What Are Hemorrhoids?
Hemorrhoids are normal vascular structures present in the anal canal of all people. Composed of subepithelial arteriovenous plexuses, they perform a physiologic function in fecal continence and protection of the anal sphincter. The term "hemorrhoidal disease" refers to when these structures become symptomatic — engorged, prolapsed, or bleeding.
Hemorrhoidal disease is extremely prevalent, affecting up to 50% of adults at some point in life. Peak incidence occurs between 45 and 65 years of age. Although it rarely poses a health risk, it causes significant discomfort and impact on quality of life.
Hemorrhoids are classified as internal (above the dentate line, lined by mucosa) and external (below the dentate line, lined by anoderm). The clinical presentation, treatment, and prognosis differ between the two types.
Normal Structures
Hemorrhoids are physiologic vascular cushions that contribute to anal continence. Disease occurs when they become symptomatic.
High Prevalence
Affects up to 50% of adults at some point. It's the most common cause of rectal bleeding, though it always warrants thorough investigation.
Severity Grades
Internal hemorrhoids are classified in grades I through IV by degree of prolapse, which guides therapeutic strategy.
Pathophysiology
The pathophysiology of hemorrhoidal disease involves degeneration of the supporting connective tissue of the hemorrhoidal cushions, associated with hemodynamic changes in the submucosal vascular plexuses. With weakening of the support tissue (Parks ligament and Treitz muscle), the hemorrhoidal cushions slide distally and become prone to prolapse.
Increased intra-abdominal pressure — from prolonged straining, chronic constipation, pregnancy, or prolonged sitting on the toilet — contributes to vascular engorgement. The arteriovenous anastomoses in the hemorrhoidal plexuses dilate, increasing arterial blood flow and the volume of the cushions.
Local inflammation plays a relevant role. Blood stasis and mechanical trauma during evacuation injure the vascular endothelium, triggering an inflammatory cascade with release of mediators such as prostaglandins and matrix metalloproteinases, which contribute to additional degradation of the supporting tissue.
Risk factors include chronic constipation, chronic diarrhea, prolonged straining, low-fiber diet, sedentary lifestyle, pregnancy, obesity, and family predisposition. Aging contributes through progressive degeneration of connective tissue.
Symptoms
Symptoms vary by type (internal vs external) and grade of hemorrhoidal disease. Painless rectal bleeding is the most frequent symptom of internal hemorrhoids, while pain is more characteristic of thrombosed external hemorrhoids. Many patients erroneously attribute all anorectal symptoms to hemorrhoids.
Clinical Manifestations
- 01
Rectal bleeding
Bright red blood, typically at the end of defecation, on the surface of stools or on toilet paper. Painless in internal hemorrhoids.
- 02
Hemorrhoidal prolapse
Protrusion of tissue through the anus during defecation. May reduce spontaneously (grade II) or require manual reduction (grade III).
- 03
Pruritus and perianal irritation
Caused by mucous secretion from hemorrhoidal prolapse and difficulty with local hygiene. May lead to perianal dermatitis.
- 04
Acute perianal pain
Characteristic of thrombosed external hemorrhoid — painful, hardened, bluish perianal nodule. Intense pain in the first 48-72 hours.
- 05
Sensation of incomplete evacuation
Internal hemorrhoidal prolapse can cause a sensation of rectal fullness and tenesmus.
- 06
Mucous incontinence
In advanced grades, permanent prolapse may compromise the anal seal, allowing mucus to escape.
CLASSIFICATION OF INTERNAL HEMORRHOIDS (GOLIGHER)
| GRADE | FEATURE | TYPICAL CONDUCT |
|---|---|---|
| Grade I | Bleed, without prolapse | Conservative treatment + ambulatory procedures |
| Grade II | Prolapse and reduce spontaneously | Rubber band ligation or sclerotherapy |
| Grade III | Prolapse, require manual reduction | Rubber band ligation or surgery |
| Grade IV | Permanently prolapsed, irreducible | Surgical treatment |
Diagnosis
Diagnosis of hemorrhoidal disease is clinical, based on history and proctologic examination. Digital rectal examination and anoscopy are fundamental. Internal hemorrhoids are not palpable on digital examination and can only be adequately evaluated by anoscopy.
