Hemorrhoids - Types, Symptoms and Treatment

Hemorrhoids are swollen and inflamed veins in the anus and rectum, which can cause pain, itching and anal bleeding.

The terminal portion of the intestine is composed of the rectum, anal canal and the anus. As in any other part of our body, this region is vascularized by arteries and veins, which are called hemorrhoids arteries and veins. Hemorrhoids are the name given to this set of vessels that stands in the anal canal. What is popularly known as hemorrhoids is actually what we call a hemorrhoidal disease. However, to avoid confusion, I will use the popular language and call a hemorrhoidal disease just hemorrhoids.


Most of our veins contain valves that help blood to always follow in the same direction, preventing its return, even against gravity. For example, blood always runs in the veins of the leg against gravity, thanks to the valves it can climb without getting dammed legs. When veins become ill and their valves stop working, a situation known as varicose veins appears, tortuous veins where blood gets congested.

Unlike veins from the body, hemorrhoid veins do not have valves to prevent damming of blood. Therefore, any increase in pressure in these veins provides your engorgement. The hemorrhoids are like varicose hemorrhoid veins. As with any varix, dammed blood increases the risk of vein thrombosis and inflammation.

So piles (or hemorrhoids) are dilated veins in the rectum and anus, which may be accompanied by inflammation, thrombosis or bleeding.

Classification of hemorrhoids

The hemorrhoids are classified as:
  • Internal hemorrhoids, when they occur in the rectum
  • External hemorrhoids, when occur at the end of the anus or anal canal

The internal hemorrhoids are further classified into four grades:
  • Hemorrhoids Grade I: No prolapse through the anus
  • Hemorrhoids Grade II: Prolapse upon bearing down but spontaneously reduce
  • Hemorrhoids Grade III: Prolapse upon bearing down and requires manual reduction
  • Hemorrhoids Grade IV: Prolapsed and cannot be manually reduced

The internal hemorrhoids of grade I and grade II are not visible and usually go unnoticed by patients, since no one is looking at the anus while defecating. As the rectum and anal canal have little innervation, this type of hemorrhoids usually do not cause pain.

The external hemorrhoids, as well as internal of grade III and IV, are easily identified and often inflamed causing pain and / or pruritus (itching).

Causes of hemorrhoids

Hemorrhoids causes
Hemorrhoids causes
The hemorrhoids are a very common disorder. It is estimated that more than half of the population over age 50 suffer from hemorrhoids to varying degrees. The main risk factors are:
  • Constipation
  • Efforts to evacuate
  • Obesity
  • Chronic diarrhea
  • Holding the feces frequently, avoiding defecate wherever there is a will
  • Diet low in fiber
  • Pregnancy
  • Anal sex
  • Family history of hemorrhoids
  • Smoking
  • Cirrhosis and portal hypertension
  • Long periods sitting on the toilet (some people think that the very design of the vessel triggers the formation of hemorrhoids)

The habit of crouching evacuation, very common in the Middle East and Asia, is associated with a lower incidence of hemorrhoids. Apparently seated evacuation, like most of us usually do, can increase the incidence of hemorrhoids.

Regardless of risk factors, the piles are formed when there is increased pressure in the haemorrhoid veins or weakness in the tissues of the wall of the anus, responsible for supporting them.

Symptoms of hemorrhoids

The hemorrhoids may be symptomatic or not. As stated previously, the internal hemorrhoids tend to be less symptomatic. The only telltale sign of its existence may be the presence of blood around the stool.

Bleeding from hemorrhoids typically presents a small amount of blood that is alive around the feces. Sometimes, the patient may notice drops of blood in the vessel after the evacuation. It is also common to have blood on toilet paper after cleaning.

The internal hemorrhoids can cause pain when there is a thrombosis or chronic stress to evacuate because of the prolapsed hemorrhoid outside the anal canal. The internal hemorrhoids of grade III and IV may be associated with fecal incontinence and the presence of a mucous discharge, which causes irritation and itching anal.

The external hemorrhoids are symptomatic as a rule. They are associated with bleeding and pain when defecating and sitting. In cases of thrombosis of hemorrhoids, pain can be intense. Itching is another common symptom. The external hemorrhoids are always visible and palpable.

Despite being a common cause of anal bleeding, it is important never to assume that bleeding is due to hemorrhoids without consulting a doctor. Several diseases, such anal fissure, rectal cancer, diverticular disease and infections can also manifest with bloody stools. Moreover, nothing prevents the patient of having hemorrhoids and other diseases that also curse with anal bleeding, like cancer, for example. Therefore, all anal bleeding should be evaluated by a doctor, preferably a proctologist.

Bleeding from hemorrhoids is usually of a small amount, but if frequent, it may even lead to anemia. Bleedings of large volumes are not common in hemorrhoids, but can occur in some cases.

An important differential diagnosis of hemorrhoids is anal fissure. Both cause pain and bleeding, but the bleeding is usually minor in fissure and pain when defecating is more intense.

Can hemorrhoids turn into cancer?

