Hemorrhoids

If you are reading this because you saw blood after a bowel movement, or because something near your bottom hurts and you have been too embarrassed to ask anyone about it — take a breath. Hemorrhoids are one of the most common conditions there is. Roughly half of all adults will have symptomatic hemorrhoids by about age 50. They are not a sign that you did anything wrong, they are not dirty, and they are not a secret you need to keep. Almost everyone gets them eventually. This page explains plainly what they are, what helps, when a procedure is worth it, and — importantly — the one situation where you must not just assume "it's only hemorrhoids."

Overview
Epidemiology
Pathophysiology
Etiology and Risk Factors
Clinical Presentation
Diagnosis
Treatment
Complications
Prognosis
Prevention
Recent Research and Advances
Research Papers
Connections
Featured Videos

1. Overview

Here is something most people do not know: everyone has hemorrhoids. Hemorrhoids are not a disease you catch — they are normal cushions of blood vessels, smooth muscle, and connective tissue that sit just inside (and just outside) the anal canal. They are part of your body's design. These cushions help seal the anus and contribute a small amount to continence, helping you tell the difference between gas, liquid, and stool. The word "hemorrhoids" only becomes a problem when these cushions enlarge, slip downward, become inflamed, bleed, or clot. When doctors say someone "has hemorrhoids," they really mean symptomatic hemorrhoidal disease.

There are two main kinds, and the difference matters a great deal for what you feel:

Internal hemorrhoids sit above a line inside the anal canal called the dentate line. The tissue above that line has very few pain-sensing nerves. That is why internal hemorrhoids are usually painless — the classic story is bright red blood on the toilet paper, dripping into the bowl, or coating the stool, with no pain at all. When they enlarge they can bulge or "prolapse" out during a bowel movement and may need to be pushed back in.
External hemorrhoids sit below the dentate line, where the skin is loaded with pain nerves. These can become a tender lump. When a blood vessel inside an external hemorrhoid clots (a thrombosed external hemorrhoid), it produces a sudden, firm, purple, very painful lump at the anal opening — the kind of pain that makes sitting miserable.

So a simple rule of thumb: painless bleeding usually points to internal hemorrhoids; a painful lump usually points to an external or thrombosed hemorrhoid. The vast majority of hemorrhoid problems are managed without surgery, and a great many resolve with nothing more than fiber, fluids, and changing a few bathroom habits.

2. Epidemiology

Hemorrhoids are extraordinarily common — arguably the single most common anorectal complaint people bring (or are too embarrassed to bring) to a clinician. In the United States, gastrointestinal disease burden estimates list hemorrhoids among the most frequent reasons for gastrointestinal-related outpatient visits, accounting for millions of clinic visits and substantial healthcare cost each year (Peery and colleagues, Gastroenterology, 2019).

A frequently cited figure is that around half of adults develop symptomatic hemorrhoids by age 50. A careful screening-colonoscopy study by Riss and colleagues found that, when investigators actively looked, the prevalence of hemorrhoids in adults was about 38.9% — and many of those people had no symptoms at all, which underscores how normal the tissue is (International Journal of Colorectal Disease, 2012).

Symptoms tend to peak between roughly ages 45 and 65, then become somewhat less common in advanced old age. They affect men and women at broadly similar rates overall, though pregnancy and childbirth drive a distinct spike in women. People in higher-income, lower-fiber dietary settings appear to be affected more, which fits the long-standing observation that fiber matters. Because of stigma, true prevalence is almost certainly underreported — many people self-treat for years and never mention it.

3. Pathophysiology

To understand why hemorrhoids act up, picture three small vascular cushions lining the upper anal canal, each held in place by connective-tissue and muscle scaffolding (the muscle of Treitz / Park's ligament). Several things can go wrong with this setup:

The supporting tissue weakens and stretches. With age, repeated straining, and the steady downward push of gravity and bowel movements, the connective tissue anchoring the cushions degrades. The cushions then slide downward and prolapse. This "sliding anal cushion" model is the leading explanation for internal hemorrhoidal disease (Lohsiriwat, World Journal of Gastroenterology, 2012).
Abnormal blood flow and vascular changes. The cushions are fed by arteries and drained by veins. Increased arterial inflow and impaired venous drainage cause the cushions to engorge, dilate, and become fragile, which is why they bleed bright red (arterial-rich) blood.
Inflammation and tissue remodeling. Engorged, prolapsing tissue gets irritated, with local inflammation, microscopic vessel changes, and breakdown of the surrounding matrix.

