Hemorrhoids: Causes, Symptoms, Grades and Treatment — Overview, Diagnosis & Treatment Options | MyMedicPlus

Hemorrhoids (piles) are engorged vascular cushions in the anal canal and lower rectum. All humans have three normal internal hemorrhoidal vascular cushions (at 3, 7, and 11 o'clock in the lithotomy position) that contribute to anal continence by providing a vascular seal. Pathological hemorrhoids develop when these cushions prolapse, bleed, or thrombose due to engorgement. They are classified as internal (above the dentate line, covered by insensate rectal mucosa — hence painless unless strangulated) or external (below the dentate line, covered by pain-sensitive anoderm and perianal skin). Internal hemorrhoids are graded by the Goligher system: Grade I (bleed, do not prolapse), Grade II (prolapse on straining, reduce spontaneously), Grade III (prolapse requiring manual reduction), Grade IV (irreducibly prolapsed or incarcerated). Symptomatic hemorrhoids affect approximately 75% of people at some point in their lives, with peak incidence between ages 45 and 65. Hemorrhoids are not life-threatening but cause significant morbidity and healthcare burden.

The vascular cushion theory (revised from the traditional varicosity theory) holds that hemorrhoids result from loosening of the submucosal supporting connective tissue that anchors the vascular cushions to the underlying sphincter, leading to sliding and prolapse. Factors that increase intraabdominal pressure and venous congestion are key risk factors. Chronic constipation with straining at stool is the most cited behavioral risk factor — prolonged straining increases pudendal nerve stretch and pelvic floor pressure. Low-fiber diet producing small, hard stools requires more propulsive straining. Diarrhea with frequent defecation is also associated. Pregnancy is a major risk factor due to progesterone-induced venous relaxation, elevated intraabdominal pressure, and constipation. Portal hypertension from liver cirrhosis causes anorectal varices (distinct from hemorrhoids) but may worsen hemorrhoids. Obesity, prolonged sitting, low physical activity, and family history are additional risk factors. Anal intercourse increases external hemorrhoid risk.

Bright red rectal bleeding — painless, coating toilet paper, or dripping into the bowl after defecation — is the hallmark of internal hemorrhoids. Bleeding is typically separate from the stool, distinguishing it from colorectal cancer where blood may be mixed with stool. Prolapse is reported as a feeling of incomplete rectal emptying, mucus discharge, perianal soiling, or a reducible perianal swelling. Perianal pruritus results from mucus seepage and fecal contamination of the perianal skin. Internal hemorrhoids are painless unless they become strangulated (Grade IV prolapse with edema and ischemia) or ulcerated. External hemorrhoids cause perianal discomfort and swelling. Acute thrombosed external hemorrhoids present as a sudden, severe, exquisitely tender, blue-purple perianal lump developing after straining or physical exertion — severe pain peaks at 48–72 hours. It is essential to exclude more serious diagnoses (colorectal cancer, anal fissure, fistula, IBD) before attributing rectal bleeding to hemorrhoids.

Diagnosis is clinical, based on history and proctoscopy (anoscopy). Rigid proctoscopy visualizes internal hemorrhoids directly: the cushions appear as bluish-purple vascular masses that prolapse into the lumen. Digital rectal examination excludes perianal abscess, fistula, and low rectal tumors. Flexible sigmoidoscopy or colonoscopy is mandatory for: rectal bleeding in patients over 45 years, bleeding with change in bowel habit, unexplained iron deficiency anemia, and any patient with concerning features for colorectal cancer per NICE NG12 — colonoscopy cannot be omitted simply because hemorrhoids are identified. Hemorrhoidal bleeding is a diagnosis of exclusion of colorectal pathology in higher-risk patients. EUA (examination under anesthesia) is required when adequate office examination is impossible due to pain or non-cooperation. No blood tests are specific for hemorrhoids; FBC may reveal iron deficiency anemia from chronic bleeding.