NO! HEMORRHOIDS DO NOT CAUSE CANCER! However, the symptoms can be similar to intestinal tumors, especially in cancers of the rectum and anus. It is therefore important to establish the differential diagnosis, especially in patients over 50 years. Enhancing recommendation: all anal bleedings should be evaluated by a physician.

Diagnosis of hemorrhoids

In external hemorrhoids physical examination is sufficient for diagnosis. You must perform digital rectal examination and, if there is still doubt, anoscopy (a mini endoscopy where you view the video straight through).

In elderly patients with rectal bleedings, even if hemorrhoids are identified, it is convenient to perform a colonoscopy to rule out other causes. Because hemorrhoids are very common at this age, nothing prevents the patient to have a second cause for the bleeding, such as cancer or diverticulum of the intestine.

Treatment of hemorrhoids

Nonsurgical treatment

During crises, sitz baths in lukewarm water twice or three times per day may provide relief for acute symptoms. For pregnant women warm moist compresses are suggested. You should also avoid cleaning anus with toilet paper, bidet or giving preference to the jets of warm water.

In people with constipation, laxatives then indicated to decrease the urge to push to evacuate. The passage of too bulky and hardened feces can cause injury. Drinking enough water is important because it helps to moisten the stool, reducing constipation.

Increasing fiber intake demonstrably improves the symptoms of hemorrhoids. The results can be noticed with only 15 days after change of diet. The use of supplements based on methylcellulose or psyllium yields good results. Attention, the use of fiber does not treat hemorrhoids, but it helps in controlling the symptoms, especially the itching and bleeding.

Ointments and creams for hemorrhoids, such as Proctyl Xyloproct can be used temporarily, since they serve as a lubricant for the passage of feces and contain anesthetics in their formula. Some creams contain steroids as Ultraproct also in its formula, which help to decrease inflammation. The relief with creams or ointments is only temporary and you should not use them without medical supervision.

Suppositories with corticosteroids are another option when there is much pain or itching, however, it is a treatment that should not be used for more than a week due to possible side effects.

Remedies for hemorrhoids tablet, one that seems to have the best effect is Daflon. Ainsa just improves symptoms, it is not definitely for hemorrhoids treatment. Other drugs, such as Varicell, have not been proven effectiveness. Avoiding spicy foods is a very famous tip for those who have hemorrhoids, however, there is no evidence that pepper actually worsens symptoms. This should be assessed individually. There are patients with hemorrhoids eating chili at ease and do not feel worse, while others swear that a little pepper is enough to "annoy" their hemorrhoids.

Surgical treatment

If nonsurgical treatment is not sufficient to control symptoms, minimally invasive treatments can be tried.

In small thrombi with external hemorrhoids treatment can be done in the doctor's office with a small incision under local anesthesia to remove the clots. This is sufficient to relieve the symptoms.

Ligation of hemorrhoids

In more severe cases, which cannot be controlled with simple measures elastic hemorrhoid ligation may be necessary. A rubber is introduced into the base of the hemorrhoid, causing constriction and necrotic thereof. After several days, usually between two to four, hemorrhoids "drop" out alone through the anus. It is a technique that can be done in the office of the proctologist. It is usually painless and often does not need anesthesia. Rubber band ligation is indicated for hemorrhoids of grade I and II. It may be used in some cases for hemorrhoids III. It is the technique most widely used today and has a success rate of 80%.

Another option for the treatment of hemorrhoids is sclerotherapy. It consists of injecting a chemical solution by means of special needles that causes necrosis of hemorrhoids. The substance causes severe inflammation and causes the hemorrhoid "dry" and be absorbed. A third option is to laser or infrared coagulation. Of the three techniques, rubber band ligation is the one that presents the best results.


If less invasive techniques are not effective, or if the hemorrhoid is of grade III or IV, treatment should be done with traditional surgery called hemorrhoidectomy. There are two popular techniques:
  • Milligan Morgan or Ferguson, which is a surgery performed under epidural anesthesia, which removes all the tissue around the region with hemorrhoidal disease.
  • The Longo technique, which uses a device to perform the stapling of hemorrhoids.

The Longo technique is more modern and tends to be more tolerated by the patient because the postoperative period is much less painful.

THD for the treatment of hemorrhoids

A new treatment option for hemorrhoids is transanal hemorrhoidal dearterialization (THD), a technique created in 1995 and refined over the past few years. The technique consists of introducing a small Doppler apparatus (ultrasound) for identifying the anus haemorrhoidal artery; through a small needle these arteries are sutured to reduce the flow of blood that arrives in regions where there are hemorrhoids. When less blood arrives, the pressure inside hemorrhoid decreases, making them "dry".

The THD technique has no cuts and risk of bleeding is very low. The postoperative period is less painful than the techniques with no cuts and low rate of recurrence of hemorrhoids. The recovery time is shorter and the patient can return to normal activities within 48 hours. The procedure is done under local anesthesia and light sedation.

The THD is a relatively new technique and there are no studies that compare its long-term efficacy with older techniques, however, the tendency is to become the method of choice in the treatment of hemorrhoids.

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