Hemorrhoids: Symptoms, Treatment

Brief overview

• Symptoms: Itching, oozing, pain, foreign body sensation, sometimes blood on stool or toilet paper, stool smearing in underwear
• Treatment: Depending on severity, wound ointments, zinc paste or herbal ointments (witch hazel, aloe vera), cortisone ointment, local anesthetics, sometimes flavonoids, sclerotherapy, strangulation (rubber band ligation), surgery
• Causes and risk factors: enlargement of the vascular cushion of hemorrhoids, risk factors: severe pressure due to constipation or heavy lifting, low-fiber diet, little exercise, obesity, pregnancy, sedentary lifestyle
• Diagnosis: Medical history, physical examination with inspection, palpation of the rectum, anal endoscopy (proctoscopy) and/or rectoscopy (rectoscospy).
• Course of disease and prognosis: With therapy, symptoms are easily treatable, the earlier the better, complications such as skin irritation, anal eczema, anemia, and rarely fecal incontinence are possible.

What are hemorrhoids?

Everyone has hemorrhoids (also: piles), both men and women. Hemorrhoids are a spongy vascular pad with a good blood supply that sits at the exit of the rectum. Together with the sphincter muscles, it seals the anus and provides a fine seal.

However, if the hemorrhoids become enlarged, discomfort often results. Because the fine seal of the anus is disturbed by enlarged hemorrhoids, stool smearing sometimes occurs. In addition, those affected complain of pain, itching and burning at the anus. Doctors then speak of hemorrhoidal disease. Colloquially, it simply means: someone has hemorrhoids.

The hemorrhoids sometimes appear as a single lump, or several lumps form in the vascular cushion. A ring-shaped protrusion of this tissue is also possible.

Hemorrhoids are not contagious and usually not dangerous. If they are pronounced, in some cases they emerge outward and are then visible to the naked eye. The hemorrhoids can be felt by themselves in some cases. Hemorrhoidal disease manifests itself in varying degrees of severity and is a very common condition in Western industrialized nations.

Do hemorrhoids regress? Hemorrhoids or hemorrhoidal disease itself does not usually go away on its own. In mild cases, however, the symptoms may regress after a few days and the affected person is free of symptoms again. However, severe hemorrhoids require medical treatment.

Symptoms of hemorrhoids

Internal hemorrhoids that are only very mild often cause hardly any symptoms or only in phases. Phases in which the hemorrhoids are completely without symptoms sometimes alternate with phases with milder symptoms, such as itching or mild burning during bowel movements.

Some sufferers report that hemorrhoids itch and/or hurt, especially at night. One possible explanation for why hemorrhoids itch and/or hurt at night is that the itching and/or pain is more noticeable when at rest.

Often, these mild hemorrhoid symptoms occur when constipation occurs due to lifestyle (low-fiber diet, little or no exercise or physical activity).

What to do when hemorrhoids bleed?

Bleeding hemorrhoids are usually harmless. However, since other conditions also cause blood in the stool, it is important to have this clarified by a doctor.

Hemorrhoids often bleed after a bowel movement, because pressing causes more blood to accumulate in the vessels. The blood lies on top of the stool, sticks to the toilet paper or drips into the toilet. Normally, bleeding from hemorrhoids is mild. In an advanced stage, they are sometimes very heavy. Then you should definitely see a doctor.

How long can hemorrhoids bleed? It is important to know that hemorrhoids usually stop bleeding after a short time. However, each bowel movement may cause a slight bleeding again. If the hemorrhoids have been bleeding for days, a visit to the doctor is advisable.

Do hemorrhoids cause a so-called pencil stool? As a rule, hemorrhoids do not cause a pencil-like deformation of the stool with a small diameter. The cause of pencil stool is a narrowing in the rectum, which causes diseases such as rectal cancer or, more rarely, irritable bowel syndrome or Crohn’s disease. Medical clarification is urgently advisable in this case.

Advanced hemorrhoid symptoms

In advanced hemorrhoids, itching and burning at the anus occur. In addition, some patients with hemorrhoids complain of a feeling of pressure or a foreign body sensation in the anus. Weeping hemorrhoids and sore skin in the anal region or palpable protrusions are also part of the symptoms. The latter are nothing other than hemorrhoids that have fallen out of the anal canal.

Due to the already irritated and moist skin in the anal area, in some cases inflamed and swollen hemorrhoids occur. When hemorrhoids are swollen, this sometimes causes pain. If particularly severe pain occurs with hemorrhoids, this is also a reason to see a doctor. On the one hand, it is conceivable that there may be another cause behind the pain, and on the other hand, it is possible for the doctor to treat the pain.

