Hemorrhoids occur when the veins in the wall of the anus and rectum become swollen and stretched. Hemorrhoids that occur in the rectum are called internal hemorrhoids. They cannot usually be seen, but may droop down outside the anus. Those that form in the anus are called external hemorrhoids. They often appear as a small bulge under the skin.

Hemorrhoids are very common. They occur when an increase of pressure in the veins around the anus and rectum cause the veins to enlarge. This may occur due to many factors, including straining during a bowel movement, pregnancy and childbirth. Although hemorrhoids often cause bleeding, pain and a feeling of fullness in the rectum, they may not cause any problems in some people.

The diagnosis of hemorrhoids follows an evaluation of the patient’s medical history, including bowel habits and symptoms, and a physical examination by a gastroenterologist or other physician. A variety of tools (e.g., anoscope, sigmoidoscope) may be used to visually examine the anus and rectum.

Hemorrhoids that do not cause symptoms typically require no treatment. If symptoms are present, they often go away in a few days and can usually be treated with measures that patients can perform at home. These include eating more fiber, avoiding irritation to the area and soaking the anus in warm water. Surgery is very rarely needed for hemorrhoids, but may be performed to relieve excessive bleeding or pain. Most surgeries can be performed in a physician's office.

Hemorrhoids are swollen, stretched veins in the wall of the anus and rectum. They are very common both in men and women, although some people may not exhibit any symptoms.

According to the American College of Gastroenterology (ACG), about half of all Americans over the age of 50 have hemorrhoids. However, many people who believe they have hemorrhoids actually do not. Several anal and rectal problems (e.g., fissures, fistulae, abscesses) have similar symptoms and are often confused with hemorrhoids. Hemorrhoids may cause bleeding with bowel movements, pain and a feeling of fullness in the rectum.

There are two different types of hemorrhoids:

• Internal hemorrhoids. Hemorrhoids that form in the rectum, located above the anus. They cannot usually be seen, but may droop down and protrude outside of the anus.
  
  
• External hemorrhoids. Hemorrhoids that form under the skin in the anus, below the rectum. They typically appear as a small bulge or lump under the skin around the anus.

Hemorrhoids occur when an increase of pressure in the veins around the anus and rectum causes these veins to swell and enlarge. There are numerous possible causes of this increased pressure, including:

• Straining during bowel movements. Often considered the most common cause of hemorrhoids. This frequently occurs in patients with chronic constipation. Although this straining is known to irritate existing hemorrhoids, some scientists believe that is does not directly contribute to the development of new hemorrhoids.
  
  
• Long periods of time on the toilet. Sitting on the toilet for a long time causes increased pressure on the veins in the anal canal.
  
  
• Pregnancy and childbirth. A developing fetus places a lot of pressure on the rectal area. Hormonal changes during pregnancy may cause the veins around the anus and rectum to swell. The act of childbirth also places severe pressure on the veins in this area.
  
  
• Frequent heavy lifting. Lifting heavy objects can cause strain similar to that caused by constipation. Much like straining during bowel movements, frequent heavy lifting is known to make hemorrhoids worse and is often thought to contribute to their formation. However, some scientists do not believe this contribution is a direct link.
  
  
• Sitting or standing for too long. Sitting down or standing for extended periods of time increases the pressure in the anal and rectal veins. This may lead to hemorrhoids and worsens hemorrhoids that already exist.
  
  
• Other possible causes include:
  
• • Obesity
  • Chronic cough
  • Chronic diarrhea
  • Liver disease
  • Overuse of laxatives or enemas

Hemorrhoids are more likely to develop as a patient ages. Most people develop them after the age of 30. Patients who have family members with hemorrhoids are also more likely to develop hemorrhoids at some point in their life. This is believed to be due to an inherited tendency for hemorrhoid formation, meaning that the patient is more susceptible than other patients to the factors that cause hemorrhoids.

Hemorrhoids are generally not a serious condition. In many cases, they cause no symptoms at all. The appearance of streaks of bright red blood on the toilet paper or stool after a bowel movement is the most common sign of internal hemorrhoids. In some cases, blood may drip from the rectum into the toilet water. This bleeding occurs when swollen veins are broken by straining, rubbing or scratching and is usually painless. There is typically only a small amount of bleeding. Severe blood loss due to bleeding hemorrhoids is very rare, but may cause anemia.

