Definition and Clinical Features

hemorrhoid image

Hemorrhoids are dilated, spongy veins that can be on the outside of the anus or inside the anus where they can’t be seen. On the outside, they feel like soft lumps unless a blood clot forms in the lump and it becomes a hard, painful lump. The most common presenting symptom is bleeding, which happens toward the end of defecation and is often bright red and painless.

Blood dripping or squirting into the bowl at the end of defecation is highly suggestive of hemorrhoids. Prolapse of tissue and thrombosis may also occur. The patient may also complain of swelling and itching, but pain may also be present if there is thrombosis involving the external hemorrhoids.

Some patients have large prolapsing and vascular hemorrhoids that remain outside and become traumatized as the patient sits on hard surfaces or rides a car. Such patients will complain of spontaneous bleeding and staining of their underwear in between bowel movements.

On the other hand, some large fourth-degree hemorrhoids do not bleed because their exposed mucosa becomes thick and calloused. Bleeding unrelated to defecation should always raise the possibility of another pathology such as a carcinoma.

In most cases, hemorrhoids are easily and instantly recognized by their typical appearance. A hemorrhoid is a bluish-red cushion of tissue covered by smooth, shiny mucosa. First-degree hemorrhoids are only visible by anoscopy, but larger hemorrhoids protrude to a greater or lesser extent through the external anal orifice. Straining increases the engorgement and prolpase of hemorrhoids. The apex, or the pedicle, which is located towards the rectum, is narrow and pink or red. The base, which tends to hang out, is broader and is bluish or purple. Skin tags may be located at this end.

Hemorrhoids are cushions of vascular tissue that are basically normalized in most people. The hemorrhoids drain blood away from the anal area, which is considered a highly vascular area.

Inside the anal canal are three primary cushions, located in the left lateral anus (three o’clock), the right anterior anus (eleven o’clock) and the right posterior anus (seven o’clock). In a sense, they form a ring. When large, they hang out as radical folds in these three cushions.

The so called hemorrhoidal cushions do not bother people unless they become damaged or diseased in some way. These cushions technically aren’t arteries and they aren’t veins. Instead they are special sets of blood vessels known as sinusoids, consisting of smooth muscle, connective tissue and blood. This collection of blood vessels is called the hemorrhoidal plexus. They are very vascular and bled a lot when nicked or cut.

The hemorrhoidal plexus is important for stool continence. It is believed that these cushions contribute to up to twenty percent of pressure of anal closure and protects the anal sphincter muscles as stool passes the anus. Patients are present with symptoms of hemorrhoids when the hemorrhoidal cushions slide down from their original position and end up partly outside the body. Patients also get symptoms when the pressure in the venous system of the anus is increased, feeding back that increase in pressure to the sinusoids.

Types of Hemorrhoids

There are two types of hemorrhoids: the internal hemorrhoids which arise from the superior hemorrhoidal plexus and the external hemorrhoids from the inferior hemorrhoidal plexus. There is a line called the dentate line that separates the interior from the exterior hemorrhoidal plexuses.

  1. Internal Hemorrhoids

You can’t see or feel internal hemorrhoids as they lie inside the rectum about a fingers length from view. Because they are not covered with skin, they do not generally hurt, even when inflamed and swollen.

Generally, bleeding is the only symptom you get when the internal hemorrhoids have become engorged; however, these hemorrhoids can stretch downward and can prolapsed through the anus, causing increased bleeding and the feeling of a large lump coming through the anus. Prolapsed hemorrhoids can actually hurt but, fortunately they recede back into the rectum on their own so that no medical attention is needed. You or your physician can also push them into place without difficulty.

Internal hemorrhoids can be completely asymptomatic until you have a bowel movement. Then the stool rubs against the hemorrhoids, causing them to bleed, often profusely. The stool will be bloody, usually on the outside of the stool.

