Harvard Women's Health Watch

What to do about hemorrhoids

Bulging blood vessels in the backside can be a pain, but you have many options for treating them.

Some women have a passing encounter with hemorrhoids during pregnancy. By midlife, many more of us have had one or more of the classic symptoms, which include rectal pain, itching, bleeding, and possibly prolapse (protrusion of hemorrhoids into the anal canal). Leakage of feces may also occur. Although hemorrhoids are rarely dangerous, they can be a painful recurrent bother. Fortunately, there's a lot we can do about them.

What are hemorrhoids?

In one sense, everyone has hemorrhoids — pillow-like clusters of veins that lie just beneath the mucous membranes lining the lowest part of the rectum and the anus. Trouble develops when these veins become swollen and distended, like varicose veins in the legs. And like varicose veins, hemorrhoids may be a byproduct of our blood vessels' constant battle against gravity to get blood back to the heart — and part of the price we pay for being upright creatures.

There are two kinds of hemorrhoids: internal ones, which occur in the lower rectum, and external ones, which develop under the skin around the anus. External hemorrhoids are the most uncomfortable, because they irritate and erode the overlying skin. The pain may be sudden and severe if a blood clot forms inside an external hemorrhoid. The clot usually dissolves but may leave excess skin (a skin tag) that itches or becomes irritated.

Internal hemorrhoids are usually painless, but they often result in bleeding, which may show up bright red on toilet paper or dripping into the toilet bowl. An internal hemorrhoid may also prolapse and extend beyond the anus, causing potential problems. For one thing, it may collect small amounts of mucus and microscopic stool particles, leading to a condition called pruritus ani (anal itching). The problem worsens if you repeatedly wipe to relieve the itch.

Anatomy of hemorrhoids

Hemorrhoids are distended blood vessels that form either externally (around the anus) or internally (in the lower rectum).

What causes hemorrhoids?

Experts don't fully agree, but several mechanisms are probably at work. Large, prolapsing hemorrhoids are associated with chronic constipation, straining during bowel movements, and prolonged sitting on the toilet — all of which can cause blood to pool and enlarge the vessels. Inadequate fiber intake may also contribute.

People with hemorrhoids tend to have a higher than average resting anal canal tone — that is, the smooth muscle of the anal canal is tighter than average, even when they're not straining. Constipation adds to the trouble, because straining during a bowel movement increases pressure in the anal canal and pushes the hemorrhoids against the sphincter muscle. Finally, hemorrhoids may bulge and prolapse because the connective tissues that support and hold them in place become weaker with age.

Diagnosing hemorrhoids

Hemorrhoids can usually be diagnosed from a simple medical history and physical exam. External hemorrhoids are generally visible, especially if a blood clot has formed. Your clinician may perform a digital rectal exam to check for blood in the stool. She or he may also examine the anal canal with an anoscope, a short, lighted plastic tube inserted into the rectum. If there's evidence of rectal bleeding or blood in the stool, a sigmoidoscopy or colonoscopy may be recommended to rule out conditions such as colorectal polyps or cancer, especially in people over age 50.

For purposes of determining the best treatment, internal hemorrhoids are often classified according to the degree of protrusion into the anal canal. First-degree hemorrhoids don't protrude, and they may or may not bleed; second-degree hemorrhoids protrude with defecation and retract on their own; third-degree hemorrhoids protrude and must be manually reduced (pushed back into their normal position); and fourth-degree hemorrhoids protrude and cannot be reduced.

Conservative treatment

Most hemorrhoid symptoms improve dramatically with simple measures. Here are some things to try:

Add fiber. Boost the fiber in your diet with either high-fiber foods or a fiber supplement or both. When taken with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids and the resulting risk of bleeding, inflammation, and swelling. High-fiber foods include prunes, dates, apples, pears, strawberries, broccoli, Brussels sprouts, carrots, peas, spinach, legumes (for example, baked beans or kidney beans), bran cereals, and oatmeal. Fiber supplements include psyllium (Metamucil, Konsyl, Perdiem), methylcellulose (Citrucel), calcium polycarbophil (FiberCon, Fiber-Lax, Mitrolan), and wheat dextrin (Benefiber). Fiber can cause bloating or gas, so start slowly, and gradually increase your intake to 25 to 30 grams of fiber per day. Increase your fluid intake at the same time.