Why do hemorrhoids itch? The itching of hemorrhoids is often a result of impaired fine closure of the anus; this causes intestinal secretions to leak out in some cases. The skin sometimes softens and is irritated. Cleaning with toilet paper may also further irritate the skin.

Diarrhea is not a typical symptom of hemorrhoids. Nevertheless, diarrhea-like symptoms sometimes occur in the course of the disease: Affected individuals often report mucous secretions from the bowel.

The reason for this is that enlarged hemorrhoids usually prevent the anus from sealing properly. Simple traces of stool in the underwear are also a sign of hemorrhoids.

Constipation caused by hemorrhoids? As a rule, hemorrhoids do not cause constipation, but are usually a consequence of it. Therefore, healthy bowel habits with adequate fluid intake and enough fiber are instrumental in hemorrhoidal disease.

Pus also does not usually occur in connection with hemorrhoids. The cause of pus on the anus is generally an inflammation that leads to an abscess. An abscess, so to speak, is a boil or collection of pus that sometimes occurs in the anal area.

False (external) hemorrhoids

True (internal) hemorrhoids arise from dilated arteries of the vascular cushion located inside the rectum near the exit (anus).

Doctors refer to these hemorrhoids as anal venous thrombosis, anal thrombosis or perianal thrombosis. Unlike hemorrhoids, venous rather than arterial blood vessels are blocked in this case. They occur suddenly and are permanently painful. Unlike hemorrhoids, they are located only on the outside and are constantly palpable as hard, bulging lumps on the outer edge of the anus.

Hemorrhoids: Treatment

There are several ways to have pathologically enlarged hemorrhoids treated. Depending on the severity of the hemorrhoidal condition, various treatment options can be considered. Doctors distinguish between the following degrees of severity of hemorrhoidal disease:

• Hemorrhoids grade 1: Mildest and most common form of hemorrhoids, are not palpable and are only visible during an anal canal examination (proctoscopy).
• Grade 2 hemorrhoids: bulge outward when pressed and then retract back into the anal canal on their own.
• Grade 4 hemorrhoids: are permanently visible on the outside of the anus, can no longer be pushed back into the anal canal, often some anal mucosa also protrudes (anal prolapse)

Hemorrhoid duration: How long it takes for mild hemorrhoids to go down, or how long the hemorrhoid swelling lasts, varies. As a rule, mild forms of hemorrhoids lead to a reduction in symptoms and a regression of the hemorrhoid swelling within a few days. If the symptoms persist for longer than one to two weeks, it is advisable to consult a doctor.

The first point of contact for hemorrhoids is your family doctor. He will then refer you to the right place. For hemorrhoids, which doctor is ultimately the right specialist depends on the type of treatment. Possible specialized specialists include: Proctologists, surgeons or gastroenterologists.

Basic therapy for hemorrhoids

The basis of any hemorrhoid treatment is a healthy diet and regular bowel movements. Both also help to prevent hemorrhoids.

Measures of basic therapy for hemorrhoids are:

• Eat foods with lots of fiber on a regular basis. This prevents constipation. There is a lot of fiber in whole-grain bread, muesli, wheat bran, psyllium husks, sesame seeds, oatmeal, legumes, vegetables and fresh fruit (with peel).
• Drink at least one and a half liters of fluid per day. This allows the absorbed dietary fiber to swell well in the intestines. Water and other calorie-free drinks such as unsweetened tea are particularly recommended.
• Try to eat as few foods as possible that promote constipation. These include white bread, chocolate, white rice and white pasta. Black tea also makes the intestines sluggish if it has been steeped for a long time.
• Take time for bowel movements, if possible always at the same time of day. This will help your bowels get used to regular bowel movements.
• Do not push too hard during bowel movements.
• Before using laxatives – including natural or herbal products – it is advisable to talk to your doctor.

This type of diet and the other measures form the basic treatment for hemorrhoidal disease and are generally advisable even after hemorrhoid surgery.

In addition, conservative measures can be applied if necessary, for example a pain-relieving hemorrhoid cream or hemorrhoid ointment. In the case of persistent symptoms or a severe hemorrhoidal condition, for example, if “external” hemorrhoids (already bulging out of the anus) are already present, surgical treatment to remove them is usually necessary.

