Hemorrhoid: Symptoms, Types, Causes and Treatment

Hemorrhoids are a common, often uncomfortable condition affecting millions worldwide. Despite their prevalence, understanding the nature, causes, and most effective treatments for hemorrhoids remains crucial for those seeking relief and improved quality of life. This article explores the symptoms, types, causes, and modern treatment options for hemorrhoids, synthesizing the latest evidence-based research for a comprehensive guide.

Symptoms of Hemorrhoid

When hemorrhoids become symptomatic, they can significantly impact daily comfort and activities. Recognizing the key symptoms early can guide individuals toward effective management and help distinguish hemorrhoids from other anorectal conditions.

Symptom	Description	Quality of Life Impact	Sources
Bleeding	Painless bright red blood, typically during or after bowel movement	Can cause anxiety, discomfort	1 3 7
Pain	Pain or discomfort, especially with external or thrombosed hemorrhoids	May limit activity, sitting	2 3 7
Itching	Pruritus ani (anal itching), often from irritation or mucus discharge	Embarrassment, distraction	3 5 7
Prolapse	Bulging of hemorrhoidal tissue from the anus, especially after defecation	Discomfort, hygiene issues	3 6 7
Soiling	Mucus discharge or fecal seepage, leading to underwear staining	Hygiene concerns, distress	3 5
Incomplete evacuation	Sensation that bowel movement is unfinished	Repeated toilet visits, stress	2

Table 1: Key Symptoms

Understanding Hemorrhoidal Symptoms

Hemorrhoids often announce themselves with painless rectal bleeding—bright red blood noticed on toilet paper or in the toilet bowl after a bowel movement is a hallmark symptom 1 7. Although alarming, the bleeding is rarely severe.

Pain is more typical of external hemorrhoids, particularly when a blood clot (thrombosis) forms, causing sudden, severe discomfort. Internal hemorrhoids are usually painless unless prolapsed or complicated 7 12.

Itching (pruritus) and soiling are common, caused by irritation from mucus discharge or incomplete cleansing. This can be frustrating and lead to embarrassment in social situations 3 5 7.

Prolapse refers to the descent of internal hemorrhoidal tissue through the anal opening, which may retract spontaneously or require manual reduction in advanced cases 3 6 7. Prolapse can be accompanied by a feeling of fullness or dragging sensation.

Symptoms often overlap with other conditions such as irritable bowel syndrome, especially in advanced hemorrhoidal disease (Grade 3–4), where bloating, abdominal pain during evacuation, and a sensation of incomplete evacuation are frequent. These symptoms can diminish well-being and disrupt daily life 2.

Impact on Daily Life

The symptom burden from hemorrhoids varies; some individuals experience only minor inconvenience, while others find their social life and overall well-being disrupted. Validated tools, such as the Hemorrhoidal Disease Symptom Score, now help measure both specific symptoms and the overall impact on quality of life, ensuring a patient-centered approach to management 3.

Types of Hemorrhoid

Understanding the classification of hemorrhoids is essential for proper diagnosis and management. Hemorrhoids are classified based on their anatomical location, severity, and clinical features.

Type	Location/Characteristic	Typical Symptoms	Sources
Internal	Above dentate line (anal canal)	Bleeding, prolapse	6 7 12
External	Below dentate line (anal verge)	Pain, swelling, thrombosis	6 7 12
Thrombotic	Clotted blood in hemorrhoidal tissue	Sudden severe pain	6 7 12
Mixed	Features of both internal and external	Varied symptoms	6 7

Table 2: Hemorrhoid Types

Internal vs. External Hemorrhoids

Internal hemorrhoids originate above the dentate line within the anal canal. They are typically painless because this area lacks pain-sensitive nerve endings. Symptoms can include painless bleeding, prolapse (bulging out of the anus), and, in advanced cases, discomfort or soiling from mucus discharge 7 12.

External hemorrhoids develop below the dentate line, where the skin is richly innervated. They can cause significant pain, especially if a blood clot forms (thrombosis), leading to a sudden, painful lump at the anal verge. Swelling and itching are also common 7 12.

Thrombotic and Mixed Hemorrhoids

A thrombotic hemorrhoid occurs when blood pools and forms a clot within the hemorrhoidal tissue, usually in an external hemorrhoid. This leads to acute, severe pain and swelling 6 12.

Mixed hemorrhoids display both internal and external features, leading to a combination of symptoms such as bleeding, prolapse, pain, and soiling 6 7.

Grading and Clinical Classification

Traditionally, internal hemorrhoids are graded based on the degree of prolapse:

• Grade I: No prolapse, just prominent vessels
• Grade II: Prolapse on straining but spontaneously reduce
• Grade III: Prolapse requires manual reduction
• Grade IV: Irreducible prolapse

Some experts advocate for a classification based not just on anatomical location and prolapse but also on dominant symptoms—such as bleeding, prolapsing, thrombotic, or mixed hemorrhoidal disease—to guide more rational, symptom-based treatment 6.

Causes of Hemorrhoid

The underlying causes of hemorrhoids are complex and multifactorial. Although commonly attributed to lifestyle factors, the evidence for some traditional risk factors is mixed.

Cause	Risk Factor/Mechanism	Evidence Summary	Sources
Constipation	Straining increases pressure	Strongly associated	1 9 10 11
Low fiber diet	Hard stools, straining	High grain fiber protective	9
Prolonged sitting	Increased venous pressure	Possible association	7 9
Obesity	Increased intra-abdominal pressure	Mixed evidence	10
Pregnancy	Hormonal, mechanical factors	Unclear; evidence limited	7 9 11
Aging	Weakened support tissues	Associated with mucosal type	11

Table 3: Causes and Risk Factors

Mechanical and Lifestyle Factors

Constipation is a well-established risk factor for hemorrhoids. Frequent straining during bowel movements increases pressure in the hemorrhoidal vessels, leading to their enlargement and eventual symptom development 9 10 11. Hard, dry stools resulting from a low-fiber diet exacerbate the problem, while high grain fiber intake appears protective 9.

