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Hemorrhoids are submucosal anal tissue cushions prone to bleeding.


Bright red, painless rectal bleeding during defecation is the most common presentation [4]. Other symptoms include [7] anal itching, anal or pelvic pain especially during sitting, one or more palpable lumps that feel hard, congested and tender. There may also be complains of sudden, sharp pain during bowel movements that subsides eventually.

Perineal Pain
  • The recurrence rate after 2 years was 18.3%, and complications included pyrexia, low blood pressure, perineal pain and rectal ulcers, but those were mild [ 17 ].[ncbi.nlm.nih.gov]
Localized Edema
  • No edema rate was 70.8% in the treatment group higher than 43.8% in the control group; mild local edema rate was 26% in the treatment group lower than 39.6% in the control group obvious local edema was 3.03% in the treatment group lower than 16.7% in[ncbi.nlm.nih.gov]
  • Abstract A new syndrome in which 7 cases share common clinical features of urethral discharge only at defecation, constipation, and hemorrhoids is reported. The discharge occurred only with constipation.[ncbi.nlm.nih.gov]
  • BACKGROUND: Constipation, a low fiber diet, sedentary lifestyle and gravidity are commonly assumed to increase the risk of hemorrhoids. However, evidence regarding these factors is limited.[ncbi.nlm.nih.gov]
  • This can occur during pregnancy or childbirth, and due to constipation. The pressure causes the normal anal veins and tissue to swell. This tissue can bleed, often during bowel movements.[nlm.nih.gov]
  • More information eMedicine - Hemorrhoids Yale University MD reviews the causes of external and internal hemorrhoids and their link to constipation, low-fiber diet, and pregnancy.[curlie.org]
Rectal Bleeding
  • In a 62-yr-old woman who complained of recurrent rectal bleeding, hemorrhoids with mucosal prolapse were found. Virus-related cirrhosis also was present.[ncbi.nlm.nih.gov]
  • Bright red, painless rectal bleeding during defecation is the most common presentation.[ncbi.nlm.nih.gov]
  • Evaluation of rectal bleeding in patients with portal hypertension is discussed and possible therapeutic options are described.[ncbi.nlm.nih.gov]
  • You have rectal bleeding. Your provider may want to check for other, more serious causes of the bleeding.[nlm.nih.gov]
Rectal Pain
  • Symptoms Bleeding during bowel movements, itching, and rectal pain are the most common hemorrhoid symptoms. External hemorrhoids Rectal pain occurs mainly with external hemorrhoids. Blood may pool under the skin, forming a hard, painful lump.[healthlinkbc.ca]
  • "Anytime you have bleeding, feel a lump in the anus, or have rectal pain, you should see a doctor to make sure you don't have a more serious cause of the symptoms," says Aline J.[everydayhealth.com]
Fecal Incontinence
  • Neither fecal incontinence nor chronic pain should occur. Anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by following this procedure.[ncbi.nlm.nih.gov]
  • Minor fecal incontinence occurred only after conventional hemorrhoidectomy in 2 ( 5 .4%) patients.[ncbi.nlm.nih.gov]
  • In Group II, 2 patients reported fecal incontinence as a consequence of surgery.[dx.doi.org]
  • Straining during bowel movements can eventually weaken anal sphincter muscles or damage nerves, possibly leading to fecal incontinence. Fecal incontinence care at Mayo Clinic Oct. 12, 2018 References Fecal incontinence.[mayoclinic.com]
  • Hysterectomized women, therefore, are more prone to fecal incontinence [ 141 ]. Finally, impaired rectal compliance has been reported after STARR [ 14 ], which may contribute to fecal incontinence by reducing the rectal reservoir [ 142 ].[doi.org]
  • One patient required 1 unit of blood immediately postoperatively, but none have required further transfusion or reported hematochezia in more than three months of follow-up.[ncbi.nlm.nih.gov]
  • These include hematochezia, congestive haemorrhoidal cushions and inflammation of perianal mucosa in the short term.[ncbi.nlm.nih.gov]
  • Characteristic symptoms include tearing pain with defecation and hematochezia that is usually present as blood on the toilet paper.[doi.org]
Urethral Discharge
  • The syndrome of prostatorrhea, constipation, and hemorrhoids should be considered in patients with idiopathic urethral discharge and in infertile patients.[ncbi.nlm.nih.gov]
Intracranial Hemorrhage
  • Patients who harbor brain arteriovenous malformations are at risk for intracranial hemorrhage. These malformations are often seen in inherited vascular diseases such as hereditary hemorrhagic telangiectasia.[ncbi.nlm.nih.gov]


A detailed history and thorough physical examination is enough to identify as well as grade the disease.

Laboratory tests

Laboratory tests are seldom required. An occult blood test of stool and/or stool guaiac may be performed to confirm fresh bleeding (occult blood may point towards an upper gastrointestinal bleed).


A Doppler ultrasound and in some rare or severe cases, a CT scan may be conducted. A sigmoidoscopy or anoscopy may be performed to see the extent of hemorrhoids. Scoping is also encouraged in such patients to exclude cancer.

Test results

Diagnosis is mainly based on history and physical examination. Test result may aid in ruling out cancer and any other lower gastrointestinal tract pathology.


Conservative management

Conservative treatment is first line of management where the patient is advised to take plenty of fluids, and a high fibre diet [8]. The use of stool softeners, particularly in patients who frequently suffer from constipation, can help in somewhat managing the condition. Non steroidal anti-inflammatory drugs (NSAIDs), corticosteroids like cortisone, and topical analgesics like lidocaine, may also help. The use of comfortable cotton undergarments may help prevent ulceration and infection.