Internal hemorrhoids are not usually painful. This is because the membranes in the rectal area do not possess pain-sensitive nerves. However, internal hemorrhoids that droop down and protrude out of the anus may become painful if they are rubbed raw. Internal protruding hemorrhoids that are strangled by a reduced blood supply, which occurs only in severe cases, may lead to extreme pain. Hemorrhoids that contain a blood clot (thrombus) may also be painful. The pain associated with hemorrhoids may range from slightly tender to severe and burning.

In some cases, hemorrhoids are associated with rectal discharge of mucus. This may result in a feeling that there is still stool in the rectum after a bowel movement. Hemorrhoids may also cause a similar feeling of fullness without a mucus discharge. They can also become inflamed.

Skin tags may develop in patients with external hemorrhoids. These small outgrowths of residual or excess skin around the anus tend to occur after a hemorrhoid with a blood clot has healed. Although they cause no problems directly, they may be difficult to keep clean.

Anal itch (pruritus ani) is often associated with hemorrhoids. However, it is not actually a symptom of the hemorrhoids themselves. Instead, it develops due to poor anal hygiene or habits which often accompany hemorrhoids. Draining mucus that is not properly cleaned off the skin around the anus and particles of stool caught around the anus and hemorrhoids may irritate the skin and cause this itch. However, too much rubbing or aggressive cleaning of the area may also result in anal itch.

Individuals who notice bleeding from their rectum, blood in their stool or blood in the toilet after a bowel movement should consult a physician. Although blood is a common sign of hemorrhoids, it also can indicate other digestive diseases, including colorectal and anal cancers. Physicians can identify the cause of the patient’s bleeding and recommend treatment methods. Patients should also contact a physician if over-the-counter hemorrhoid medications and self-care measures fail to relieve symptoms.

The diagnosis of hemorrhoids follows an evaluation of the patient's medical history and a physical examination by a primary care physician or gastroenterologist. Diagnostic tests may also be used. The patient is generally asked about bowel habits, including frequency and any recent changes in patterns, and certain symptoms such as pain, bleeding or itching. The physical examination typically involves a digital rectal exam, in which the physician inserts a gloved, lubricated finger into the rectum to feel for abnormalities. It is often easy to diagnose hemorrhoids after visually examining the anus and rectum. To do this, the physician may use a variety of tools, including:

• Anoscope. A short, hollow tube used to examine the last few inches of the rectum.
  
  
• Proctoscope. A longer tube used to examine the entire rectum. This may be more useful for diagnosing internal hemorrhoids.
  
  
• Sigmoidoscope. An even longer, flexible, lighted tube used to examine deeper into the sigmoid colon (the lower part of the large intestine just above the rectum). This is frequently used to determine if a more serious condition, such as a tumor, exists.

  

Hemorrhoids that do not cause symptoms typically do not require treatment. Even when symptoms do occur, they often go away on their own in just a few days. If a temporary source of pressure (e.g., pregnancy) caused the hemorrhoids, they will usually disappear after the source is gone (e.g., following childbirth).

Hemorrhoids can usually be treated with measures that patients can perform at home. Fiber and plenty of fluids help to eliminate constipation and reduce straining during bowel movements. Eating more fiber-rich foods (e.g., fruits and vegetables) or taking fiber supplements such as bulking agents can help reduce occurrence. It is also important to increase the amount of fluids consumed. Spicy foods are generally not recommended when hemorrhoids cause symptoms.

People with hemorrhoids should locate a toilet as soon as possible if they experience the urge to have a bowel movement. A bowel movement should not be forced either. It is best to allow sufficient time rather than straining.

Exercise may help relieve pressure around the anus and rectum and ease the symptoms of hemorrhoids. It is also important to avoid irritating the hemorrhoids and the anal area. Tips to avoid irritation include:

• Use moist toilet paper or towelettes instead of dry toilet paper.
  
• Blot the area clean instead of rubbing.
  
• Keep the anal area clean by washing daily with warm water.
  