The bleeding is bright red rather than dark because the blood comes from these well-oxygenated arteriovenous cushions, not from old blood sitting higher up in the gut. A thrombosed external hemorrhoid is a different mechanism: a clot forms within an external hemorrhoidal vein, the tissue swells acutely, and the stretched, pain-sensitive skin over it produces sharp pain that typically peaks in the first 48 hours.

4. Etiology and Risk Factors

Hemorrhoids develop from a combination of habits, pressure, and aging tissue. The common contributors are practical and, encouragingly, several are within your control:

Constipation and straining. Hard stools and pushing hard on the toilet raise pressure in the anal canal and drag the cushions downward. This is the single most modifiable factor.
Low-fiber diet. Too little dietary fiber leads to small, hard stools that require straining. (See Constipation.)
Prolonged sitting on the toilet — especially with a phone. Sitting for long stretches lets the cushions engorge with blood; the toilet seat's open center offers no support. The modern habit of scrolling on a phone for 10–20 minutes per visit is a genuine and growing contributor.
Pregnancy and childbirth. The weight of the uterus, hormonal softening of tissue, and the pushing of vaginal delivery all promote hemorrhoids; they are very common in the third trimester and postpartum (Poskus and colleagues, BJOG, 2014).
Aging connective tissue. The supporting scaffolding naturally weakens over the decades.
Heavy lifting and chronic straining. Repeatedly bearing down — heavy weightlifting, certain occupations, chronic cough — raises abdominal and anal pressure.
Chronic diarrhea. Frequent loose stools also irritate and inflame the area (see Chronic Diarrhea).
Obesity and a sedentary lifestyle contribute through pressure and sluggish bowel habits.

Myth check. Contrary to popular belief, sitting on cold or hard surfaces does not cause hemorrhoids, and spicy food does not cause them (spicy food may briefly aggravate the burning of an existing problem, but it does not create one). And crucially: hemorrhoids do not turn into cancer. They are not pre-cancerous and they do not "become" colorectal cancer. That myth causes needless fear — but it should never be used as a reason to ignore bleeding, for the reason explained below.

5. Clinical Presentation

What hemorrhoids feel like depends on which kind you have:

Painless rectal bleeding. The hallmark of internal hemorrhoids: bright red blood on the toilet paper, dripping into the bowl, or streaking the outside of the stool. Usually small amounts.
A bulge or prolapse. A soft lump that comes out during a bowel movement and either goes back on its own, has to be pushed back, or stays out.
Itching, irritation, moisture, or a feeling of incomplete emptying around the anus, often from prolapsed tissue.
A sudden, very painful lump (thrombosed external hemorrhoid). Firm, purple-blue, tender, worst in the first day or two.

Grading internal hemorrhoids (I–IV)

Doctors grade internal hemorrhoids by how much they prolapse — this guides treatment:

Grade I: bleed but do not prolapse (stay inside).
Grade II: prolapse during a bowel movement but slip back in on their own.
Grade III: prolapse and must be pushed back in by hand.
Grade IV: prolapsed and cannot be pushed back in (or re-prolapse immediately); may include thrombosis.

The one thing you must not assume away

This is the most important paragraph on this page, so read it carefully. Most rectal bleeding really is from hemorrhoids. But you cannot tell for certain on your own, and bleeding from colorectal cancer can look identical — bright red blood with no pain. Hemorrhoids do not cause colorectal cancer, but a person can have both at the same time, and assuming "it's just my hemorrhoids" is how some cancers get missed for too long.

