Hemorrhoidal disease

Hemorrhoidal disease

Enlarged hemorrhoids are a very common condition that can cause major discomfort, especially when going to the bathroom. Treatment depends on the grade of the enlargement.


Every person has hemorrhoids in their anus. Hemorrhoids are a dense, ring-like mesh of blood vessels (“vascular cushions”) located at the outlet of the rectum. Together with the sphincter, hemorrhoids control the process of emptying the bowels through swelling, thereby ensuring that the intestines are “sealed” (including against flatulence). If the blood vessels in this tissue cushion expand, this tissue may enlarge and cause uncomfortable symptoms. The tissue may take on a lump-like shape and may also emerge outside of the anus. While doctors refer to this situation as hemorrhoidal disease, most people just call it “having hemorrhoids”, as it will be referred to from here.

Hemorrhoids can have many causes. They appear to run in families (genetic predisposition) to some extent. Stool consistency (both too hard and too soft) and the bowel movement process (defecation) can also both play a role. Years of excessive straining when trying to pass stool as well as sitting on the toilet for too long appear to especially promote the development of pathological hemorrhoids.

Pregnant women are disproportionately at risk of developing hemorrhoids, as are people who are overweight, consume large amounts of alcohol or coffee, frequently eat very spicy foods, abuse laxatives, or sit on cold surfaces.

Enlarged hemorrhoids are a very common problem: half of all people will experience them at least once during their lifetime.

The condition typically begins between the ages of 45 and 65 years old. Some studies have reported an equal frequency of hemorrhoids between men and women, while other studies have reported that men are more frequently affected than women.

The symptoms caused by hemorrhoids are not specific and can also be caused by other diseases of the anal region. The symptoms also do not correlate with the size of the hemorrhoids. Hemorrhoids are frequently detected by bright red bleeding from the anus, often during or shortly after a bowel movement. Other possible symptoms of pathological hemorrhoids include burning, dampness, shooting pain, and itching in the anal region, as well as oily stools (dirty underwear), all of which may be of varying intensity. As a result, anal eczema may develop over time. Small cracks called anal fissures can also form in the anal canal and be very painful. Hemorrhoids may also be noticeable by a sensation of pressure or a foreign body in the anus.


Hemorrhoidal disease is divided into four grades. In grade I, the enlarged tissue is not visible externally but is easily seen by proctoscopy. For grade II, the tissue may emerge from the anus (hemorrhoid prolapse) during a bowel movement but returns back into the rectum spontaneously. With grade III, the prolapsed hemorrhoid does not return to the rectum by itself but can be pushed back in manually. At grade IV, the prolapse remains outside of the anus and cannot be pushed back in manually.


Hemorrhoids are suspected whenever a patient reports having corresponding symptoms to his or her doctor. The doctor then usually asks which symptoms occur in which situations, and when they originally started.

This conversation is typically followed by an examination of the anal region, including an inspection of the anus and probing of the anal canal, in order to analyze the size of the hemorrhoids and to rule out any other possible causes of the symptoms.

The presence of pathological hemorrhoids can be confirmed by a proctoscopy. During this procedure, an examination tube of about finger thickness containing an integrated camera and light source is inserted about eight to ten centimeters into the rectum. This allows the doctor to evaluate the hemorrhoids directly and to treat them immediately if necessary (see below).

To further investigate the patient’s symptoms, the doctor may also perform an endoscopic analysis of the rectum by inserting an examination tube about 25 centimeters (called a rectoscope) into the rectum, or even perform a complete examination of the large intestine (colonoscopy). These procedures are performed in order to rule out other potential causes of the symptoms.


The goal of treating hemorrhoids is not to remove the tissue cushion, since it plays an important role in maintaining the ability to control bowel movements. Instead, the goal is to restore the physiological, meaning normal, situation in order to relieve the patient of his or her symptoms.

The treatment for hemorrhoids depends on their stage. At an early stage (grade I hemorrhoids), lifestyle changes are usually sufficient. Developing new bowel movement habits and consistent dietary fiber intake to regulate stools are often sufficient. However, for higher-grade hemorrhoids surgery is usually required.

Typically, hemorrhoids are first attempted to be treated with locally acting hemorrhoid medications like ointments or suppositories, or even with “sitz baths” or gauze pads. However, there is no clear evidence that these measures can permanently cure hemorrhoidal disease. Nonetheless, hemorrhoid medications may reduce the local inflammation associated with hemorrhoids. Ointments may also be helpful in cases of anal eczema.

During a proctoscopy, a medication called a sclerosing agent can be injected into the hemorrhoid to shrink it. This procedure is called sclerotherapy and is the standard therapy for grade I hemorrhoids. Although sclerotherapy must be repeated several times, symptoms typically improve greatly after two to three rounds of treatment.

As an alternative to sclerotherapy, lump-like hemorrhoids can be wrapped with a small rubber band (a procedure called rubber band ligation) during a proctoscopy. Following, the hemorrhoid withers after a few days and then falls off. Rubber band ligation is the preferred choice for grade II hemorrhoids.

If a hemorrhoid has already reached grade III or IV, surgery is typically required to treat it. During surgery, the enlarged hemorrhoid is removed.

Outlook and prognosis

There is no way to predict how a pathological hemorrhoid will continue to develop. It may remain at its original enlarged size, but it is equally possible that it will develop into hemorrhoidal disease with all of its associated symptoms.

However, it must also be kept in mind that hemorrhoids tend to return (recur) after treatment. Following successful sclerotherapy, about 70% of patients develop a new pathological hemorrhoid within three years. The recurrence rate after successful rubber band ligation is 25% over the first four years. Hemorrhoids can even return after surgical treatment.

This is why it is important to take measures to prevent new hemorrhoids in order to keep the disease from getting worse. Consistent stool regulation makes this possible. Stools should be soft, and it should be possible to pass them without straining. Sitting on the toilet for a long amount of time should be avoided (No reading the news on the toilet) and going to the bathroom when the urge arises should not be delayed.

A high-fiber diet – meaning a diet containing many fruits, vegetables, grains, and sufficient fluid intake – can be beneficial. Should these steps not be sufficient to properly regulate bowel movements, soluble fibers such as psyllium (Plantago ovata) may also be helpful. Soluble fibers can absorb a great deal of water, which leads to stools that are soft but not runny.

Other measures that can help prevent pathological hemorrhoids include weight loss for people who are overweight, as well as regular exercise. However, activities with intense exertion, like weight training, should be avoided.