Excluding other causes of rectal bleeding is essential, particularly colorectal neoplasia. Patients over 40 with rectal bleeding, or of any age with alarm signs (change in bowel habit, weight loss, anemia), should undergo colonoscopy.
DIAGNÓSTICO DIFERENCIAL
Differential Diagnosis
Anal Fissure
- Intense pain on defecation
- Scarce bright bleeding
- Pectinate line — visible fissure on examination
- Spasm of the internal sphincter
Testes Diagnósticos
- Proctologic inspection
- Careful anoscopy
Anorectal Cancer
- Palpable indurated mass
- Persistent bleeding without improvement
- Weight loss, inguinal adenopathy
- Change in bowel habit
- Bleeding without visible prolapse in patients > 40 years — colonoscopy mandatory
Testes Diagnósticos
- Colonoscopy
- Biopsy
- Staging CT
Rectal Prolapse
- Externalization of the entire rectal thickness
- Mucosa with concentric folds (vs radial folds in hemorrhoids)
- Associated fecal incontinence
Testes Diagnósticos
- Proctologic examination
- Defecography if needed
Perianal Crohn's Disease
- Fistulas, atypical fissures (lateral)
- Voluminous and edematous skin tags
- Associated bowel disease
- Recurrent perianal abscesses
- Complex perianal fistula — suspect Crohn's
Testes Diagnósticos
- Colonoscopy with biopsy
- Pelvic MRI
- Fecal calprotectin
Condyloma Acuminatum
- Multiple verrucous lesions in the perianal region
- HPV — history of sexual exposure
- Intense anal pruritus
- No internal rectal bleeding
Testes Diagnósticos
- Visual inspection
- Biopsy to confirm and exclude carcinoma
Anal Fissure and Anorectal Cancer: The Two Critical Diagnoses
Anal fissure is the main differential diagnosis of symptomatic hemorrhoids. While hemorrhoidal pain is mild or absent (except in thrombosis), fissure pain is intense and burning during defecation, persisting for hours afterward. Careful proctologic inspection easily distinguishes the two. Treatment differs substantially — fissure responds to topical nitrates and botulinum toxin, not to rubber band ligation.
Anorectal cancer — squamous cell carcinoma of the anal canal or rectal adenocarcinoma — is the most important exclusion in any patient with rectal bleeding. Red flags that mandate colonoscopic investigation: bleeding in a patient older than 40, bleeding mixed with stools (not only on paper or in the toilet), change in bowel habit, weight loss, or palpable mass on digital examination. Hemorrhoids should never be assumed as the cause of bleeding without excluding neoplasia.
Rectal Prolapse vs Hemorrhoidal Prolapse
Grade III-IV hemorrhoidal prolapse can be confused with full rectal prolapse. The distinction is clinical: in prolapsed hemorrhoids, the externalized mucosa shows radial folds and grooves between the hemorrhoidal cushions; in rectal prolapse, the mucosa forms concentric folds and the entire rectal wall is externalized. Rectal prolapse usually associates with significant fecal incontinence — uncommon in isolated hemorrhoids.
Treatment also differs: rectal prolapse requires specific surgical correction (rectopexy or rectal resection), while grade III-IV prolapsed hemorrhoids respond to rubber band ligation or conventional surgical hemorrhoidectomy. The proctologist makes this distinction during physical examination.
Perianal Crohn's Disease and Condyloma
Perianal Crohn's disease manifests with fistulas, abscesses, atypical fissures (especially lateral), and edematous skin tags — a picture very different from typical hemorrhoids but one that can coexist. Suspected perianal Crohn's requires colonoscopy with biopsy and pelvic MRI to map fistulous tracts. Treatment is entirely different, with biologic agents and surgical drainage.