Please get evaluated — do not just self-treat — if you have rectal bleeding AND any of the following:

You are age 45 or older with new bleeding (colorectal screening now starts at 45).
A change in bowel habits — new constipation, diarrhea, narrower (pencil-thin) stools, or a feeling of incomplete emptying.
Unintended weight loss, fatigue, or signs of anemia (paleness, breathlessness, low iron).
Dark, tarry, or maroon blood, or blood mixed through the stool (higher-up bleeding), rather than bright red on the surface.
A family history of colorectal cancer or inflammatory bowel disease.
Bleeding that does not settle within a week or two of sensible self-care.

Getting checked is not an overreaction — it is exactly what a good clinician wants you to do. In most cases it confirms hemorrhoids and reassures you. In a few cases it catches something important early.

6. Diagnosis

Diagnosing hemorrhoids is usually quick and far less awkward than people fear. It typically involves:

History. Bright red blood, pain or no pain, lumps, itching, bowel habits, fiber intake, and any red-flag features listed above.
External inspection. Looking at the anal area for external hemorrhoids, skin tags, a thrombosed lump, fissures, or prolapsed internal tissue (sometimes asking you to gently bear down).
Digital rectal exam. A gloved, lubricated finger checks for masses, tenderness, and tone. (Soft internal hemorrhoids often cannot be felt this way — that is normal and does not mean nothing is there.)
Anoscopy. A short, lighted scope lets the clinician see internal hemorrhoids directly and grade them. This is the best office tool for confirming internal hemorrhoids.

When more is needed. If there are red-flag features, if you are due for colorectal screening, or if the source of bleeding is uncertain, a colonoscopy (or flexible sigmoidoscopy) is recommended to examine the colon and rule out other causes. Major society guidelines emphasize that hemorrhoids should never be a blanket explanation for bleeding when warning signs are present (Davis and colleagues, ASCRS, 2018; van Tol and colleagues, European Society of Coloproctology, 2020).

7. Treatment

The good news: most hemorrhoids respond to simple measures, and the treatments are arranged in a sensible ladder — start gentle, escalate only if needed.

Step 1 — Conservative care that actually works

Fiber — this is the strongest evidence and the foundation of treatment. Aim for about 25–35 grams of fiber a day, increased gradually to avoid gas and bloating. A Cochrane systematic review found that fiber supplements meaningfully reduce bleeding and the risk of persistent symptoms in hemorrhoidal disease (Alonso-Coello and colleagues, Cochrane Database of Systematic Reviews). Soluble fiber (psyllium, oats, beans) softens and bulks the stool so you no longer have to strain.
Drink enough water. Fiber works best with adequate fluids; together they keep stool soft.
Do not strain, and do not linger. Go when you feel the urge, keep toilet visits short (a few minutes), and leave the phone outside the bathroom. Prolonged sitting and pushing are direct causes.
Sitz baths. Sitting in a few inches of plain warm water for 10–15 minutes, two to three times a day (and after bowel movements), relaxes the area and eases pain and itching. No additives are needed.
Topical agents — honest expectations. Over-the-counter creams, ointments, and suppositories (witch hazel, lidocaine, soothing barriers) can give short-term symptom relief — they calm itching, burning, and discomfort, but they do not cure the hemorrhoid or shrink it long term. Topical steroids (e.g., hydrocortisone preparations) should be used for less than about one week, because longer use thins and damages the delicate perianal skin.
Stool softeners or osmotic laxatives can help in the short term if stools are hard, but fiber and fluids are the durable fix.

Step 2 — Office (non-surgical) procedures

If conservative care is not enough for internal hemorrhoids (commonly grades I–III), several quick office procedures can be done without general anesthesia:

Rubber band ligation — the most effective non-surgical option for internal hemorrhoids. A tiny rubber band is placed at the base of the hemorrhoid, cutting off its blood supply so it shrinks and falls off within days. It is done above the dentate line so it is usually well tolerated. It is widely regarded as the office treatment of choice for grade I–III internal hemorrhoids (Cataldo and colleagues, ASCRS practice parameters; Migaly and Sun review, 2016).
Sclerotherapy. A solution is injected to scar and shrink the hemorrhoid — useful for smaller or bleeding internal hemorrhoids and for people who cannot stop blood thinners.
Infrared or bipolar coagulation. Heat or light energy is applied to seal off the hemorrhoid's blood supply; good for smaller hemorrhoids, often with less pain.

