Overview
Hemorrhoids are swollen and enlarged veins around the anus. About 50% of adults experience hemorrhoids during their lifetime; their frequency increases significantly after age 50.
Despite being very common, late diagnosis is common because they are considered taboo. In fact, they are easily and effectively treatable.
Types
1. Internal hemorrhoids:
- Inside the anus
- Usually painless
- Bleeding is the main symptom
- Grading:
- Grade 1: Internal, does not protrude
- Grade 2: Protrudes when defecating, retracts on its own
- Grade 3: Protrudes, can be pushed back manually
- Grade 4: Permanently protruded, cannot be reduced
2. External hemorrhoids:
- Outside the anus
- Painful, itchy
- Severe pain if thrombosed
Symptoms
Internal hemorrhoids:
- Bright red blood in stool (on toilet paper or in the toilet)
- Sensation of protrusion from the anus
- Itching, irritation
- Mucus discharge
- Feeling of incomplete evacuation
- Usually painless
External hemorrhoids:
- Swelling, hardness around the anus
- Pain, tenderness
- Itching
- Thrombosed hemorrhoid: sudden severe pain, purple-black color
- Increased pain when sitting
- Pain after toileting
Causes
Swelling of veins in the anus due to excessive pressure or strain:
- Excessive straining on the toilet
- Constipation
- Diarrhea (chronic)
- Sitting on the toilet for long periods
- Inactivity
- Pregnancy
- Obesity
- Lack of fiber in the diet
- Excessive heavy lifting
- Aging (weakening of vessel walls)
Risk Factors
- Constipation or chronic diarrhea
- Insufficient fiber intake
- Insufficient water
- Excess weight
- Pregnancy
- Age (over 50)
- Family history
- Anal sex
- Standing or sitting for long periods
- Heavy lifting
Complications
- Anemia (chronic bleeding)
- Thrombosis (sudden severe pain)
- Incarcerated hemorrhoid
- Strangulation (if blood flow is cut off)
- Anal fissure
- Anal fistula
- Urinary retention
- Decreased quality of life
When to See a Doctor
- Rectal bleeding (must be evaluated - cancer differential)
- Severe pain
- Complaints not responding to over-the-counter medications
- Thrombosed hemorrhoid (sudden hard swelling)
- Protruded hemorrhoid
- Recurring cases
- New-onset complaint over age 50
- Family history of colon cancer
- Weakness, paleness (sign of anemia)
Emergency:
- Severe bleeding
- Severe pain, fever
- Signs of shock
Diagnosis and Treatment
Diagnosis:
- Physical examination
- Anoscopy (anal canal examination)
- Sigmoidoscopy / colonoscopy (especially over age 50, to rule out cancer)
Treatment:
1. Conservative treatment (for Grade 1-2 and external hemorrhoids):
Diet and lifestyle:
- High-fiber diet (25-30 g per day)
- Plenty of water (2-2.5 L per day)
- Fiber supplement (psyllium)
- Regular exercise
- Do not sit long on the toilet
- Do not strain excessively
- Proper toilet position (feet slightly elevated)
Medications:
- Topical creams (hydrocortisone, lidocaine)
- Phytotherapy (horse chestnut, diosmin)
- Pain reliever (paracetamol)
- Softeners (to prevent constipation)
- Warm sitz baths (2-3 times a day, 10-15 min)
2. Office procedures (Grade 2-3):
- Rubber band ligation (most common)
- Sclerotherapy
- Infrared coagulation
- Bipolar coagulation
3. Surgery (Grade 3-4):
- Hemorrhoidectomy: Surgical removal of hemorrhoids
- Stapled hemorrhoidopexy
- THD/HAL (transanal hemorrhoidal dearterialization)
- Laser hemorrhoidoplasty
4. Thrombosed hemorrhoid:
- Surgery within first 48-72 hours (clot removal)
- Conservative in later period
Prevention
Nutrition:
- 25-30 g of fiber per day (vegetables, fruits, whole grains, legumes)
- Plenty of water (2-2.5 L per day)
- Less processed food
- Reduce spicy foods
- Limit caffeine
Toilet habits:
- Do not delay when you have the urge
- Do not sit on the toilet for long (5-10 min enough)
- Do not strain excessively
- Gentle cleaning after toilet (wet wipes or bidet)
- Avoid rough toilet paper
Lifestyle:
- Regular exercise
- Maintain a healthy weight
- Do not sit for long (walk 5 min every hour)
- Proper lifting technique
- Quit smoking
During pregnancy:
- Change positions frequently
- Sleep on left side
- Plenty of water, high-fiber foods
- Exercise (with doctor's approval)
- Prevent constipation