What are hemorrhoids? How they develop, types and symptoms

The wall of the anal canal has three main soft cushions that are rich in blood vessels. They help the anus close tightly and are part of normal anatomy. The problem begins when these cushions fill with more blood than normal and the supporting tissue that holds them in place weakens.

Hemorrhoids usually develop like this:

1. Constipation, straining or sitting on the toilet for a long time raises the pressure in the anal canal.
2. The veins in the cushions fill with blood, widen and swell.
3. The supporting tissue weakens, and the cushions slide down and turn into lumps.
4. The thin lining over the lump is damaged by hard stool and starts to bleed.

The condition can stay hidden for a long time: in some people the first symptom appears after a few weeks, in others only years later. If the cause is not removed, the lumps usually don't shrink on their own; on the contrary, they grow.

Hemorrhoids are divided into two main types depending on where the lump is. They are separated by a boundary inside the anal canal called the dentate line: above it is a mucous lining that does not feel pain, and below it is very sensitive skin.

Internal hemorrhoids

Internal hemorrhoids are located inside the anal canal, above the dentate line. Because there are few pain nerves in this area, internal hemorrhoids often don't hurt; their main sign is bright red blood after a bowel movement. As the lumps grow, they start to come out during bowel movements. A lump that comes out and doesn't go back in can get squeezed, swell and become very painful.

External hemorrhoids

External hemorrhoids are located at the edge of the anus, under the skin. They feel like a soft lump you can touch and cause itching, burning and difficulty keeping the area clean. Small external hemorrhoids that cause no symptoms often need no treatment. Internal and external hemorrhoids often occur together; this is called mixed hemorrhoids.

Thrombosed hemorrhoids

Thrombosis occurs when a blood clot forms inside a hemorrhoid. It often happens suddenly after heavy straining, lifting something heavy, sitting for a long time or drinking alcohol. A hard, bluish lump appears at the edge of the anus that is very painful to touch and to sit on. The acute phase usually lasts a few days. In this situation, seeing a proctologist early can shorten the painful period.

The 4 stages of internal hemorrhoids

Internal hemorrhoids are divided into four stages based on how far the lumps come out (prolapse):

• Stage I: the lumps stay inside the anal canal and can't be seen; often the only sign is bleeding.
• Stage II: the lump comes out during a bowel movement and then goes back in on its own.
• Stage III: the lump that comes out doesn't go back on its own and has to be pushed back in by hand.
• Stage IV: the lumps stay outside all the time and can't be pushed back in, even by hand.

The higher the stage, the less effective non-surgical treatment becomes. We show which treatment is chosen at each stage in the table on our hemorrhoid treatment page.

Hemorrhoids can show up as:

• bright red blood after a bowel movement: on the toilet paper, on the stool or as drops in the toilet bowl;
• a lump coming out of the anus during a bowel movement;
• itching, burning or moisture around the anus;
• discomfort, pain or swelling when sitting;
• a feeling that the bowel hasn't emptied completely;
• traces of mucus or blood on your underwear.

Bleeding is light at first but can become heavier at later stages. Long-lasting bleeding can lead to anemia (a low blood count): paleness, weakness, dizziness and heart palpitations are its signs.

What happens if hemorrhoids are not treated?

Hemorrhoids usually progress slowly, but if left untreated they can lead to these complications:

• a clot forming in the lump (thrombosis) and sudden, severe pain;
• a prolapsed lump getting squeezed by the anal muscle: the lump swells, darkens and becomes very painful. This is an emergency;
• anemia from long-term bleeding;
• constant moisture, itching and skin irritation around the anus.

The longer you wait, the more a problem that could have been solved with simple methods turns into one that needs bigger surgery. The sooner you see a doctor, the simpler the treatment.

What do hemorrhoids look like?

Many people search online for “hemorrhoid pictures,” so let us describe in words what they look like:

• A prolapsed internal hemorrhoid is a soft, moist, bright red or dark red swelling coming out of the anus. Large ones look like berries stuck together, such as a raspberry.
• An external hemorrhoid is a soft bump at the edge of the anus, skin-colored or slightly bluish.
• A thrombosed hemorrhoid is a tense, hard, dark blue-purple lump the size of a pea or a cherry that is very painful to touch.
• An anal skin tag is a soft, skin-colored fold of skin that usually doesn't hurt. It is often what remains after a past thrombosis or inflammation, and it is not a hemorrhoid.

