What Are Hemorrhoids? 

Hemorrhoids, also referred to as piles, are the result of inflamed swollen veins in your rectum and anus, that can form either internally or externally. Sometimes the walls of these veins and blood vessels stretch so thin that the veins bulge and get irritated causing pain and discomfort. Affecting both men and women, almost everyone is bothered at some point in their life by hemorrhoids. Nobody is immune to hemorrhoids and in fact everyone has them. Hemorrhoids are normal cushions of tissue that are filled with blood vessels and found at the end of the rectum, just inside the anus. However, when these blood vessels become enlarged and inflamed it can be very painful and is what people commonly refer to as “having hemorrhoids”.

Luckily for everyone, hemorrhoids aren’t particularly harmful and are more of a nuisance than anything, just causing a number of not so pleasant symptoms. Typical symptoms including itching, burning, stinging and bleeding. Bleeding happens when hard stool damages the thin walls of the blood vessels in hemorrhoids. Sometimes they can become infected or bleed heavily, prompting urgent intervention and even surgery. Although generally not dangerous, the issue should still be resolved one way or another, as they can cause more problems than you want to deal with down the road.

There are two types of hemorrhoids, which are:

1) External hemorrhoids, which form under the skin around the anus. And,

2) Internal hemorrhoids, which form in the lining of the anus and lower rectum.

The two basic types include internal and external hemorrhoids. Internal hemorrhoids are more common, and external hemorrhoids tend to feel like a large lump around the outside of the anus that can make sitting painful. Bleeding is fairly common with a swollen external hemorrhoid. You can have both at the same time. Internal hemorrhoids usually do not cause pain or discomfort, while external hemorrhoids often do.

Internal hemorrhoids are far enough inside the rectum that you can't usually see or feel them. They don't generally hurt because you have few pain-sensing nerves there. Bleeding may be the only sign of them.

 External hemorrhoids are under the skin around the anus, where there are many more pain-sensing nerves, so they tend to hurt as well as bleed.

Swollen internal hemorrhoids might come out of the anus and can then be seen as soft lumps of tissue. These are called protruding or prolapsed hemorrhoids. Larger hemorrhoids can make it feel like something is pushing against the anus, which can make sitting very uncomfortable1.

Hemorrhoids are classified by how severe they are:

Stage 1: Mildly enlarged hemorrhoids that cannot be seen from outside the anus.

Stage 2: Larger hemorrhoids that may protrude outside of the anus at times, especially during bowel movements, but then go back in on their own.

Stage 3: Hemorrhoids that come out of the anus during bowel movements or engaging in physical activity and do not go back in on their own and can only be pushed back inside the anus.

Stage 4: Hemorrhoids that are always outside the anus and can no longer be pushed back inside. In severe cases, this is known as rectal prolapse1. A particularly painful form of stage 4 hemorrhoids comes in the form of a thrombosed hemorrhoid. This refers to a (usually) external hemorrhoid that have no blood flow because the vein connected to them has a thrombosis (blood clot). The thrombosis responsible for a thrombosed hemorrhoid can take two to three weeks to reabsorb without major treatment, but can be very painful.

A particularly painful form of stage 4 hemorrhoids comes in the form of a thrombosed hemorrhoid. This refers to a (usually) external hemorrhoid that have no blood flow because the vein connected to them has a thrombosis (blood clot). The thrombosis responsible for a thrombosed hemorrhoid can take two to three weeks to reabsorb without major treatment, but can be very painful.

(1) https://www.ncbi.nlm.nih.gov/books/NBK279467/

What Are the Symptoms?

Hemorrhoids don’t always cause symptoms, so you may not realize you have them. But overall, common symptoms include:

• Anal itching
• Anal pain, especially while sitting
• Bright red blood on toilet tissue, stool, or in the toilet bowl • Pain or discomfort during bowel movements
• One or more hard tender lumps near the anus

More specifically, the symptoms of hemorrhoids depend on the type you have. If you have external hemorrhoids, you may have: anal itching, one or more hard, tender lumps near your anus, anal ache or pain, especially when sitting. Too much straining, rubbing, or cleaning around your anus may make your symptoms worse.

If you have internal hemorrhoids, you may have: bleeding from your rectum––bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement, a hemorrhoid that has fallen through your anal opening, which is called prolapse.

Internal hemorrhoids that are not prolapsed most often are not painful. Prolapsed internal hemorrhoids may cause pain and discomfort. Although hemorrhoids are the most common cause of anal symptoms, not every anal symptom is caused by a hemorrhoid. Some hemorrhoid symptoms are similar to those of other digestive tract problems. For example, bleeding from your rectum may be a sign of bowel diseases such as Crohn’s disease, ulcerative colitis, or cancer of the colon or rectum.

What Are the Causes?

