Patient education: Hemorrhoids (Beyond the Basics)
- Ronald Bleday, MD
Ronald Bleday, MD
- Associate Professor of Surgery
- Harvard Medical School
Hemorrhoids are enlarged or swollen veins in the lower rectum. The most common symptoms of hemorrhoids are rectal bleeding, itching, and pain. You may be able to see or feel hemorrhoids around the outside of the anus, or they may be hidden from view, inside the rectum (figure 1A-B).
Hemorrhoids are common, occurring in both men and women. Although hemorrhoids do not usually cause serious health problems, they can be annoying and uncomfortable. Fortunately, treatments for hemorrhoids are available and can usually minimize the bothersome symptoms.
More detailed information about hemorrhoids is available by subscription. (See "Hemorrhoids: Clinical manifestations and diagnosis" and "Home and office treatment of symptomatic hemorrhoids".)
Hemorrhoids are more common in people who are older and in those who have diarrhea, pelvic tumors, during or after pregnancy, and in people who sit for prolonged periods of time and/or strain (push hard) to have a bowel movement.
Symptoms of hemorrhoids can include the following:
●Painless rectal bleeding
●Anal itching or pain
●Tissue bulging around the anus
●Leakage of feces or difficulty cleaning after a bowel movement
Rectal bleeding — Many people with hemorrhoids notice bright red blood on the stool, in the toilet, or on the toilet tissue after a bowel movement. The amount of blood is usually small. However, even a small amount of blood in the toilet bowl can cause the water to appear bright red, which can be frightening. Less commonly, bleeding can be heavy.
While hemorrhoids are one of the most common reasons for rectal bleeding, there are other, more serious causes. It is not possible to know what is causing rectal bleeding unless you are examined. If you see bleeding after a bowel movement, call your healthcare provider. (See "Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)".)
Itching — Hemorrhoids commonly cause itching and irritation of skin around the anus.
Pain — Hemorrhoids can become painful. If you develop severe pain, call your healthcare provider immediately because this may be a sign of a serious problem.
To diagnose hemorrhoids, your clinician will examine your rectum and anus, and may insert a gloved finger into the rectum. If there is bleeding, testing should include a procedure that allows your healthcare provider to look inside the anus (called anoscopy) or colon (sigmoidoscopy or colonoscopy). (See "Patient education: Flexible sigmoidoscopy (Beyond the Basics)".)
INITIAL HEMORRHOID TREATMENT
There are measures you can take at home to relieve hemorrhoid symptoms (table 1). One of the most important steps in treating hemorrhoids is avoiding constipation (hard or infrequent stools). Hard stools can lead to rectal bleeding and/or a tear in the anus, called an anal fissure. In addition, pushing and straining to move your bowels can worsen existing hemorrhoids and increase the risk of developing new hemorrhoids. (See "Patient education: Anal fissure (Beyond the Basics)".)
Fiber supplements — Increasing fiber in your diet is one of the best ways to soften your stools. Fiber is found in fruits and vegetables. The recommended amount of dietary fiber is 20 to 35 grams per day (table 2). (See "Patient education: High-fiber diet (Beyond the Basics)".)
Several fiber supplements are available, including psyllium (sample brand names: Konsyl, Metamucil), methylcellulose (sample brand name: Citrucel), polycarbophil (sample brand name: FiberCon), and wheat dextrin (Benefiber). Start with a small amount and increase slowly to avoid side effects.
Laxatives — If increasing fiber does not relieve your constipation, or if side effects of fiber are intolerable, you can try a laxative.
Many people worry about taking laxatives regularly, fearing that they will not be able to have a bowel movement if the laxative is stopped. Laxatives are not "addictive" and using laxatives does not increase your risk of constipation in the future. Instead, using a laxative may actually prevent long-term problems with constipation. (See "Patient education: Constipation in adults (Beyond the Basics)".)
Warm sitz baths — During a sitz bath, you soak the rectal area in warm water for 10 to 15 minutes two to three times daily. Sitz baths are available in most drugstores. It is also possible to use a bathtub and sit in 2 to 3 inches of warm water. Do not add soap, bubble bath, or other additives in the water. Sitz baths work by improving blood flow and relaxing the muscle around the anus, called the internal anal sphincter.
Topical treatments — Various creams and suppositories are available to treat hemorrhoids, and many are available without a prescription. Pain-relieving creams and hydrocortisone rectal suppositories may help relieve pain, inflammation, and itching, at least temporarily.
You should not use hemorrhoid creams and suppositories, particularly hydrocortisone, for longer than one week, unless your healthcare provider approves.
MINIMALLY INVASIVE TREATMENT
If you have bothersome hemorrhoids after using conservative measures, you may want to consider a minimally invasive procedure. Most procedures are performed as a day surgery. The following procedures are intended for treatment of internal hemorrhoids.
Rubber band ligation — Rubber band ligation is the most widely used procedure. It is successful in approximately 70 to 80 percent of patients.
Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Many patients report a sense of "tightness" after the procedure, which may improve with warm sitz baths. Patients are encouraged to use fiber supplements to avoid constipation.
Delayed bleeding may occur when the rubber band falls off, usually two to four days after the procedure. In some cases, a raw and sore area develops five to seven days following the procedure. Other less common complications of rubber band ligation include severe pain, thrombosis of other hemorrhoids, and localized infection or pus formation (abscess). Rubber band ligation rarely causes serious complications.
Laser, infrared, or bipolar coagulation — These methods involve the use of laser or infrared light or heat to destroy internal hemorrhoids.
Sclerotherapy — During sclerotherapy, a chemical solution is injected into hemorrhoidal tissue, causing the tissue to break down and form a scar. Sclerotherapy may be less effective than rubber band ligation.
If you continue to have symptoms from hemorrhoids (such as bleeding, pain, or prolapse) despite medical therapies or office-based procedures, you may require surgery.
Options for surgical treatment for hemorrhoids include hemorrhoidectomy (surgically removing excess hemorrhoidal tissues), which works for both internal and external hemorrhoids, and other procedures (eg, stapled hemorrhoidopexy and hemorrhoidal arterial ligation), which only work for internal hemorrhoids. If you need surgery, your doctor can help you figure out which procedure is best for you.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Hemorrhoids (The Basics)
Patient education: Bloody stools (The Basics)
Patient education: High-fiber diet (The Basics)
Patient education: Anal pruritus (anal itching) (The Basics)
Patient education: Pregnancy symptoms (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)
Patient education: Flexible sigmoidoscopy (Beyond the Basics)
Patient education: Anal fissure (Beyond the Basics)
Patient education: High-fiber diet (Beyond the Basics)
Patient education: Constipation in adults (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Approach to the patient with anal pruritus
Hemorrhoids: Clinical manifestations and diagnosis
Etiology and evaluation of chronic constipation in adults
Etiology of lower gastrointestinal bleeding in adults
Management of chronic constipation in adults
Home and office treatment of symptomatic hemorrhoids
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Diabetes and Digestive and Kidney Diseases
●American Society of Colon and Rectal Surgeons
- Clinical Practice Committee, American Gastroenterological Association. American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126:1461.
- Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005; :CD004649.
- Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006; :CD005393.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.