Internal hemorrhoids are not covered by skin but by columnar epithelium, the same tissue that covers the inside of the rectum. There no pain fibers in columnar epithelium. Internal hemorrhoids can be classified or graded as to the amount of prolapsed the hemorrhoid has. For example:

  • Grade I hemorrhoid—does not prolapsed and is merely a prominent blood vessel.
  • Grade II hemorrhoid—this prolapses when you bear down but suck back in spontaneously when you are not straining.
  • Grade III hemorrhoid—this prolapses upon bearing down and needs manual reduction.
  • Grade IV hemorrhoid—the hemorrhoid is prolapsed and cannot be manually reduced.

Fortunately, even high grade hemorrhoids can be treated with surgical treatment.

  1. External Hemorrhoids

External hemorrhoids are covered with skin so they can become irritated or painful. They feel like grape-sized or smaller lumps around the anus. Generally they are just irritating to have and don’t hurt unless stool collects around them, causing itching and burning of the hemorrhoids. External hemorrhoids can become clotted with dried blood forming a larger grape-sized painful and purple hard lump. This often needs to be treated under the care of a doctor and they can become extremely uncomfortable.

External hemorrhoids that become complicated by thrombosis of the external anal venous network (below the dentate line) appear as a hard bluish-black lump in the perianal area. If untreated, the overlying epithelium is eroded by pressure necrosis and the blood clot starts protruding from the lump.

Once the clot falls off, it leaves a small ulcer, which can mimic an ulcerating anal carcinoma. Hemorrhoids that become complicated by thrombosis of the prolapsed internal (and sometimes external) venous network cause severe pain.

These strangulated piles require emergency treatment. The appearance of the tensely swollen black-bluish mass of tissue at the anal orifice, along with exquisite tenderness, is unmistakable. There is extensive edema and congestion of both external and internal hemorrhoids. If left untreated, the edema metamorphoses to ulceration and necrosis.

Important Hint

The main symptom of hemorrhoids, both internal and external is bleeding. If you experience bleeding from the anus, with or without a bowel movement, you need to know that there are far more serious things that can cause the same kind of bleeding.

The worst is colorectal cancer, which can cause a change in bowel movements, weight loss and bleeding from the anus, usually with a bowel movement. Just because you have hemorrhoids doesn’t mean that the hemorrhoids are the cause of the bleeding. If you have a strong family history of colorectal cancer or are over the age of 50 years, you need to strongly consider having a screening colonosocopy for colon polyps or colon cancer. This can be a lifesaving preventative examination that you should have if you are a candidate for the test. Never assume it is hemorrhoids as that can be a deadly decision.

The prevalence of hemorrhoids can be alarming. Data from the National Center for Health Statistics estimate that 10 million people in the United States have had symptomatic hemorrhoids; however, this may actually underestimate the problem, because the majority of patients may not seek professional care, preferring self-medication instead.

Those who eventually seek medical care complaining of hemorrhoids often have another reason for their complaint. In a recent audit, only 20% of patients initially believed to have symptomatic hemorrhoids when presenting to their physician actually had hemorrhoids as the etiology of their complaints.

Statistics show that 50 percent of American adults have hemorrhoids by the age of 50. Only a very small percent of these people actually attempt to seek treatment for their condition. This amounts to about 10.4 million people in the US having hemorrhoids and seeking treatment. In addition, each year an additional 1 million new cases among Americans develop. About 10–20 percent of all cases eventually need surgery.

Not everyone has symptoms from their hemorrhoids but 23 million people in the US or about 12.8 percent of adults have internal hemorrhoids and are symptomatic. About 1.9 million people receive treatment as outpatients for their condition in emergency department (ED).

For people older than 45 years of age, 25 percent of sufferers are women and 15 percent of sufferers are men. This is because women tend to get hemorrhoids in pregnancy and once they get them, they tend to not go away. Some people have a genetic predisposition that makes them more likely to get hemorrhoids. If you have several family members who have hemorrhoids, you should practice good hygiene and do what you can to avoid getting hemorrhoids. Yes, they are preventable.

