Introduction

We all have hemorrhoids. Hemorrhoids are normal “cushions” of tissue filled with blood vessels, found at the end of the rectum, just inside the anus. Together with a circular muscle called the anal sphincter, they help to control bowel movements. But when people talk about “having hemorrhoids,” they usually mean symptoms such as itching or bleeding caused by enlarged hemorrhoids. This condition is also known as “piles.”

Many people are ashamed of having enlarged hemorrhoids: They don’t like to talk about their symptoms, and might be reluctant to go to the doctor. Some might be afraid of having a physical examination or finding out that they have a serious illness. But seeing a doctor about your symptoms is important if you want to have the right treatment.

Symptoms

Hemorrhoid problems can cause various symptoms. These often include itching, mucus discharge or a burning sensation in the anus. Painless bleeding is common too. This can happen if hard stool damages the thin walls of the blood vessels in hemorrhoids. Bleeding from hemorrhoids is usually visible as bright red or red blood, on toilet paper or in the stool. If you have blood in your stool, it’s important to see a doctor rather than try to diagnose the problem yourself.

Swollen hemorrhoids might come out of the anus and can then be seen as soft lumps of tissue. This is called a protruding or prolapsed hemorrhoid. Sometimes hemorrhoids are confused with anal skin tags. These are small flaps of skin that grow around the anus and can cause similar symptoms.

Larger hemorrhoids generally lead to more severe symptoms. They can make it feel like something is pushing against the anus, or like there is something in that area, and sitting can be very uncomfortable. People might also feel like their bowel isn’t really empty, although they have just gone to the toilet. Mucus or stool might come out by accident too, particularly when passing wind. More severe hemorrhoids can be very painful.

Hemorrhoids can be classified according to how severe they are:

• Grade 1: Slightly enlarged hemorrhoids that can’t be seen from outside the anus.
• Grade 2: Larger hemorrhoids that sometimes come out of the anus, for example while passing stool or – less commonly – during other physical activities. They then go back inside again on their own.
• Grade 3: Hemorrhoids that come out of the anus when you go to the toilet or do other physical activities, but don’t go back inside on their own. They can be pushed back inside, though.
• Grade 4: Hemorrhoids that are always outside the anus and can no longer be pushed back inside. Usually, a small bit of the anal lining comes out of the anus too. This is also known as rectal prolapse.

Hemorrhoid tissue, cross-section view: normal (above) and enlarged (below)

Causes and risk factors

Increased pressure on the anal canal (the last section of the rectum) can cause hemorrhoids to become enlarged. Various factors might make this more likely. For example:

• Being overweight
• Chronic constipation
• Frequent diarrhea
• Regularly lifting heavy objects
• Pregnancy and giving birth

The risk of enlarged hemorrhoids increases with age – probably because the tissue becomes weaker over time. And hemorrhoid problems are thought to run in families too.

Prevalence

Every year, about 4 out of 100 adults in Germany go to a doctor because of hemorrhoid problems. But a lot of people don't seek medical help. It is estimated that more than half of all adults over the age of 30 are affected by hemorrhoids at some point in their lives.

Outlook

It’s not possible to predict the course of enlarged hemorrhoids. They might get worse and cause more severe symptoms. But they might not get bigger, and the symptoms might improve again. Hemorrhoids that are already enlarged don't get smaller on their own again, though.

Enlarged hemorrhoids can irritate the surrounding tissue too, which increases the risk of anal eczema. In anal eczema, the skin around the anus is red and inflamed, accompanied by itching and weeping. Small blisters and scabs might form as well.

Diagnosis

When you go to see a doctor, you will probably first be asked about your symptoms and whether you have other medical conditions. The doctor will then look at your anus to see whether it is inflamed, and whether enlarged hemorrhoids come out of it when you push, or whether they are already outside.

Depending on your symptoms, various examinations might be done. If there’s blood in your stool, the doctor may suggest a colonoscopy (looking inside your bowel with a camera). Some people are afraid of having physical examinations and the possible associated pain. But most of these examinations don't hurt, even if they’re sometimes considered to be unpleasant or embarrassing. They’re a normal part of everyday life for medical professionals.