Hemorrhoid treatment with medication

One group of drugs used for the treatment of hemorrhoids are so-called “externals” or “hemorrhoidalia”. This means that they are applied in the form of ointments, gels, creams, suppositories and/or anal tampons (suppositories with a mullein insert). They are used for symptomatic therapy. This means that they relieve acute symptoms, but do not eliminate the cause.

Medications for the treatment of hemorrhoids that are taken orally are called “internals”. They are used in the form of tablets, for example. They relieve acute symptoms and are intended to improve the healing process after surgery.

Anti-inflammatory drugs

Wound ointments or zinc paste can be used to treat painful hemorrhoids. Herbal creams, ointments or suppositories are also helpful for hemorrhoids, for example preparations based on Hamamelis virginiana (virgin witch hazel) or aloe vera.

In addition, in some cases your doctor may prescribe ointments containing cortisone. They contain, for example, prednisolone or hydrocortisone acetate. These active ingredients inhibit the immune system, which counteracts the inflammation at the anus and the hemorrhoids.

Use ointments containing cortisone only as long as your doctor has recommended. If you use it longer, you run the risk of developing skin atrophy. This means that the skin becomes thinner and therefore more vulnerable. In addition, cortisone ointments promote fungal infections in the intestines.

Ointments and creams against hemorrhoids during pregnancy and breastfeeding? In principle, doctors prescribe these medications as well as psyllium husks here only with restraint. Before using certain products, even over-the-counter, talk to your doctor. In many cases, a high-fiber diet, exercise (as much as possible) and good anal hygiene will already prevent constipation.

Local anesthetics

Just like cortisone ointments, doctors prescribe local anesthetics only for short-term use. The reason: they sometimes cause allergies. If you have had an allergic reaction to local anesthetics in the past, it is important to tell your doctor before hemorrhoid treatment.

How is the medication applied?

You apply the ointments directly into the anus with the help of an applicator. Alternatively, a compress can be coated with the ointment and then used as an insert.

Some active ingredients are also offered by manufacturers as anal tampons. These are suppositories that are provided with a gauze strip. They remain in the anal canal and release their active ingredient there. Conventional suppositories, on the other hand, release their active ingredient in the upper sections of the intestine.

Flavonoids

In Austria and Switzerland – but not in Germany – so-called flavonoids are approved. These are secondary plant substances such as diosmin and hesperidin for oral administration. They are used for acute complaints, but also postoperatively. Flavonoids reduce the extensibility of blood vessels and prevent their permeability to blood fluid.

Sclerosing, icing or strangulation of hemorrhoids

Mild hemorrhoids (especially grade one to two) are often sclerosed by the doctor. To do this, he injects a sclerosing substance in the area of a hemorrhoid, such as zinc chloride. This blocks the flow of blood into the hemorrhoid, and the tissue shrinks and solidifies. Doctors call this method sclerotherapy.

When exactly hemorrhoids improve after sclerotherapy varies somewhat from person to person. However, there is usually relief from hemorrhoid symptoms within a few days. Which behavior is advisable after sclerotherapy of hemorrhoids, you discuss with your attending physician.

Hemorrhoids can also be sclerosed by infrared light. However, this so-called infrared coagulation is not considered very successful.

Another option is to ice the hemorrhoids with nitrous oxide or liquid nitrogen. Doctors refer to this as cryohemorrhoidectomy. However, similar to infrared coagulation, the chances of success are not very high.

Better chances of success are offered by “ligating” the hemorrhoids. Rubber band ligation or hemorrhoid ligation is performed by physicians especially for second-degree hemorrhoids, but sometimes also for first- and third-degree hemorrhoids.

It is strongly advised not to lance hemorrhoids (yourself). This poses a risk of infection in addition to injury. Always consult a doctor for safe treatment if you have a hemorrhoid condition.

Hemorrhoid surgery

The last option for hemorrhoid treatment is traditional hemorrhoid surgery. In this procedure, the doctor cuts out the hemorrhoids completely. This hemorrhoidectomy is indicated when other treatment methods (such as sclerotherapy) fail to relieve symptoms. Surgery is often performed for third- and fourth-degree hemorrhoids.

In the long term, higher grade hemorrhoids, such as grade 4, usually cannot be treated sustainably without surgery. Nevertheless, conservative therapy is also recommended for hemorrhoids of any degree.

Modern surgical procedures of hemorrhoids treatment.

There are now also some modern procedures that can be used to remove hemorrhoids. They are considered gentler than a classic hemorrhoidectomy. One example is the stapler operation according to Longo.