Condyloma acuminatum (HPV) causes verrucous lesions in the perianal region that can be confused with hemorrhoidal skin tags or external hemorrhoids. Sexual history, the characteristic verrucous appearance, and biopsy confirm the diagnosis. Excluding squamous cell carcinoma in situ (anal intraepithelial neoplasia) in suspicious lesions is essential.
Treatment
Treatment of hemorrhoidal disease follows a stepwise approach. Most patients respond to conservative measures — increased fiber intake, adequate hydration, avoidance of prolonged evacuation effort, and proper hygiene. Ambulatory and surgical procedures are reserved for refractory or advanced cases.
Conservative Treatment
Dietary fiber (25-30 g/day), hydration, avoiding prolonged straining, warm sitz baths, topical creams with local anesthetic. Effective for grades I-II with mild symptoms.
Ambulatory Procedures
Rubber band ligation (most effective for grades II-III), injection sclerotherapy, infrared photocoagulation. Performed in the office without general anesthesia, with same-day discharge.
Surgical Treatment
Excisional hemorrhoidectomy (Milligan-Morgan or Ferguson) for grades III-IV. Stapled hemorrhoidopexy (PPH) as a less painful alternative. THD (transanal hemorrhoidal dearterialization) is a minimally invasive option.
Acute Hemorrhoidal Thrombosis
Surgical excision if presentation is within the first 48-72 hours. After this window, conservative treatment with analgesia and local measures, since natural reabsorption occurs in 2-4 weeks.
Acupuncture as Treatment
Acupuncture is investigated as complementary therapy in hemorrhoidal disease, with potential to relieve perianal pain, reduce local inflammation, and improve bowel function. Proposed mechanisms include pain modulation via activation of descending inhibitory pathways, anti-inflammatory effects through cytokine regulation, and improved intestinal motility.
Clinical studies, predominantly from the Asian literature, suggest that acupuncture can reduce pain and bleeding in patients with grade I and II hemorrhoidal disease. Electroacupuncture at perineal and lumbosacral points may modulate anal sphincter tone and reduce local vascular engorgement.
Available evidence is limited in quantity and methodologic quality. Acupuncture doesn't replace standard conservative measures or procedures indicated for advanced grades. Its most promising role appears to be as an adjuvant in postoperative pain management after hemorrhoidectomy and in regulating intestinal transit.
Prognosis
Prognosis of hemorrhoidal disease is excellent in the vast majority of cases. With adequate conservative measures — especially increased fiber intake — more than 90% of patients with mild symptoms achieve satisfactory relief. The disease rarely poses a health risk.
Outpatient procedures such as rubber band ligation have a 70-80% success rate for grade II and III hemorrhoids. Recurrence is possible, especially if predisposing factors (constipation, straining) aren't corrected.
Surgical treatment (hemorrhoidectomy) has the lowest recurrence rate — under 5% at 5 years — but is associated with significant postoperative pain and a recovery period of 2 to 4 weeks. Rare complications include anal stenosis, fecal incontinence, and late bleeding.
Myths and Facts
Myth vs. Fact
Sitting on cold surfaces causes hemorrhoids
No scientific evidence supports the claim that cold surfaces cause hemorrhoidal disease. The main factors are straining, constipation, low-fiber diet, and prolonged time on the toilet.
Spicy food causes hemorrhoids
Spicy food doesn't cause hemorrhoidal disease, but it can exacerbate symptoms in patients who already have it by irritating the anal mucosa. There's no need to preventively eliminate condiments from the diet.
Hemorrhoids can turn into cancer
Hemorrhoids are not precursors of cancer. However, symptoms can overlap (both cause rectal bleeding), making proper medical evaluation essential to differentiate the two conditions.
Hemorrhoid surgery is very painful and should be avoided at all costs
Modern techniques (THD, circular stapler) have significantly reduced postoperative pain. Moreover, most patients don't need surgery — outpatient procedures resolve most cases.