Radical and definitive surgical treatment is indicated in approximately one out of ten patients with hemorrhoidal disease [9]. The transanal hemorrhoidal dearterialization (THD) procedure is an effective treatment of hemorrhoidal disease [10]. Other procedure such as stapling are also used to treat hemorrhoids.


Prognosis depends upon the grade of hemorrhoids. The lower the grade of hemorrhoids, the better is the prognosis. They can be graded according to the following criterias:


  • Grade I: This is the initial stage of hemorrhoids. It involves no prolapsed, just prominent vessels [6].
  • Grade II: This is the second stage in which there is prolapse upon straining or bearing down but with spontaneous reduction.
  • Grade III: There is prolapse but with no spontaneous reduction. It can be, however, reduced manually.
  • Grade IV: Prolapse is persistent and cannot be manually reduced.


The exact cause of symptomatic hemorrhoids is unknown [2]. There may be an alteration in the muscle tissue of the internal hemorrhoid plexus which is one of the causative factors for development of hemorrhoids [3]. Venous stasis that is common during pregnancy, can be a risk factor. Constipation and forcible straining during stools can be a major predisposing factor. A combination of factors such as weakening of the vessel walls due to old age, undue straining due to long standing constipation, portal hypertension, childbirth and obesity may contribute to the development of symptomatic hemorrhoids.



Hemorrhoids are a very frequent complaint in outpatient departments and clinics. It is common in the older age group, and almost one half of individuals older than 50 years complain of the symptoms [4].


They occur almost equally in both sexes. Some studies reveal a slightly higher frequency in females mainly because of the added stress of pregnancy and childbirth.


Hemorrhoids can occur at any age but the most common age group is 45-65 years. They are rare in people younger than 30.


They are common in whites, especially those belonging to a higher socioeconomic status.

Sex distribution
Age distribution


An unusual change in the normal structure of hemorrhoid plexus is the pathology behind the disease [5]. Hemorrhoids consist of dilated submucosal vessels that protrude beneath the anal or rectal mucosa. Due to exposure, they easily become subject to trauma which results in inflammation and thrombosis. Superficial ulceration may also occur.


Hemorrhoids, on the basis of their position, can be classified into 2 types:

  • External hemorrhoids

When collateral vessels within the inferior hemorrhoidal plexus become dilated and inflamed, they are called external hemorrhoids. They are located below the anorectal line.

  • Internal hemorrhoids

Dilation of the vessels of the superior hemorrhoidal plexus is termed as internal hemorrhoids. They are located within the distal rectum, along or above the anorectal line.


Hemorrhoids can be easily prevented simply be implementing a high fibre diet and drinking 8-10 glasses of water every day. Adding a higher content of whole grain and bulky fibrous food not only helps prevent hemorrhoids but also keeps the bowel in good shape. Stool softeners may also be used. By avoiding development of constipation and overdue straining during defecation, hemorrhoids can be prevented from occurring.


Hemorrhoids are dilated cushions of distal rectum and/or anal tissue that may or may not protrude out of the anal canal. They are uncomfortable and may be a source of bleeding; they can also thrombose and get inflamed, and are prone to painful ulceration [1]. Due to one or more reasons, the blood vessels present in the hemorrhoidal plexus, located in the submucosa of the distal rectum and anal canal may get congested and dilated. This dilatation of blood vessels causes pain and often, bleeding. Sometimes, the dilatation may get so severe that it may proceed to prolapse. Hemorrhoids are very common, affecting about 5% of the population.

Patient Information


Hemorrhoids are engorged fibrovascular cushions lining the anal canal [4]. They are swellings or dilatations of the blood vessels present inside the anal canal. They become congested and tender, due to certain causes, and result in discomfort during sitting and bowel movements and are prone to bleed.


Hemorrhoids are commonly due to long lasting constipation resulting in straining during defection. Other causes include pregnancy and childbirth, portal hypertension and obesity.


Symptoms include sharp pain during bowel movements accompanied with fresh, bright red coloured blood. There may also be palpable, tender lumps within the anus, itching around the perineum, pelvic pain and sometimes a red coloured lump might appear to be falling or coming out of the anus during straining.


Conservative treatment includes dietery modifications, topical analgesics and stool softeners. Surgically, transanal hemorrhoidal dearterialization (THD) is a safe procedure and is, at present, one of the most effective treatments of hemorrhoidal disease [10].



  1. Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. Aug 2014;109(8):1141-57; (Quiz) 10
  2. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. Feb 1990;98(2):380-6.
  3. Raahave D, Jepsen LV, Pedersen IK. Primary and repeated stapled hemorrhoidopexy for prolapsing hemorrhoids: follow-up to five years. Dis Colon Rectum. Mar 2008;51(3):334-41.
  4. Perera N, Liolitsa D, Iype S, Croxford A, Yassin M, Lang P, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. Aug 15 2012;8:CD004322.
  5. Faucheron JL, Gangner Y. Doppler-guided hemorrhoidal artery ligation for the treatment of symptomatic hemorrhoids: early and three-year follow-up results in 100 consecutive patients. Dis Colon Rectum. Jun 2008;51(6):945-9.
  6. Senapati A, Nicholls RJ. A randomised trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids. Int J Colorectal Dis. Jun 1988;3(2):124-6.
  7. Ho YH, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL, et al. Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum. Dec 2000;43(12):1666-75.
  8. Bove A, Bongarzoni G, Palone G, Chiarini S, Calisesi EM, Corbellini L. Effective treatment of haemorrhoids: early complication and late results after 150 consecutive stapled haemorrhoidectomies. Ann Ital Chir. Jul-Aug 2009;80(4):299-303.
  9. Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. Mar 2001;44(3):405-9.
  10. Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum. May 1995;38(5):453-6; discussion 456-7.

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Last updated: 2019-07-11 22:29