It is suitable for third-degree hemorrhoids. During the procedure, the doctor punches out a strip of anal mucosa above the hemorrhoids using a special stapling device (stapler). He then “pulls” the prolapsed hemorrhoids back into the anal canal and staples the edges of the wound together.

The method is considered less painful than surgical removal of the hemorrhoids. Patients usually need less pain medication afterward and in many cases leave the hospital sooner. However, there are also disadvantages, including the increased risk of recurrence: new hemorrhoids form more quickly and more frequently after Longo surgery than after hemorrhoidectomy.

Therefore, to relieve the pain, doctors advise some measures postoperatively. Just as stool regulation (by means of a high-fiber diet) plays a role in the treatment of hemorrhoids without surgery, it is also the case with surgery. If the stool is soft, this contributes to pain relief.

In addition, doctors usually prescribe painkillers after hemorrhoid surgery and recommend thorough but gentle douching of the anal region with clean water to help the wound heal. In some cases, doctors may prescribe an antibiotic postoperatively, but this is not always necessary.

There is no general answer to how long light bleeding will occur after hemorrhoid surgery. Here, the doctor assesses to what extent the strength and duration of bleeding are within the regular scope of the operation or from when they represent a complication and need to be treated. In principle, it is strongly recommended to clarify this with the physician.

On average, hemorrhoids can be expected to require about one to four weeks of inability to work or sick leave after surgery. The healing time of the hemorrhoid wound after surgery takes approximately between four and eight weeks.

Home remedies for hemorrhoids

Home remedies such as sitz baths with anti-inflammatory tannins or flaxseed, sitz rings/sitz cushions (in the case of ring-shaped hemorrhoids) and cooling compresses help in many cases to alleviate a hemorrhoidal condition.

Good hygiene of the anal region, using only water and thorough drying with soft toilet paper or cloth is also advisable. Many doctors also advise not to use wet toilet paper, as this can cause additional irritation in some cases.

Caution is also advised with anal showers. Anal showers do not help against hemorrhoids and sometimes even lead to injuries to the enlarged hemorrhoids.

In principle, home remedies such as ointments, seat cushions or cooling compresses are already sufficient to make mild hemorrhoidal complaints disappear. They are also useful for more advanced hemorrhoidal conditions, as they often relieve the symptoms and support medical treatment.

Home remedies have their limits. If the symptoms persist for a long period of time or even worsen, it is necessary to consult a doctor.

You can learn more home remedies and valuable advice for hemorrhoidal suffering in the article Hemorrhoids – Home Remedies.

Hemorrhoids: Causes and risk factors

Many people wonder how you get hemorrhoids in the first place: basically, hemorrhoids are a dilation of the arterial blood vessels of the hemorrhoidal cushion. But exactly why hemorrhoids develop has not been conclusively clarified.

There are now several theories about which risk factors promote their development. These include:

• Lifting heavy loads increases pressure in the abdomen: People who regularly carry heavy loads also have an increased risk of developing hemorrhoids.
• Frequent diarrhea leads in some cases to the fact that the sensitive closing system of the anus is no longer sufficiently trained. As a result, the arteries in the hemorrhoidal cushion sometimes enlarge.
• Congenital weakness of the blood vessel walls: Such a weakness of the blood vessel walls probably also contributes to the fact that the risk for hemorrhoids increases with age. The blood vessel walls lose elasticity as the years go by.

Although hemorrhoids are not usually caused by drinking alcohol, it is still better to avoid alcohol and other stimulants that irritate the gastrointestinal tract if you have acute symptoms. Other risk factors for hemorrhoids may be overweight and sedentary work. These circumstances lead to an obstruction of the blood outflow.

Anal intercourse or other sex practices do not cause hemorrhoids. However, if hemorrhoids are already present, anal intercourse is not advisable during the period of acute symptoms.

Hemorrhoids due to stress? One often reads on the Internet about stress as a trigger for hemorrhoids. In fact, there is evidence that stress is not a risk factor but, on the contrary, plays a protective role in the disease.

Causes of hemorrhoids in pregnant or childbearing women: In women, there are other risk factors for hemorrhoids, namely pregnancy and childbirth. The latter refers to hemorrhoids that sometimes occur due to pushing during childbirth. However, these hemorrhoids often disappear after eight to 24 weeks.

You can read more about hemorrhoids in expectant mothers in the article Hemorrhoids – Pregnancy.

Hemorrhoids due to cold? There is a persistent myth that sitting on a cold floor can cause hemorrhoids. A lot of sitting or little movement is generally a risk factor for hemorrhoids, but the cold does not play a role in this.

