Condition Basics

What are hemorrhoids?

Hemorrhoids are swollen veins in the anal canal. This common problem can be painful, but it's usually not serious. Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the opening of the anus to form external hemorrhoids. You can have both types at the same time.

What causes them?

Hemorrhoids are usually caused by too much pressure on the veins in the pelvic and rectal area. Sitting on the toilet a long time or straining to have a bowel movement creates pressure that causes these veins to swell and stretch. Things that can lead to hemorrhoids include constipation, pregnancy, and being overweight.

What are the symptoms?

The most common symptoms of both internal and external hemorrhoids are bleeding during bowel movements, itching, and rectal pain. You may find streaks of blood on the toilet paper or blood in the toilet bowl after a bowel movement.

How are they diagnosed?

Your doctor can tell if you have hemorrhoids by asking about your past health and doing a physical examination. The doctor may examine your rectum with a gloved finger or a lighted scope. If this doesn't show a clear cause of your problems, your doctor may do other tests.

How are hemorrhoids treated?

For most external hemorrhoids, home treatment is all you need. This includes slowly adding fibre to your meals, drinking more water, and using an ointment to stop itching. The same treatment can be used for most internal hemorrhoids. If your hemorrhoids are severe, you may need medical treatment to shrink or remove them.

Cause

Hemorrhoids are usually caused by too much pressure on the veins in the pelvic and rectal area. If you sit on the toilet a long time or strain to have a bowel movement, the extra pressure causes the veins in this tissue to swell and stretch. The result is hemorrhoids.

Things that can lead to hemorrhoids include:

• Diarrhea, constipation, or rushing to complete a bowel movement. These may lead to straining and can put more pressure on veins in the anal canal.
• Pregnancy and labour. This is because of greater pressure on the blood vessels in the pelvic area. Straining to push the baby out during labour can make hemorrhoids worse.
• Being overweight. This may put more pressure on the pelvic veins.
• Medical conditions. For example, long-term heart and liver disease may cause blood to pool in the pelvic area.

Things that make hemorrhoids worse include:

• Sitting or standing for a long time. This may cause blood to pool in the anal area and put more pressure on the veins.
• Frequent heavy lifting or holding your breath when lifting heavy objects. This can suddenly put more pressure on blood vessels.

Prevention

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

• Avoid constipation.
  • Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fibre.
  • Drink plenty of fluids.
  • Get some exercise every day. Try to do moderate to vigorous activity at least 2½ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.
  • Take a fibre supplement, such as Benefibre or Metamucil, every day if needed. Read and follow all directions on the label.
• Practice healthy bowel habits.
  • Use the toilet as soon as you have the urge.
  • Avoid straining to pass stools. Relax and give yourself time to let things happen naturally.
  • Avoid holding your breath while passing stools.
  • Avoid reading while sitting on the toilet. Get off the toilet as soon as you have finished.
• Modify your daily activities.
  • Avoid prolonged sitting or standing. Take frequent short walks.
  • Avoid lifting heavy objects, if possible. If you must lift heavy objects, always exhale as you lift the object. Don't hold your breath when you lift.
  • Sleep on your side if you are pregnant. This will lower pressure on the blood vessels in your pelvis. This can help keep hemorrhoids from becoming bigger.

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Symptoms

Hemorrhoids may cause:

• Rectal bleeding. You may see bright red blood on the toilet paper or in the toilet after a bowel movement. You may see blood on the stool.
• Itching. Hemorrhoids often seep mucus. It can irritate the skin and cause itching.
• Discomfort. You may still feel the urge to pass stool right after having a bowel movement.
• Pain.
  • External hemorrhoids may cause blood to pool under the skin. This can form into a hard, painful lump.
  • Large internal hemorrhoids that bulge from the anus may be painful if they're squeezed by the anal muscles. They may be very painful if the blood supply to the hemorrhoid is cut off. Emergency treatment may be needed.

What Happens

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

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

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

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

During labour, hemorrhoids may start or get worse because of the intense straining and pressure on the anal area while pushing to deliver the baby.

External hemorrhoids

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

When a vein within an external hemorrhoid gets irritated, blood may clot under the skin, forming a hard, bluish lump. This is known as a thrombosed, or clotted, hemorrhoid. Thrombosed hemorrhoids can be very painful.

Internal hemorrhoids

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

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

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

When to Call a Doctor

Common symptoms of hemorrhoids may be a sign of other serious health problems. Colon or rectal cancer and other conditions have many of the same symptoms as hemorrhoids. Call your doctor if you have symptoms like these:

• Stools are black or tarry or change size and shape.
• A lump or bulge that isn't tender and that doesn't go away forms at the anal opening.
• Rectal bleeding becomes heavy or changes colour (such as from bright red to dark red).

If you have hemorrhoids, call your doctor if:

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

Watchful waiting

Watchful waiting is a wait-and-see approach. And in most cases, bleeding caused by hemorrhoids should stop after 2 to 3 days. Continue home treatment to prevent bleeding from starting again. Call your doctor if bleeding:

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

Examinations and Tests

Your doctor can tell if you have hemorrhoids by asking about your past health and doing a physical examination.