Prolonged sitting—whether on the toilet or due to sedentary lifestyle—can increase pressure in the anal veins, potentially contributing to hemorrhoid formation 7 9.

Obesity may play a role by increasing intra-abdominal pressure, though evidence is mixed. Some studies have found a higher prevalence in overweight individuals, while others have not 10.

Pregnancy has often been cited as a risk factor, likely due to hormonal changes and increased pelvic pressure, but recent research suggests the association is not as strong as previously thought 9 11.

Vascular and Tissue Changes

Hemorrhoids are essentially the abnormal enlargement and downward displacement of the anal cushions—normal structures that help with continence. Over time, degeneration of the supporting connective tissue and changes in vascular tone or hyperplasia can predispose these cushions to become symptomatic 1 8.

There are also two main types based on etiology:

• Vascular hemorrhoids (more common in younger men): Caused by straining and high pressure gradients during defecation
• Mucosal hemorrhoids (more common in older adults and pregnant women): Related to deterioration of anal sphincter function and support tissues 11

Other Contributing Factors

• Genetic predisposition and anatomical variations may play a role, though research is ongoing 8.
• Abnormal bowel habits, including frequent diarrhea or repeated toilet visits, may also contribute 2.

Despite these associations, the precise cause remains incompletely understood, and some traditionally blamed factors (such as pregnancy or lack of exercise) may not be as significant as once thought 9.

Treatment of Hemorrhoid

Treatment of hemorrhoids depends on the type, severity, and impact on quality of life. Most cases can be managed conservatively, but advanced or complicated cases may require procedural or surgical intervention.

Treatment Type	Examples	Indications/Benefits	Sources
Lifestyle/Conservative	Fiber, fluid intake, exercise, topical creams	First-line for mild cases	1 5 7 12 13 15
Medical Therapy	Venoactive drugs (MPFF), anti-inflammatories	Reduce symptoms, bleeding	1 5 12 13
Office Procedures	Rubber band ligation, sclerotherapy, infrared coagulation	Effective for grades I–III	1 7 12 15
Surgical Options	Hemorrhoidectomy, stapled hemorrhoidopexy, laser hemorrhoidoplasty	Severe or refractory cases	1 12 14 15

Table 4: Hemorrhoid Treatments

Lifestyle and Conservative Measures

Lifestyle changes form the cornerstone of hemorrhoid management, particularly for mild to moderate disease:

• Increase dietary fiber through fruits, vegetables, and whole grains to soften stools and reduce straining
• Adequate hydration to prevent hard stools
• Regular exercise to promote healthy bowel function
• Avoid prolonged sitting on the toilet and respond promptly to the urge to defecate 1 7 12 15

Topical agents, such as corticosteroid creams and over-the-counter ointments, can provide temporary relief from itching and discomfort 7.

Micronized purified flavonoid fraction (MPFF) and other venoactive drugs have demonstrated efficacy in reducing bleeding, pain, and overall symptom burden—particularly in early-stage disease 5 13. In a large multicenter study, MPFF-based conservative treatment was effective in over 75% of patients, especially those with grade I–II hemorrhoids 13.

Office-Based Procedures

When conservative measures are insufficient, minimally invasive procedures can be highly effective:

• Rubber band ligation: A rubber band is placed around the base of the internal hemorrhoid, cutting off its blood supply and causing it to wither 1 7 12.
• Sclerotherapy: Injection of a sclerosing agent to shrink the hemorrhoid 1 7 12.
• Infrared coagulation: Applies heat to coagulate and shrink hemorrhoidal tissue 7.

These options are suitable for grades I–III internal hemorrhoids and offer rapid, office-based relief with minimal downtime 1 7 12 15.

Surgical Interventions

Surgery may be necessary for:

• Persistent or severe symptoms (Grades III–IV)
• Complicated hemorrhoids (prolapsed, thrombosed, strangulated)
• Failed conservative or office-based treatments

Hemorrhoidectomy (surgical removal) remains the gold standard for advanced disease but is associated with postoperative pain and potential complications such as anal stricture or incontinence 1 12.

Stapled hemorrhoidopexy and Doppler-guided artery ligation are newer, less painful techniques that may be appropriate for certain cases 12 15.

Laser hemorrhoidoplasty is a minimally invasive procedure that has shown promising results in reducing postoperative pain and allowing rapid return to daily activities, especially for grades II–III hemorrhoids 14.

Special Considerations

Management may be tailored for specific populations:

• Pregnant women: Emphasis on conservative measures; surgery is rarely indicated 12.
• Immunocompromised or cirrhotic patients: Require careful risk assessment and individualized therapy 12.

Conclusion

Hemorrhoids are a prevalent condition with diverse symptoms and causes, but effective management is possible with the right approach. Here are the key takeaways:

• Symptoms: Bleeding, pain, itching, prolapse, and soiling are most common, and can significantly affect quality of life.
• Types: Classified as internal, external, thrombotic, or mixed, based on location and symptoms.
• Causes: Multifactorial—constipation and straining are major contributors, while high fiber intake is protective; evidence for other factors (pregnancy, obesity) is mixed.
• Treatment: Ranges from lifestyle and dietary changes to advanced minimally invasive procedures and surgery, depending on the severity and impact.

Remember: Early recognition and appropriate therapy can relieve symptoms, prevent complications, and restore quality of life. If you experience persistent anorectal symptoms, consult a healthcare provider for personalized evaluation and care.