Don't diagnose yourself from pictures. Warts (condylomas), an anal fissure, a polyp and, rarely, a tumor can also look like a lump near the anus. Only a doctor's examination can tell the difference.

The main cause of hemorrhoids is pressure in the anal canal staying high for a long time. Factors that lead to this:

• chronic constipation and straining on the toilet;
• long-lasting diarrhea;
• sitting on the toilet for more than 5 minutes, especially with your phone;
• a low-fiber diet and not drinking enough water;
• a desk job, lack of movement, long hours behind the wheel;
• heavy lifting, weight training;
• excess weight;
• pregnancy and childbirth;
• family tendency: if hemorrhoids run in your family, the risk is higher.

That is why office workers, drivers, people who do heavy physical work, people who lift weights, pregnant women and older people are in the risk group.

Holding in stool is also harmful. When you think “I'll wait until I get home,” the bowel absorbs water from the stool, the stool hardens and the next bowel movement turns into straining. On the causes and treatment of constipation: constipation treatment.

Hemorrhoids in women

In women, the strongest triggers of hemorrhoids are pregnancy and childbirth. During pregnancy, the hormone progesterone reduces the tone of the blood vessel walls, the growing uterus presses on the pelvic veins, you move less and constipation becomes more common. Pushing during labor can force existing hemorrhoids out. After childbirth, hemorrhoids often occur together with an anal fissure and a rectocele. We wrote about this in our article 5 intimate problems after childbirth.

During pregnancy and breastfeeding, any medication, including suppositories and ointments, should be prescribed only by a doctor. Many women put off an examination for years because they feel embarrassed. Seeing a female proctologist makes this much easier: both the doctor and the team are women.

Hemorrhoids in men

In men, hemorrhoids are more often linked to heavy physical work, weight training, long hours of sitting at work and driving. Men also often delay seeing a doctor out of embarrassment and sometimes come in at an advanced stage. If you lift weights, don't hold your breath while lifting, and avoid movements that sharply increase pressure inside the abdomen.

Measures at home ease the symptoms and slow the progression of the disease, but they don't replace an examination:

• drink about 1.5–2 liters of water a day (unless your doctor has told you otherwise);
• eat fruit, vegetables and whole grains every day;
• don't sit on the toilet for more than 5 minutes and don't strain; put a small stool under your feet;
• after a bowel movement, wash the anal area with warm water, and avoid scented wipes and lots of soap;
• for pain and itching, a warm sitz bath can bring relief;
• cut down on very spicy and fatty foods and alcohol, as they can make symptoms worse.

Don't buy suppositories or ointments at the pharmacy on your own or because friends recommended them. Folk remedies such as garlic, various oils and herbal baths don't cure hemorrhoids, and some can burn and irritate the lining; you also lose time. On common misconceptions: 10 proctology myths people believe.

Treatment depends on the stage. In the first two stages, correcting your diet and toilet habits, plus medication prescribed by a doctor when needed, often helps. If the lumps come out and don't go back in on their own (stages III–IV) or medication doesn't help, surgery is offered: LHP (laser hemorrhoidoplasty), removal of the hemorrhoids with LigaSure, or the Longo procedure (stapled hemorrhoidopexy). Laser treatment is not suitable for stage IV or for very large external hemorrhoids. We explain who each method suits on our hemorrhoid treatment and laser treatment pages.

Don't delay an examination if:

• you have seen blood on toilet paper or in your stool, even once;
• you can feel a lump at the edge of the anus;
• itching, burning or pain lasts more than a week;
• your bowel habits have changed: constipation alternates with diarrhea, or your stools have become thinner;
• you are over 40 and have constipation or bleeding.

Don't wait: seek urgent care if the bleeding is heavy or won't stop, you feel dizzy and weak, your stool is black, a prolapsed lump won't go back in and is turning dark, a very painful hard lump has suddenly appeared at the edge of the anus, or you have a fever along with the pain.

Read about other possible causes of bleeding in our article blood on toilet paper.