Hemorrhoids are a type of varicose vein that tends to occur as we get older; about 75% of Americans have hemorrhoids at some point. Being constipated or passing large, hard stools may contribute to developing hemorrhoids. In many cases, however, there is no obvious cause. The increased pressure during pregnancy may also cause hemorrhoids. Contributing factors include the following:

• Some medical conditions (such as cirrhosis -- end stage liver disease)
• Pregnancy
• Sitting for a long period of time (especially sitting on the toilet)
• Obesity
• Lifestyle
• Chronic diarrhea
• Chronic constipation and straining
• Diet low in fiber or fluids
• Straining while doing something physical or lifting something heavy
• Standing for long stretches of time

Some people may be more likely to get hemorrhoids if other family members, like their parents, had them. A buildup of pressure in your lower rectum can affect blood flow and make the veins there swell. That may happen from extra weight, when you're obese or pregnant.
 
Researchers propose that degradation (or disintegration) of the supporting tissues of the anal cushions causes hemorrhoids to develop. An increase in intra-abdominal pressure during pregnancy or when constipated and sitting on the toilet for a prolonged period of time while straining are major contributing factors for the development of hemorrhoids. Weakening of supporting tissue as a result of aging and genetics may also serve as another cause.

Irritants in the diet can exacerbate hemorrhoids, including strong spices such as red pepper and mustard, and drinks such as coffee, decaffeinated coffee, and alcohol. Stress can cause hemorrhoids, as can pregnancy (due to pressure of the baby in the abdomen, as well as hormonal changes that cause blood vessels to enlarge – these hemorrhoids usually disappear after delivery). Obesity, chronic diarrhea and anal intercourse can also lead to hemorrhoids.

How Common Are They?

Hemorrhoids are common in both men and women and affect about 1 in 20 Americans2. About half of adults older than age 50 have hemorrhoids2. It’s suggested that as much as 75% of adults will have hemorrhoids at some point or another during their lifetime, lower estimates figure roughly 50%. There are 20 million+ people in America who suffer from hemorrhoids (12.8 % of U.S. adults). So, although it can be an embarrassing and taboo subject to talk about, it is a very common condition.

(2) Fox A, Tietze PH, Ramakrishnan K. Anorectal conditions: hemorrhoids. FP Essentials. 2014;419:11–19.

Diagnosis 

Your doctor can often diagnose external hemorrhoids with a physical exam. For internal hemorrhoids, your doctor may do a rectal examination (inserting a gloved finger in the rectum). Your doctor may also use an anoscope or sigmoidoscope to look inside the anal canal. An anoscope is a hollow, lighted tube for viewing the lower few inches of the rectum. Sigmoidoscopy looks at the lower colon, or sigmoid, and a colonoscopy looks at the entire colon. You may need other tests to find internal hemorrhoids or rule out other conditions that can cause anal bleeding. Your doctor will ask you to provide your medical history and describe your symptoms. He or she will ask you about your eating habits, toilet habits, enema and laxative use, and current medical conditions. Your doctor will check the area around your anus for:

• lumps or swelling
• internal hemorrhoids that have fallen through your anal opening, called prolapse
• external hemorrhoids with a blood clot in a vein
• leakage of stool or mucus
• skin irritation
• skin tags––extra skin that is left behind when a blood clot in an external hemorrhoid dissolves
• anal fissures—a small tear in the anus that may cause itching, pain, or bleeding

How Doctors Treat Hemorrhoids / Conventional Treatments

Typically, doctors will prescribe or suggest medications to treat your hemorrhoids. The Problem with this is that these products generally only treat the symptoms and not the root cause of the hemorrhoids. If your symptoms are severe or aren't getting better after a couple of weeks, your doctor may want do a procedure to shrink or remove the hemorrhoids. Aside from prescribing medications will also use the following methods to treat hemorrhoids.

Rubber Band Ligation

This procedure is often done on prolapsed hemorrhoids, internal hemorrhoids that can be seen or felt outside. Using a special tool, the doctor puts a tiny rubber band around the hemorrhoid, which shuts off its blood supply almost instantly. Within a week, the hemorrhoid will dry up, shrink, and fall off8.

Doppler Guided Hemorrhoidal Artery Ligation

A relatively new procedure to help safely treat hemorrhoids.

Coagulation or cauterization

With an electric probe, a laser beam, or an infrared light, your doctor will make a tiny burn to remove tissue and painlessly seal the end of the hemorrhoid, causing it to close off and shrink. This works best for prolapsed hemorrhoids9.

Sclerotherapy 

A doctor injects a solution into an internal hemorrhoid, which causes scar tissue to form. The scar tissue cuts off the blood supply, often shrinking the hemorrhoid10.

Surgery

For large internal hemorrhoids or extremely uncomfortable external hemorrhoids, your doctor may want to do a traditional hemorrhoidectomy to remove them, or a newer technique using staples. If you wait and do nothing to treat your hemorrhoids, surgery may become the only treatment option later on down the road.