This is not the case with another condition that is often confused with hemorrhoids: anal vein thrombosis or anal thrombosis. One cause of anal vein thrombosis is actually sitting on a cold floor. Also, the bulge in anal vein thrombosis often appears blue or bluish, which is less common in hemorrhoids.

Hemorrhoids: Examinations and diagnosis

Sometimes other diseases are the reason for the complaints, such as perianal thrombosis, an anal abscess, herpes, eczema or fungal infections. In the worst case, colon cancer is behind it (blood in the stool!). Therefore, do not be afraid to visit your family doctor at an early stage if you suffer from the above-mentioned complaints.

Detailed conversation

First of all, the doctor will talk to you in detail in order to obtain your medical history (anamnesis). To do this, he will ask you the following questions, among others:

• How long have you had the symptoms?
• Have you noticed blood after a bowel movement?
• Do you feel pain or itching at the anus?
• Do you suffer from constipation or diarrhea?
• Do you eat a lot of fruits and vegetables? Do you drink enough fluids?
• Do you have a job where you sit a lot or are you physically active while doing so?
• For women: Are you or have you been pregnant?

• Do you have any other symptoms such as weight loss, loss of appetite, night sweats, fever or intestinal cramps?

Examinations

This is followed by the physical examination, which consists of individual examinations.

First, the physician assesses the skin conditions of the intestinal outlet (inspection). This allows him to see whether the region is inflamed or irritated. Other anal diseases such as anal vein thrombosis are also visible in this way. In the case of small hemorrhoids, the doctor sometimes asks for a short squeeze, as these then partially protrude from the anus.

Next, the doctor usually palpates the anus area and the anal canal with his finger (digital-rectal examination). This enables him to examine the anal sphincters and the condition of the anal mucosa. The examination often already provides clear indications of hemorrhoids. If further examinations are necessary, the general practitioner will refer you to a specialist.

Sometimes a colonoscopy of the entire large intestine is necessary. In the case of blood in the stool, this is used to rule out colon cancer. The diagnosis of hemorrhoids plays a secondary role here.

Are hemorrhoids dangerous?

Many sufferers ask themselves the question, “Are hemorrhoids dangerous?” The answer to this is: basically, hemorrhoids are not threatening and have a good prognosis. The earlier they are known, the better they can be treated. For this reason, an early visit to the doctor is advisable.

Complications may occur in the course of hemorrhoidal disease. Enlarged hemorrhoids in some cases lead to skin irritation. This in turn promotes anal eczema: the skin at the anus is red and inflamed, it weeps and itches. In addition, skin blisters and scabs sometimes form.

In some cases, hemorrhoids become incarcerated as they exit the anus. Doctors then speak of incarceration. This is very painful. As a result of the hemorrhoid being pinched or unpinned, the blood backs up in the vessels and the blood flow slows down. Sometimes a thrombosis forms in this way. Doctors then speak of thrombosed hemorrhoids (hemorrhoidal thrombosis).

Hemorrhoids provide fecal continence by sealing the anus. In the case of enlarged hemorrhoids, this is no longer sufficiently possible in some cases. As a result, there is a risk of fecal incontinence if the disease persists over a long period of time: the affected person passes stool uncontrollably.

Hemorrhoid surgery: possible complications.

After hemorrhoid surgery, there is usually always a certain risk that complications will occur. These include, for example:

• Postoperative bleeding
• @ Pain
• Blood clots (thrombosis) at the anus

Infections, abscesses and narrowing of the bowel outlet (anal stenosis) are also possible. In addition, slight swelling of the anus is possible after hemorrhoid surgery. Provided that this regresses over time and there is no infection, this is usually within the usual range of surgical procedures.

Rarely does hemorrhoid surgery lead to fecal incontinence and serious complications are very rare.

Preventing hemorrhoids

There are certain basic hemorrhoid treatment measures that also play an important role in preventing hemorrhoidal disease. These are, first and foremost, a high-fiber diet and regular bowel movements.

• Make sure you eat a diet rich in fiber to prevent constipation.
• Drink enough fluids so that the fiber also swells in the intestines.
• Try to avoid foods such as white bread, chocolate or white pasta as they promote constipation.
• To prevent hemorrhoids, make sure you get enough exercise, such as regular exercise.
• Try to reduce excess weight.
• Avoid heavy pressing when visiting the toilet. It is advisable to take time for bowel movements and to take laxatives only after consulting your doctor.