• Do not scratch or use irritating soaps around the anus.
  
• Keep the anal area dry (a hair dryer can be used).

When hemorrhoids protrude beyond the anus, they often return inside the anus on their own. However, they may need to be gently pushed back in with a finger. Soaking the anus in warm water cleans the area and usually eases symptoms. This can be accomplished by squatting in a partially filled tub or using a sitz bath. A sitz bath involves a special container for warm water that can be placed on the toilet. Patients may benefit from soaking the area several times a day. When swelling occurs in or around a hemorrhoid, cold compresses may help.

Medicated creams and suppositories are also available over-the-counter and often help relieve symptoms. Numbing agents or witch hazel compresses may be recommended for some patients. Pain relievers, such as acetaminophen, aspirin or ibuprofen, may also be recommended to alleviate any discomfort.

Surgery is very rarely needed for hemorrhoids, but may be performed to relieve excessive bleeding or pain. Surgery may also be recommended for large hemorrhoids or hemorrhoids that fail to respond to non-surgical treatment methods. It is typically performed in the office of a physician (usually a surgeon). Procedures that are available to treat hemorrhoids include:

• Sclerotherapy. May be used to treat internal or persistently bleeding hemorrhoids. A chemical is injected into the hemorrhoids that blocks bleeding by causing the formation of scar tissue and makes the hemorrhoids shrink.
  
  
• Rubber band ligation. May be used to remove internal hemorrhoids that are large or do not respond to sclerotherapy. Tiny rubber bands are placed around the base of the hemorrhoids to cut off the circulation. This causes the hemorrhoids to wither and atrophy.
  
  
• Stapled hemorrhoidopexy. Also known as circular stapling, this relatively new procedure involves inhibiting the flow of blood to tissue through use of staples. However, recent research indicates that circular stapling may pose a greater risk of recurrence and prolapse than traditional surgery.
  
  
• Photocoagulation. A burst of infrared light or a laser is used to burn and shrink hemorrhoids.
  
  
• Electrocoagulation. Uses an electric current to destroy hemorrhoids.
  
  
• Clot removal. May be used when pain due to a blood clot in an external hemorrhoid is severe. The vein is cut with a small incision and the clot is removed. The pain may go away very rapidly after this procedure.
  
  
• Cryotherapy. Freezes the hemorrhoids. This procedure is no longer used very frequently because it is more complicated than other procedures and is often accompanied by a foul odor.
  
  
• Hemorrhoidectomy. The surgical removal of a hemorrhoid performed under anesthesia. Unlike the other surgeries, this typically requires a one or two day hospital stay.

Hemorrhoids are not inevitable and can usually be prevented. Tips to prevent hemorrhoids include:

• Eat plenty of fiber and drink plenty of fluids. Diets rich in fiber and with plenty of fluids help keep stool soft and easy to pass, reducing the need to strain during a bowel movement. Fiber-rich foods include fresh fruits and vegetables and whole grains. If such a diet is not possible, fiber supplements can be taken. It is also beneficial to eat meals on a regular schedule.
  
  
• Exercise regularly. Regular exercise helps to reduce the pressure around the anus and rectum. It also promotes normal bowel function, which helps stool pass more easily.
  
  
• Do not sit down for extended periods of time. Sitting down for a long time without getting up increases the pressure in the veins of the anal region. It is best to stand up and move around when there is a chance to do so.
  
  
• Practice good bowel habits. When feeling the urge to have a bowel movement, it is best to go as soon as possible. It is not good, however, to strain during bowel movements.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about hemorrhoids:

1. How can I tell if I have internal hemorrhoids?
   
   
2. Could I have hemorrhoids without even knowing it?
   
   
3. What seems to have caused my hemorrhoids?
   
   
4. How extensive are my hemorrhoids?
   
   
5. Are my hemorrhoids likely to cause any other symptoms in the future?
   
   
6. What would be the best way for me to relieve my symptoms?
   
   
7. How can I keep the anal area clean and dry without irritating it?
   
   
8. When are my hemorrhoids likely to go away?
   
   
9. Will I require surgery to treat my hemorrhoids?
   
   
10. How would you suggest I prevent hemorrhoids in the future?