Treatment may be administered with procedures during an office visit or in an outpatient center or a hospital. Office treatments include the following: Rubber band ligation, infrared photocoagulation, and electrocoagulation. Outpatient center or hospital treatments include the following: Hemorrhoidectomy and Hemorrhoid stapling.

Most of the patients suffering from hemorrhoids have their symptoms alleviated through diet therapy, fiber supplements, hemorrhoid cream and medical treatments, such as sclerotherapy, rubber band ligation and infrared coagulation. Medical treatments can be effective, but unless you change your diet and lifestyle, hemorrhoids may come back.

(8) https://pubmed.ncbi.nlm.nih.gov/10720835/
(9) https://pubmed.ncbi.nlm.nih.gov/14502378/
(10) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259422/

Natural Treatments

Sitz Bath

Warm (but not hot) "sitz baths" are a time-honored therapy: Sit in about 3 inches of warm water for 15 minutes or so, several times a day. This helps reduce swelling in the area and relaxes your clenching sphincter muscle. It's especially good after bowel movements. People have also reported getting relief from mixing the warm bath water with Epsom’s salts. If bowel movements are painful you can try putting a little petroleum jelly just in and around your anus.

Witch Hazel (Hamamelis virginiana)

Dab witch hazel on irritated hemorrhoids, or use over-the-counter creams or ointments made for hemorrhoid symptoms. Many "pads" used to treat hemorrhoids contain witch hazel.

Ice

Or try putting a simple cold pack on the tender area for a few minutes to numb it and bring down the swelling.

Drink Plenty of Water

Drinking more water can greatly decrease constipation and straining during bowel movements, which can help prevent hemorrhoids. It also helps alleviate strain and to make bowel movements easier and less painful if you already have hemorrhoids.

Probiotics 

Probiotics, or "friendly" bacteria, such as lactobacillus and bifidus, can help prevent and treat hemorrhoids. People who are extremely immunocompromised should speak to their physician before taking probiotics.

Butcher's Broom

Butcher’s broom can help reduce swelling and inflammation of hemorrhoids. A 2002 study conducted in Germany found that butcher’s broom was an effective means of treatment for patients suffering from chronic venous insufficiency, a condition where the flow of blood through the veins is inadequate, causing the blood to pool11.

Horse Chestnut

Horse chestnut is commonly used as an herbal remedy for poor blood flow and swelling. According to research published in Alternative Medicine Review, horse chestnut has been shown to improve microcirculation, capillary flow and vascular tone, all of which are helpful for how to get rid of hemorrhoids12.

Psyllium Husk

Psyllium husk is a natural source of pure fiber that’s sold in powder form. Studies suggest that plant fibers like psyllium husk can reduce the frequency of bleeding when using the bathroom and help avoid constipation or straining. When using psyllium husk, make sure to drink plenty of water. A 2011 animal study published in Digestive Diseases and Sciences found that psyllium husk has a gut-stimulatory and laxative effect on mice, and at higher doses it has antisecretory (reducing the normal rate of secretion of a body fluid) and antidiarrheal activity13.

Apple Cider Vinegar

Using apple cider vinegar is one of the most popular natural treatments for hemorrhoids. Simply soak a cotton ball or some toilet paper with ACV and apply it to the hemorrhoid area. Repeat this process until the inflammation disappears and symptoms resolve. You should see improvement instantly. Alternatively, add some ACV (half a cup) to a sitz bath.

Coconut Oil

Apply coconut oil directly to hemorrhoids, rinse and repeat. In addition to symptoms subsiding, the hemorrhoids should disappear over the course of just a few days.

Aloe Vera

As with the above treatments, simply apply aloe vera to the affected area to relieve symptoms. Also, Aloe Vera juice has many anti-inflammatory qualities and can help reduce painful hemorrhoid symptoms.

High-Quality Natural Herbal Supplement

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Squat, Don't Sit

This is actually heavily important and very overlooked. Conventional toilets are highly unnatural, and may be one reason hemorrhoids are rarely seen in less developed countries, where squatting is done when going to the bathroom. Sitting down to pass a bowel movement puts tremendous strain on the rectum while squatting straightens the rectum and relaxes the puborectalis muscle. This should be done along with any home remedies for hemorrhoids you may use. See “Squatty Potty”! www.squattypotty.com

(11) https://pubmed.ncbi.nlm.nih.gov/12040966/
(12) https://pubmed.ncbi.nlm.nih.gov/11302778/
(13) https://pubmed.ncbi.nlm.nih.gov/21082352/

Other Resources

https://www.ncbi.nlm.nih.gov
https://www.mayoclinic.org/
https://medlineplus.gov/hemorrhoids.html
https://www.researchgate.net/publication/45166133_HERBAL_TREATMENT_FOR_HEMORRHOIDS