You may not need many tests at first, especially if you are younger than 50 and your doctor thinks that your rectal bleeding is caused by hemorrhoids. Your doctor may just examine your rectum with a gloved finger. Or your doctor may use a short, lighted scope to look inside the rectum.

Rectal bleeding can be a sign of a more serious problem, such as colon, rectal, or anal cancer. So if the first examination doesn't show a clear cause of your problems, your doctor may do tests to check for other causes of bleeding. The doctor may use a lighted scope to look at the lower third of your colon. This is called sigmoidoscopy. Or your doctor may use another kind of scope to look at the entire colon. This is called colonoscopy.

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Treatment Overview

Most hemorrhoids can be treated with simple changes to diet and bowel habits. Most don't require surgery or other treatment unless the hemorrhoids are very large and painful.

Home treatment

For most external hemorrhoids, home treatment is all you need. The same home treatment can be used for most internal hemorrhoids.

• Slowly add fibre to your meals. Eat foods that have lots of fibre, such as fruits, vegetables, and whole grains.
• Use an over-the-counter ointment for a limited time to stop itching. You also may use a stool softener.
• Try suppositories. They can help relieve irritation and lubricate the anal canal during bowel movements.
• Drink plenty of water.
• Get some exercise every day.

Non-surgical procedures

The goal of these procedures is to reduce the blood supply to the hemorrhoid so it shrinks or goes away. The scar tissue left in its place helps support the anal tissue and helps prevent new hemorrhoids.

These procedures can only be done on internal hemorrhoids. They include:

• Tying off the hemorrhoids with a rubber band. This is called rubber band ligation.
• Using heat, lasers, or electric current to create scar tissue. This is called coagulation therapy.

Surgery

Surgery to remove hemorrhoids is called hemorrhoidectomy. It can be used:

• For large internal hemorrhoids.
• When you have several small hemorrhoids.
• When other treatments haven't controlled bleeding.

Sometimes a combination of treatments (for example, a non-surgical procedure and surgery) is the best way to treat hemorrhoids.

External hemorrhoids usually aren't removed with surgery unless they are very large and uncomfortable. Or they may be removed if you are having surgery on the anal area for another reason, such as for internal hemorrhoids or a tear (anal fissure). If a blood clot forms in the external hemorrhoid, the clot may need to be removed to relieve pain.

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Self-Care

Home treatment may keep your hemorrhoids from getting worse. It mainly involves having healthy bowel habits.

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

• Avoid constipation.

  Slowly add fibre to your meals. Eat foods with lots of fibre like fruits, vegetables, and whole grains. And drink plenty of water. These things may help prevent hard stools.

• Avoid making hemorrhoids worse.
  • After bowel movements, blot the anus gently with white toilet paper moistened with water or a cleansing agent. Or you can use baby wipes or other premoistened towels (such as Preparation H or Tucks).
  • Avoid rubbing the anal area. You can rinse off in the shower or on a bidet instead of wiping yourself with toilet paper. After cleansing, gently pat the anal area dry with a soft, absorbent towel or cloth.
  • Don't use soaps that contain perfumes or dyes.
• Relieve pain and itching.
  • Take over-the-counter pain relievers. Acetaminophen (Tylenol) can help with pain. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) and naproxen (Aleve) can help with pain and swelling.
  • Apply ice several times a day for 10 minutes at a time. Then place a warm compress on the anal area for another 10 to 20 minutes.
  • Take a sitz bath. Fill your bathtub with just enough warm water to cover the anal area. Do this several times a day, especially after bowel movements. Soak for about 15 minutes at a time. Be careful! If the water is too warm, it can burn you.
  • Use over-the-counter medicines as recommended by your doctor or pharmacist. They include ointments, creams, and suppositories. Examples include zinc oxide, petroleum jelly, and Preparation H.
• Take a day of bedrest.

  Do this to take pressure off inflamed, irritated veins. If you are pregnant, you may find it helpful to lie on your side. If you aren't pregnant, sleeping on your stomach with a pillow under your hips will help reduce swelling of hemorrhoids.

• Try not to sit or stand for a long time.

  Limit sitting and standing when hemorrhoids are irritated. If you must sit for a long time, sit on a pillow.

• Avoid lifting heavy objects.
• Wear cotton underwear.

  It prevents moisture buildup, which can irritate hemorrhoids.

• Wear loose clothing.

  This reduces pressure on the anal area.

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Medicines

Medicines can help relieve symptoms of hemorrhoids. Over-the-counter (OTC) treatments you can try include:

• Ointments that protect the skin. These are the best OTC products for hemorrhoids. They form a barrier over hemorrhoids. This can prevent more injury and reduce itching. Examples include zinc oxide and petroleum jelly.
• Suppositories. These can help relieve irritation. They can also lubricate the anal canal during bowel movements. They include Preparation H and Anusol.
• 1% hydrocortisone ointment. This is a type of steroid medicine. It may relieve inflammation and itching.
• Products that numb an area. Although these products help some people, others become allergic to them. Ask your doctor before you use them. These products often have "-caine" in the name or the ingredients.
• OTC pain relievers. Acetaminophen can help with pain. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help with pain and swelling.

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