Exercise. You can stimulate bowel function with moderate aerobic exercise, such as brisk walking 20 to 30 minutes a day.

Establish a regular bowel habit. When you feel the urge, go to the bathroom immediately; don't wait for a more convenient time. Stool can back up, leading to increased pressure and straining. Also, schedule a time each day — perhaps just after a meal — to sit on the toilet for a few minutes.

Sit in a sitz. You can often relieve itching, irritation, and spasm of the sphincter muscle with a warm water bath for the buttocks (sitz bath). Sit in a regular bathtub with a few inches of warm water, or go to a pharmacy and buy a small plastic tub that fits over a toilet seat. Try a 20-minute sitz bath after each bowel movement and an additional two or three times a day. Afterward, gently pat the anal area dry; don't rub or wipe hard. You can also dry the area with a hair dryer on a cool setting.

Try something topical. Over-the-counter analgesic creams can temporarily soothe pain, irritation, and itching. Creams and suppositories containing hydrocortisone are also effective, but don't use them for more than a week at a time, because they can cause the skin to get too thin (atrophy). Witch hazel wipes (Tucks) are soothing and have no harmful effects. A small ice pack placed against the anal area for a few minutes may also help. Finally, sitting on cushions rather than hard surfaces can help reduce swelling.

Treat the clot. If a clot has been present for longer than two days, apply home treatments for the symptoms while waiting for it to go away on its own. If it's more recent, the hemorrhoid can be surgically removed or the clot withdrawn in an office procedure performed by a surgeon.

Procedures to treat hemorrhoids

Some hemorrhoids can't be managed with conservative treatments alone, either because the symptoms persist or because an internal hemorrhoid has prolapsed. These hemorrhoids are usually candidates for one of several minimally invasive outpatient procedures. If symptoms continue despite these measures, surgery may be required. Surgery is usually the treatment of choice for fourth-degree and some third-degree hemorrhoids. Here are the options:

Rubber band ligation. Rubber band ligation is the most widely used procedure for treating internal hemorrhoids. Used chiefly for first- and second-degree hemorrhoids and some third-degree hemorrhoids, the technique is easy to perform, requires no anesthesia, and succeeds 70% to 80% of the time. The surgeon introduces a small elastic band into the anal canal on a ring called a ligator and places it around the base of a hemorrhoid (see illustration). The band causes the hemorrhoid to shrink and the surrounding tissue to scar as it heals, holding the hemorrhoid in place. The hemorrhoid is eliminated after two to four procedures, done six to eight weeks apart. Patients may experience pain or tightness after the procedure (usually relieved with a sitz bath), bleeding when the rubber band falls off (typically two to four days after the procedure), and sometimes a local infection. Serious complications are rare.

Rubber band ligation

To perform rubber band ligation, the clinician places a ligator over the hemorrhoid to position a rubber band around its base.

Laser, infrared, and bipolar coagulation. These methods, which are generally effective for first- and second- degree internal hemorrhoids, involve the use of light or heat to shrink the hemorrhoid and form scar tissue. They cause less pain than rubber band ligation, but are less likely to guarantee that symptoms won't return.

Hemorrhoidectomy. You probably need surgery if you have large protruding hemorrhoids, persistently symptomatic external hemorrhoids, or internal hemorrhoids that return despite minimally invasive therapies. In a traditional hemorrhoidectomy, the surgeon makes an incision around both external and internal hemorrhoid tissue, removes the affected blood vessels, and closes the incision with a continuous absorbable suture. This procedure cures 95% of cases and has a low complication rate — apart from a well-deserved reputation for being painful. General or spinal anesthesia is necessary, and most people need pain medications afterward. You'll usually be asked to take fiber supplements or laxatives to prevent fecal impaction, which can result from a combination of postoperative pain, fear of pain while defecating, and the side effects of narcotic medications. You can probably return to work in seven to 10 days.

Stapled hemorrhoidectomy. This alternative to traditional hemorrhoidectomy is often recommended after rubber band ligation has failed. The surgeon uses a stapling device to anchor the hemorrhoids in their normal position. The procedure is performed under general anesthesia, but it's less painful than traditional hemorrhoidectomy. Recovery is also quicker, but some studies suggest that the risk of recurrence is greater.