The What, Why, and How of Hemorrhoids

What are hemorrhoids?

Hemorrhoids are a collection of vessels (arteriovenous channels) that are located both within the rectum (internal hemorrhoids) and around the anus (external hemorrhoids). 

Despite being present in everyone, the term “hemorrhoid” has taken on more of a pathologic or disease state, e.g. when they become enlarged causing bleeding, itching, prolapse (internal hemorrhoids), or enlarge to cause pain due to thrombosis (clot formation in external hemorrhoids).

What are the differences between external and internal hemorrhoids?

External hemorrhoids do not cause bleeding as their initial symptom. When enlarged, they are noticeable just at the opening of the anal canal (anus) and can be tender and painful. If they are large enough, they can bleed if the overlying skin tears. Sometimes a clot is seen with bleeding. External hemorrhoids are painful as they are covered by skin which is heavily innervated with somatic nerve endings.

Unlike external hemorrhoids, internal hemorrhoids do not typically cause pain, as there are no nerves around them. Rather they cause painless rectal bleeding during defecation when enlarged. When large enough they can prolapse (fall) outside the rectum into the anal canal and can be pushed back in, though sometimes they can't. Itching is another symptom of internal hemorrhoids, as mucous from within the rectum or fecal matter comes in contact with the skin around the anus. You can see itching with external hemorrhoids too if it becomes difficult to clean due to pain.  

What causes hemorrhoids?

Everyone has hemorrhoids. However, they are not noticed until they become enlarged and create symptoms.  It is believed that they form from repeated excessive straining during defecation, during pregnancy as a result of changes in blood flow and pressure of the uterus within the pelvis, prolonged sitting, heaving lifting, constipation, frequent bowel movements, or some combination of the above. Mechanical forces may lead to slowing in blood flow resulting in thrombosis or clotting, which leads to enlargement of external hemorrhoids. Increased pressure in the rectum due to straining, hard stools, or frequent stools, leads to swelling of internal hemorrhoids.  

How do you treat hemorrhoids?

In general, the goal of treatment for either type is to ease evacuation and reduce pain. An osmotic laxative like Miralax can be used daily to prevent constipation or hard stools. Topical lidocaine (2-4%) used 3-4 times per day, Motrin/Ibuprofen, and warm Sitz baths twice a day can ease pain and swelling. In the case of external hemorrhoids, the clot will eventually reabsorb, and pain and swelling will dissipate over 1-3 weeks. 

External hemorrhoids that are acutely painful can be quickly relieved by excision of the clot, but quickly finding a colorectal surgeon to do this is not easy. Very large internal hemorrhoids that are chronically bleeding can be treated surgically or via rubber banding techniques. I refer my patients to a colorectal surgeon or other gastroenterologist with experience in these techniques. Steroids suppositories may help reduce size and itching of internal hemorrhoids. I do not recommend topical steroids for external hemorrhoids unless there is severe itching around the anus.   

What can you do to prevent hemorrhoids from coming back?

I inform all my patients to increase dietary or supplemental fiber in the diet. Guidelines recommend about 25-35 g per day. For supplementing, I typically recommend Citrucel (methylcellulose) and Fibercon (polycarbophil) taken in pill form with 8 ounces water. This can add some bulk and water to stools and facilitate ease of elimination. Other fibers like psyllium husk (metamucil) are suitable too but can cause bloating. All are available over the counter. 

Other hemorrhoid tips and information:

Many patients attribute “hemorrhoids” as the cause of any symptom of the rectum/anus but they may not always be involved. A careful history and exam can help to make the right diagnosis. Readers should always consider talking to their doctors about lingering perianal or rectal symptoms they think are attributed to hemorrhoids before taking matters into their own hands to ensure an accurate diagnosis and treatment.