Step 3 — Surgery, when it is genuinely needed

Surgery is reserved for large or stubborn cases — typically grade IV, large grade III, mixed internal/external disease, recurrent disease after banding, or a severely thrombosed/strangulated hemorrhoid.

Conventional hemorrhoidectomy. The most definitive and most durable cure, with the lowest recurrence — but it is honestly the most painful recovery, with one to several weeks of significant discomfort. Worth it for severe disease that has not responded to anything else.
Stapled hemorrhoidopexy. A stapling device lifts and tacks the prolapsing tissue back up. Generally less immediate pain than conventional surgery, but a somewhat higher recurrence/re-prolapse rate.
Doppler-guided / haemorrhoidal artery ligation (HAL/THD). A Doppler probe finds the feeding arteries, which are then tied off. The large UK HubBLe randomised trial directly compared this to rubber band ligation and found that for grade II–III hemorrhoids, rubber band ligation was a reasonable first choice, with artery ligation reserved for selected cases — useful evidence that the cheaper office procedure holds up well (Brown and colleagues, The Lancet, 2016).

The thrombosed external hemorrhoid — timing matters

For that sudden, very painful purple lump: the pain peaks early and then slowly improves over days as the body reabsorbs the clot. Surgical excision within the first ~72 hours (a small in-office procedure under local anesthetic) can give faster, more lasting relief and lower the chance of recurrence. After about 72 hours, when the pain is already easing on its own, conservative care — sitz baths, pain relief, stool softeners, and time — is usually the better path, and the lump resolves over a week or two, sometimes leaving a harmless skin tag.

Pregnancy-specific guidance

Hemorrhoids in pregnancy and after delivery are extremely common and usually improve markedly after the baby is born. First-line care is conservative and reassuring: a high-fiber diet, plenty of fluids, sitz baths, avoiding straining, and not sitting on the toilet too long. Many topical products and oral medications have limited safety data in pregnancy, so always check with your obstetric provider before using any product, and favor the non-drug measures. Procedures and surgery are generally deferred until after delivery unless symptoms are severe (Poskus and colleagues, BJOG, 2014).

8. Complications

Hemorrhoids are usually more of a nuisance than a danger, but complications can occur:

Anemia. Rarely, ongoing low-level bleeding leads to iron-deficiency anemia. Anemia from hemorrhoids should always prompt a careful search for any other source of blood loss.
Thrombosis. A clot in an external hemorrhoid causes the acute painful lump described above.
Strangulation. A prolapsed internal hemorrhoid can get trapped and have its blood supply cut off — very painful and an indication for prompt treatment.
Skin tags. After an external hemorrhoid or thrombosis resolves, a harmless flap of skin may remain; it is cosmetic and only removed if it bothers you.
Irritation and itching from chronic prolapse, moisture, and mucus.
Procedure-related issues (uncommon): bleeding, infection, urinary retention, or — after surgery — pain and, rarely, narrowing or continence changes.

9. Prognosis

The outlook is excellent. The large majority of hemorrhoid problems improve or resolve with conservative measures alone, and most of the rest are cured by a quick office procedure. Even after successful treatment, hemorrhoids can come back if the underlying habits do not change — which is exactly why fiber, fluids, and good bathroom habits are not just treatment but lifelong maintenance. Surgery, when truly needed, has high success and low recurrence, at the cost of a more uncomfortable recovery. The single most important determinant of your outcome is sticking with the boring-but-effective basics.

10. Prevention

Prevention and long-term control share the same simple playbook:

Eat enough fiber — 25–35 g/day. Build it from whole foods: beans, lentils, oats, chia seeds, prunes, pears, and other fruits, vegetables, and whole grains. Add a fiber supplement (psyllium) if diet alone falls short. Increase gradually.
Stay well hydrated. Fiber needs water to keep stool soft.
Fix your bathroom habits. Go when you feel the urge (do not "hold it"), keep visits short, do not strain, and leave the phone outside — long, distracted sitting is a real cause.
Move your body. Regular physical activity keeps the bowels regular and reduces straining.
Do not delay defecation. Postponing the urge dries out and hardens the stool, setting up the next round of straining.
Lift smart. Avoid breath-holding strain with heavy lifting; exhale through the effort.

