmc.ncbi.nlm.nih.gov/articles/PMC5711722/
  57. https://pmc.ncbi.nlm.nih.gov/articles/PMC3057743/
  58. https://pmc.ncbi.nlm.nih.gov/articles/PMC12128686/
  59. https://www.aafp.org/pubs/afp/issues/2002/0415/p1641.html
  60. https://pmc.ncbi.nlm.nih.gov/articles/PMC6223991/
  61. https://pmc.ncbi.nlm.nih.gov/articles/PMC9876604/
  62. https://pmc.ncbi.nlm.nih.gov/articles/PMC5037334/
  63. https://pmc.ncbi.nlm.nih.gov/articles/PMC3103797/
  64. https://pmc.ncbi.nlm.nih.gov/articles/PMC9474687/
  65. https://pmc.ncbi.nlm.nih.gov/articles/PMC3259422/
  66. https://pmc.ncbi.nlm.nih.gov/articles/PMC5775951/
  67. https://pmc.ncbi.nlm.nih.gov/articles/PMC11585511/
  68. https://pmc.ncbi.nlm.nih.gov/articles/PMC3324335/
  69. https://pmc.ncbi.nlm.nih.gov/articles/PMC4807324/
  70. https://pmc.ncbi.nlm.nih.gov/articles/PMC11097269/
  71. https://pmc.ncbi.nlm.nih.gov/articles/PMC11088570/
  72. https://www.ncbi.nlm.nih.gov/books/NBK549864/
  73. https://pmc.ncbi.nlm.nih.gov/articles/PMC4258566/
  74. https://pmc.ncbi.nlm.nih.gov/articles/PMC4675486/
  75. https://my.clevelandclinic.org/health/procedures/hemorrhoidectomy
  76. https://mydoctor.kaiserpermanente.org/ncal/Images/Hemorrhoidectomy%20Care%208-12_tcm75-618832.pdf
  77. https://pubmed.ncbi.nlm.nih.gov/7924705/
  78. https://pubmed.ncbi.nlm.nih.gov/29431977/
  79. https://pubmed.ncbi.nlm.nih.gov/32250228/
  80. https://pmc.ncbi.nlm.nih.gov/articles/PMC6928486/
  81. https://pubmed.ncbi.nlm.nih.gov/27468181/
  82. https://pubmed.ncbi.nlm.nih.gov/17098654/
  83. https://pmc.ncbi.nlm.nih.gov/articles/PMC9978033/
  84. https://pmc.ncbi.nlm.nih.gov/articles/PMC9859842/
  85. https://pubmed.ncbi.nlm.nih.gov/15486746/
  86. https://pmc.ncbi.nlm.nih.gov/articles/PMC7187474/
  87. https://surgery.ucsf.edu/procedure/hemorrhoidectomy
  88. https://www.pathologyoutlines.com/topic/anushypertrophiedpapillae.html
  89. https://pmc.ncbi.nlm.nih.gov/articles/PMC4576300/
  90. https://pmc.ncbi.nlm.nih.gov/articles/PMC8394877/
  91. https://www.hopkinsmedicine.org/health/conditions-and-diseases/hemorrhoids
  92. https://www.nature.com/articles/s41598-021-03838-z
  93. https://bezmialemscience.org/articles/relationship-between-toilet-type-and-hemorrhoids/bas.galenos.2022.60352
  94. https://healthinformaticsjournal.com/index.php/IJMI/article/view/930/862
  95. https://cdhf.ca/en/how-long-do-hemorrhoids-last/
  96. https://pubmed.ncbi.nlm.nih.gov/2295392/
  97. https://pmc.ncbi.nlm.nih.gov/articles/PMC2278306/
  98. https://www.researchgate.net/publication/353577947_The_Relationship_Between_Low_Fiber_Consumption_and_the_Incidence_of_Haemorrhoids_Patients
  99. https://www.gastrojournal.org/article/0016-5085%2890%2990828-O/pdf
  100. https://www.sciencedirect.com/science/article/abs/pii/S1687197912000482
  101. https://pmc.ncbi.nlm.nih.gov/articles/PMC11271563/
  102. https://pmc.ncbi.nlm.nih.gov/articles/PMC8435716/
  103. http://classics.mit.edu/Browse/browse-Hippocrates.html
  104. https://www.biblestudytools.com/dictionary/haemorrhoids/
  105. https://hrcak.srce.hr/file/225303
  106. https://pmc.ncbi.nlm.nih.gov/articles/PMC5871264/
  107. https://www.ncbi.nlm.nih.gov/books/NBK558967/
  108. https://www.sciencedirect.com/science/article/pii/S2211568421001704
  109. https://pubs.rsna.org/doi/abs/10.1148/rg.220014
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