The risk of getting hemorrhoids goes up with age and it is unlikely you’ll get the condition before age 30 unless you have them from pregnancy. The main reasons people get hemorrhoids are straining at stool, constipation, heavy lifting and pregnancy.

Foods to Avoid to Cure Hemorrhoids

  1. Avoid sugar! It is a poison for your body. Try to replace this habit. When you drink a coffee put another sweetener, stevia for example.
  2. Some medication have side effect by causing constipation (heart medication, iron supplements, antidepressants etc.). Try to avoid them.
  3. Smoking should be avoided in hemorrhoids cases. This vice has a negative impact on hemorrhoids and digestion.
  4. Stay away from toxic and processed foods. Fatty foods are an enemy for hemorrhoids because they take longer to digest than other nutrients.
  5. Avoid alcohol! Alcohol is dehydrating your body, however if you consume it, drink lots of water as well.
  1. Stay away from dairy products. All cheeses lead to constipation and should not be consumed. Even milk contains casein, which is proven to increase hemorrhoids. The only healthy dairy product often recommended is Greek Yogurt. Pure whey protein is also ok. And if you drink your coffee with milk, do not use too much milk, and try to go for skim milk. To be honest with you, if you want to cure your hemorrhoids, you must compromise, so avoid dairy products, replace milk with coconut milk or almond milk.

Also Follow These Tips to Cure Your Hemorrhoids

  • Answer nature’s call when it comes. One suffers from hemorrhoids when the veins in the anal region stretch, swell and bulge under pressure. Therefore, trying to force out stools can aggravate the condition. Go to the toilet only when you feel a strong urge to. This allows easy passage without exerting too much pressure.
  • Do not sit for very long hours. In many cases, hemorrhoids are the result of a sedentary lifestyle. Sitting for prolonged hours exerts pressure on your bum and thereby on the veins around the anus. If your job demands long hours of sitting, take a break in the middle for 5–10 minutes and walk around the block.
  • A sitz bath offers the best relief for painful hemorrhoids. Take a tub of warm water and add some Epsom salt or alum to it. Sit in the tub with the buttocks and hips immersed in the water for around 10–15 minutes. Doing so reduces the swelling and pain associated with hemorrhoids. It must be done thrice a day for effective results.
  • Try to alleviate pain and swelling with an ice pack. Take a few ice cubes in a bag and ferment the affected area; make sure you do not apply the ice directly. The cold ferment helps the problem by shrinking the inflamed veins around the anus.
  • It is also important to maintain proper anal hygiene. Often, the hemorrhoid swellings develop fissures and that is what causes bleeding. It is an open wound and therefore must be kept clean. Everytime you visit the toilet, you should wipe the region clean with soft toilet paper, baby wipes and adult wipes. Baby wipes contain ingredients such as aloe that heal and soothe the skin.
  • Wherever possible, try not to lift heavy objects or perform extremely strenuous activity. It strains the veins in the lower part of the body.
  • If the area is already inflamed making it difficult to sit down, use a cushion under your bum. Many suggest sitting on an inflated, doughnut-shaped pillow.

Set It Right with Exercise

Not many are aware of the fact that exercise can be of great help if you want to cure hemorrhoids. Exercise should be made a part of your daily routine as it helps the condition in different ways.

  1. First, it stimulates bowel movements and as such you don’t have to force when you need to go to the toilet. This reduces the chances of a reoccurrence.
  2. Second, it helps maintain healthy weight and therefore reduces the pressure on the veins around the anus.

You should add minimum 20–30 minutes of aerobic exercise to your schedule. If you are not the person for exercises, you can keep it simple with 30 minutes of walking or cycling daily. Yoga is beneficial not only for hemorrhoids but also general health.

  1. Indru Khubchandni, Nina Paonessa, Khawaja Azimuddin. Surgical Treatment of Hemorrhoids.
  2. Thomas Barrett. Hemorrhoids No More: The Complete Guide On Hemorrhoids, Causes & Symptoms.
  3. Patricia Oslo. Natural Hemorrhoids Remedies: How to cure hemorrhoids fast and naturally.