By Sonia Gulati. Medically reviewed by Tom Iarocci, MD. May 7th 2016

Although hemorrhoids are bothersome and often uncomfortable, they can often be alleviated by helpful lifestyle factors and nutritional tweaks.

Hemorrhoids (also called piles) are swollen or inflamed veins that develop around the outside of the anus (external hemorrhoids), or inside the lower rectum where you cannot see them (internal hemorrhoids) unless they protrude out. Unfortunately, you can have both types of hemorrhoids at the same time. Straining causes increased pressure on these veins and contributes to the development of hemorrhoids.

By age 50, hemorrhoids affect about half of all people and many women develop them earlier, very often during pregnancy. Hemorrhoids affect 30 to 40 percent of pregnant women, usually in the third trimester or shortly after giving birth, according to the National Institute of Diabetes and Digestive Kidney Diseases.  

Although hemorrhoids can be painful, bothersome and even a little embarrassing, they are usually not serious and can often be treated with home remedies and lifestyle changes. A rare exception is when internal hemorrhoids “strangulate,” which means losing their blood supply, and requires immediate surgery.

If you experience rectal bleeding at any time, or if you care for someone who does, and you are unsure of the exact source of the blood, contact your doctor immediately.

Inflammation is one common symptom

Symptoms of hemorrhoids vary, depending if they are found externally or internally:

  • Painless anal bleeding
  • Anal itching
  • Pain (when hemorrhoids are affected by a blood clot)

External hemorrhoids, found around the anus, are often associated with itching and bleeding. In addition, blood clots can form in an external hemorrhoid, and this may result in more severe pain and swelling.

Internal hemorrhoids are found inside the rectum and can be associated with itching, but the pain from clotting may not be as excruciating as with external hemorrhoids. Both internal and external hemorrhoids are often associated with painless rectal bleeding. Bright red blood maybe found on the toilet paper or in the toilet bowl after having a normal bowel movement. Blood also may be visible on the surface of the stool. Internal hemorrhoids can be graded or scored based on the extent to which they bulge out away from their source through the anus.

Diverse causes of hemorrhoids 

Experts have different theories about how hemorrhoids develop, and it could be that each theory is partially right. Causes of hemorrhoids may vary from person to person, and more than one cause may be at work in the same person. Regardless of the precise mechanism, aggravating conditions are believed to be important. Here are some of these causative, or associated, conditions:

  • Advancing age (hemorrhoids are rare before the age of 20)
  • Prolonged sitting or straining during bowel movements
  • Chronic diarrhea
  • Chronic constipation
  • Lack of fiber in the diet
  • Pregnancy
  • Obesity

To diagnose hemorrhoids, your doctor will take your history and perform a physical examination. A digital rectal exam is performed whereby the doctor inserts a gloved and lubricated finger into the rectum. The examinee may be asked to bear down during the physical exam, which can cause hemorrhoids to bulge out or bleed, for easier identification. The doctor may also use an anoscope, which is a hollow, lighted tube that is inserted a few inches into the anus.

Since internal hemorrhoids may be overlooked during the examination (and because not all patients with rectal bleeding have hemorrhoids), a doctor may need to rely on additional tests. These include:

  • Proctoscopy (rectoscopy): Insertion of a lubricated proctoscope (a lighted, short, straight, hollow metal tube) into the rectum.
  • Colonoscopy: Insertion of a colonscope (a flexible lighted tube) through the anus, rectum and colon. 
  • Sigmoidoscopy: Similar to a colonoscopy, this procedure uses a sigmoidoscope (shorter than a colonoscope) inserted into the rectum and the sigmoid colon.

Next Steps

In most cases, hemorrhoids are highly treatable with lifestyle changes, such as adding more fiber to your diet.  At least 25 grams of fiber can soften the stool, allowing it to pass with more ease and as a result reduce the pressure on hemorrhoids caused by straining, according to experts at the Mayo Clinic. In addition, most doctors recommend a fiber supplement to bulk up your stool, such as psyllium (Metamucil) or methylcellulose (Citrucel).

Other dietary changes you can institute right now in order to relieve symptoms, include:

  • Stay hydrated. Experts recommend adequate fluid intake (8 to 10 glasses of water) daily
  • Be a bathing beauty. Soaking in a tub of warm water for 10 minutes, several times a day.
  • Move more. Exercise for 30 minutes per day to prevent constipation and obesity, which exacerbate the condition.
  • Apply cold compresses. Apply ice packs or cold compresses to the sore area to reduce inflammation and swelling.
  • Keep it clean. Use moist towelettes or wet wipes (without perfume or alcohol) to keep the area clean right after a bowel movement.
  • Try topical creams. Over-the-counter creams and suppositories may temporarily relieve the itching of hemorrhoids. However treatments such as topical corticosteroids should be used sparingly because extended use can damage the epidermis.

If dietary and lifestyle changes do not ease hemorrhoid symptoms, then medical intervention may be necessary. Outpatient procedures can be performed in a doctor's office or a hospital. External hemorrhoids are not usually treated with invasive procedures or surgery with some exceptions. There are many outpatient treatments for internal hemorrhoids too, including:

  • Rubber band ligation: A rubber band is placed at the base of a hemorrhoid, cutting off circulation and causing the hemorrhoid to shrink.
  • Sclerotherapy: A chemical solution is injected into the blood vessel to decrease size of the hemorrhoid.
  • Bipolar, infrared and laser coagulation: Electrical current, heat or laser light, respectively, can be used to minimize the hemorrhoid.
  • Surgical removal. Surgery is a first-line treatment for certain people with internal hemorrhoids that protrude out of the anus, and for patients who present with strangulated internal hemorrhoids. Large external hemorrhoids that do not respond to the other treatments may also be removed surgically.

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