When to Seek Help
Although hemorrhoidal disease is generally benign, some situations require medical evaluation. All rectal bleeding deserves investigation, especially in patients over 40 or with risk factors for colorectal neoplasia.
Frequently Asked Questions about Hemorrhoids
Symptomatic hemorrhoids respond well to conservative treatment and outpatient procedures in most cases. Rubber band ligation, for example, has a 70-80% success rate for grades II-III. Surgical hemorrhoidectomy, reserved for refractory grade III-IV cases, offers the most lasting resolution. However, predisposing factors (constipation, straining) need to be corrected to avoid recurrence.
No. Rectal bleeding should never be automatically assumed to be hemorrhoidal. Although hemorrhoids are the most common cause of bright rectal bleeding in young adults, other causes must be excluded — especially colorectal cancer, polyps, inflammatory bowel disease, and anal fissure. In patients over 40, rectal bleeding always requires colonoscopy for investigation.
Acupuncture, performed by a physician acupuncturist, can help relieve symptoms associated with hemorrhoids — especially pain, local discomfort, and underlying constipation. Studies show improvement of vascular tone and intestinal peristalsis with acupuncture. It doesn't replace specific procedures for advanced hemorrhoids but is a valid complement for symptomatic control and for treating the constipation that aggravates the condition.
Internal hemorrhoids are classified in grades I to IV: Grade I (bleeding without prolapse) — conservative treatment; Grade II (prolapse that reduces spontaneously) — rubber band ligation; Grade III (prolapse requiring manual reduction) — rubber band ligation or surgery; Grade IV (irreducible prolapse) — surgical hemorrhoidectomy. External hemorrhoids don't follow this classification, but external thrombosis requires specific treatment.
A thrombosed hemorrhoid occurs when a clot forms inside an external hemorrhoid, causing intense, sudden pain with a firm, bluish mass in the perianal region. Within the first 72 hours, surgical excision under local anesthesia provides immediate relief. After 72 hours, conservative treatment (sitz baths, anti-inflammatories, venotonics) is preferable, since peak pain has already passed and the thrombosis usually resolves in 1-2 weeks.
Yes. Scientific evidence is consistent: increased fiber intake (25-30 g/day) softens stools, reduces straining, and decreases pressure on the hemorrhoidal plexus. Randomized studies show that fiber supplementation reduces the risk of bleeding and symptoms in grade I-III hemorrhoids by about 50%. Psyllium, wheat bran, and unpeeled fruits are good sources. Adequate hydration potentiates the effect.
Home measures are effective for mild hemorrhoids (grade I-II): warm sitz baths for 10-15 minutes, 2-3 times a day; increased fiber and hydration; topical creams with anesthetic or corticosteroid for short-term use; avoiding prolonged straining. However, medical evaluation is essential to confirm the diagnosis and exclude more serious causes of bleeding before starting any self-treatment.
Rubber band ligation of internal hemorrhoids is performed in the office, without the need for general anesthesia, and most patients report only discomfort or mild pressure during the procedure. Significant pain in the following 24-48 hours can occur if the band is placed too close to the pectinate line (region with sensory endings). The procedure is ambulatory, with return to activities in 1-2 days in most cases.
No. Hemorrhoids do not evolve into cancer. They are vascular structures, not preneoplastic lesions. However, diagnostic confusion is dangerous: anorectal cancer can be erroneously attributed to "hemorrhoids" by physician or patient, delaying diagnosis. Therefore, any rectal bleeding or perianal mass should be evaluated by a specialist physician with a complete proctologic examination.
Hemorrhoids are very common in pregnancy, especially in the third trimester, owing to increased abdominal pressure, constipation, and increased blood volume. Conservative treatment is first-line — fiber, hydration, sitz baths, and topical creams with pregnancy-safe ingredients. Most improve postpartum. In severe cases, the obstetrician and proctologist together weigh the risks and benefits of procedures during pregnancy.
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