Doctors typically first feel for anything unusual. Known as a digital rectal examination, this involves gently inserting a finger into the anus, with gloves and a little lubricant. The doctor feels the inside of the anal canal using circular movements. This allows him or her to examine the sphincter muscles and the texture of the membranes lining the anus. Grade 1 hemorrhoids generally can’t be felt in this way. But digital rectal examinations can help rule out other medical conditions. The procedure is usually not painful.

If the doctor thinks you might have enlarged hemorrhoids, a proctoscopy is normally carried out next. Here the membranes lining the rectum are examined using a short tube with a light and lens on it, known as a proctoscope. This allows the doctor to see whether you have enlarged hemorrhoids, and how big they are. The procedure takes a few minutes and is usually not painful. The rectum needs to be emptied before the procedure is carried out. This can be done using a laxative, suppository or enema.

Treatment

The choice of treatment will mainly depend on the size of the hemorrhoids and the severity of symptoms. If the hemorrhoids are only slightly enlarged, avoiding constipation and changing your behavior during bowel movements might be enough to make a difference. There’s a lot of advice out there about what you can do to relieve hemorrhoid symptoms yourself – like using creams or sitz baths (shallow warm baths), or changing your diet. While some strategies can actually help, many have not been well tested in scientific studies.

It’s a good idea to seek medical advice if the symptoms are unpleasant and distressing. You could contact your family doctor or a proctologist. Proctologists are doctors who are specialized in medical conditions affecting the rectum and anus.

Things you could discuss with a doctor include whether surgery might help, and what other options there are. For instance, sclerotherapy might be considered for the treatment of grade 1 and grade 2 hemorrhoids, and rubber band ligation might be considered for grade 2 and grade 3 hemorrhoids. Sclerotherapy involves injecting a chemical solution to reduce the blood supply to the hemorrhoids. In rubber band ligation, the hemorrhoids are tied off at the base, making them fall off after a while. If someone has grade 3 or grade 4 hemorrhoids, it might be necessary to surgically remove them.

Further information

Some treatments and surgical procedures can only be done in a hospital, such as those for enlarged hemorrhoids. Here you can find information about how to best prepare for treatment in hospital: for example, what sort of routines to expect, what paperwork you will need to take with you and what kind of procedures aren't fully covered by health insurers in Germany.

Sources

• Abramowitz L, Weyandt GH, Havlickova B, Matsuda Y, Didelot JM, Rothhaar A et al. The diagnosis and management of haemorrhoidal disease from a global perspective. Aliment Pharmacol Ther 2010; 31 (Suppl 1): 1-58. [PubMed: 20500735]
• Acheson AG, Scholefield JH. Management of haemorrhoids. BMJ 2008; 336(7640): 380-383. [PMC free article: PMC2244760] [PubMed: 18276714]
• Alexander K, Daniel WG, Diener HG, Freund M, Köhler H, Matern S. Thiemes Innere Medizin (TIM). Stuttgart: Thieme; 1999.
• Alonso-Coello P, Guyatt GH, Heels-Ansdell D, Johanson JF, Lopez-Yarto M, Mills E et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005; (4): CD004649. [PMC free article: PMC9036624] [PubMed: 16235372]
• Hahn EG, Riemann FJ. Klinische Gastroenterologie. Stuttgart: Thieme; 2000.
• Joos AK, Herold A. Hämorrhoidalleiden. Neue konservative und operative Therapien für ein weit verbreitetes Leiden. Der Gastroenterologe 2010; 5: 326-335.
• Klauber J, Geraedts M, Friedrich J, Wasem J. Krankenhaus-Report 2013. Mengendynamik: mehr Menge, mehr Nutzen? Stuttgart: Schattauer; 2013.
• Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician 2011; 84(2): 204-210. [PubMed: 21766771]
• National Institute for Health and Care Excellence (NICE). Haemorrhoids. 2012.

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.