11. Recent Research and Advances

Hemorrhoid research has matured from anecdote into rigorous clinical trials and consensus guidelines. A few threads worth knowing:

Fiber as evidence-based therapy. Systematic reviews have firmly established dietary fiber and bulk-forming agents as effective for reducing bleeding and symptoms — not a folk remedy but a guideline-recommended first-line treatment (Alonso-Coello and colleagues, Cochrane).
Head-to-head procedure trials. The UK HubBLe randomised trial put rubber band ligation against Doppler-guided artery ligation, helping clinicians choose the least invasive effective option for grade II–III disease (Brown and colleagues, Lancet, 2016).
Modern consensus guidelines. The American Society of Colon and Rectal Surgeons (2018), the European Society of Coloproctology (2020), the Italian SICCR (2020), and Japanese practice guidelines have converged on a stepwise, evidence-graded approach — fiber and lifestyle first, office procedures next, surgery last.
Less-invasive and energy-based techniques — refined sclerotherapy agents, laser hemorrhoidoplasty, and improved coagulation devices — continue to be studied for shorter recovery and less pain, though durable comparative data are still being gathered.
Better triage of bleeding. Because colorectal screening now begins at age 45, current guidance stresses not attributing rectal bleeding to hemorrhoids in at-risk patients without appropriate evaluation — a quiet but important safety advance (Lohsiriwat, World Journal of Gastroenterology, 2012 and 2015).

12. References & Research

Historical Background

Hemorrhoids are among the most ancient conditions described in medicine, appearing in Egyptian, Greek, and biblical texts; the very word comes from the Greek haîma (blood) and rhoos (flowing), literally "flowing of blood." For centuries treatment ranged from herbal salves to crude cautery and ligation. Two modern milestones reshaped care: in 1963, J. Barron popularized rubber band ligation as a simple, effective office treatment for internal hemorrhoids, and in the 1970s, surgeon-epidemiologist Denis Burkitt advanced the influential dietary-fiber hypothesis, linking low-fiber Western diets to constipation, straining, and conditions including hemorrhoids and diverticular disease — an idea later borne out by controlled fiber trials.

Key Research Papers

Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database of Systematic Reviews. 2005;(4):CD004649.
Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World Journal of Gastroenterology. 2012;18(17):2009-2017.
Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist's view. World Journal of Gastroenterology. 2015;21(31):9245-9252.
Jacobs D. Hemorrhoids. New England Journal of Medicine. 2014;371(10):944-951.
Davis BR, Lee-Kong SA, Migaly J, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Diseases of the Colon & Rectum. 2018;61(3):284-292.
van Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Disease. 2020;22(6):650-662.
Gallo G, Martellucci J, Sturiale A, et al. Consensus statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of hemorrhoidal disease. Techniques in Coloproctology. 2020;24(2):145-164.
Cataldo P, Ellis CN, Gregorcyk S, et al. Practice parameters for the management of hemorrhoids (revised). Diseases of the Colon & Rectum. 2005;48(2):189-194.
Brown SR, Tiernan JP, Watson AJM, et al. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second- and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. The Lancet. 2016;388(10042):356-364.
Sun Z, Migaly J. Review of hemorrhoid disease: presentation and management. Clinics in Colon and Rectal Surgery. 2016;29(1):22-29.
Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126(5):1463-1473.
Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. International Journal of Colorectal Disease. 2012;27(2):215-220.
Poskus T, Buzinskienė D, Drasutiene G, et al. Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study. BJOG. 2014;121(13):1666-1671.
Yamana T. Japanese practice guidelines for anal disorders I. Hemorrhoids. Journal of the Anus, Rectum and Colon. 2017;1(3):89-99.
Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology. 2019;156(1):254-272.e11.

Research Papers

Hemorrhoidal disease is one of the most-studied anorectal conditions. The PubMed searches below pull current peer-reviewed literature on its causes, evidence-based treatment, and prevention. Each link opens a live, up-to-date search in a new tab.

Connections

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