Grade I–II hemorrhoids are primarily managed conservatively: high-fiber diet (25–35g/day) with psyllium supplementation, increased water intake, warm sitz baths, and stool softeners. Topical agents (hydrocortisone-lidocaine preparations) provide symptomatic relief of pruritus but do not treat the underlying hemorrhoids. Rubber band ligation (RBL) is the most effective and cost-efficient office procedure for Grade I–III internal hemorrhoids — a rubber band placed above the dentate line causes ischemic necrosis and fibrotic fixation of the hemorrhoid; success rates exceed 85% with one to three treatment sessions. Sclerotherapy (injection of phenol in oil) and infrared coagulation are alternative office procedures for Grade I–II. Hemorrhoidectomy (open Milligan-Morgan or closed Ferguson technique) is the definitive surgical treatment for Grade III–IV hemorrhoids, refractory Grade II, or failed office procedures, with recurrence rates under 2% but higher morbidity (pain, urinary retention, stricture). Stapled hemorrhoidopexy (PPH) reduces post-operative pain but has higher prolapse recurrence rates than conventional hemorrhoidectomy. Hemorrhoidal artery ligation (HAL) with Doppler guidance is a newer sphincter-sparing option. Acutely thrombosed external hemorrhoids presenting within 72 hours of onset benefit from excision under local anesthesia — providing immediate pain relief.

Hemorrhoids are a benign, non-life-threatening condition with an excellent overall prognosis. Grade I–II internal hemorrhoids managed conservatively with dietary fiber, adequate hydration, and appropriate office procedures resolve or significantly improve in 75–85% of patients without surgery. Rubber band ligation achieves success in more than 85% of Grade I–III cases, with recurrence rates of 10–50% at 5 years if dietary habits are not modified. Hemorrhoidectomy (Milligan-Morgan or Ferguson technique) achieves definitive resolution with recurrence rates under 2%, though at the cost of higher short-term post-operative morbidity including pain and urinary retention. Symptomatic hemorrhoids that develop during pregnancy typically resolve within weeks of delivery in most cases. The single most important prognostic factor for recurrence prevention is dietary fiber intake — patients maintaining 25–35 g of dietary fiber per day with adequate fluid intake have significantly lower recurrence rates after all types of treatment. Acutely thrombosed external hemorrhoids managed with excision within 72 hours achieve immediate and complete resolution of pain in most patients. Long-term, hemorrhoids do not transform into colorectal cancer and carry no oncological risk. The principal clinical concern is ensuring that rectal bleeding is appropriately evaluated by colonoscopy to exclude colorectal cancer, particularly in patients over 45 years of age, before all symptoms are attributed to hemorrhoids.

High-fiber diet (25–35 g/day from fruits, vegetables, legumes, and whole grains) with adequate fluid intake (1.5–2 L/day) is the cornerstone of hemorrhoid prevention — randomized controlled trials show fiber supplementation reduces hemorrhoid bleeding episodes by 50% and recurrence after treatment. Avoid prolonged straining; respond promptly to the urge to defecate; limit time on the toilet (avoid reading or using phones). Regular physical activity promotes intestinal transit and reduces constipation. Maintaining healthy weight reduces intraabdominal pressure. Pregnancy-related hemorrhoids should be managed with dietary fiber and topical preparations; most resolve postpartum. Patients who have undergone rubber band ligation or sclerotherapy should maintain a high-fiber diet to prevent recurrence.

Seek medical evaluation for any rectal bleeding — never assume bleeding is from hemorrhoids without appropriate evaluation to exclude colorectal cancer, anal fissure, or inflammatory bowel disease. Urgent assessment is needed for: heavy rectal bleeding causing dizziness, weakness, or anemia; acutely prolapsed, incarcerated, strangulated internal hemorrhoids (irreducible with severe pain, hemorrhagic discharge); or an acutely thrombosed external hemorrhoid causing disabling pain within 72 hours of onset (eligible for excision). Patients over 45 with new-onset rectal bleeding, those with change in bowel habit, unintentional weight loss, or a family history of colorectal cancer require colonoscopy before treatment of hemorrhoids. Chronic unexplained iron deficiency anemia in the presence of hemorrhoids must have upper and lower GI endoscopy to exclude GI malignancy.