What the Guidance Really Says About Hemorrhoids

Key takeaways

• Typical symptoms: bright red bleeding on wiping, itching, discomfort, a lump
• Main contributor: straining and constipation
• Most useful single change: Treat constipation; it is the underlying cause for most people.
• Commonest mistake: Assuming all rectal bleeding is hemorrhoids.
• See a doctor if any of the signs under "When to speak to a doctor" below apply to you.

What it is

Swollen blood vessels in and around the anus, sometimes called piles. It sits within Digestive Health. The figures come from the bodies named at the foot of this page.

The numbers, in one place

What helps

The advice below comes straight from the guidance cited at the foot of this page.

• Treat constipation; it is the underlying cause for most people
• Avoid straining and do not sit on the toilet for long periods
• Use a footstool to raise the knees above the hips
• Try a warm sitz bath and keep the area clean and dry

What to avoid

What to steer clear of, and why it catches people out.

• Assuming all rectal bleeding is hemorrhoids
• Long-term use of steroid creams without advice
• Prolonged straining or scrolling on your phone on the toilet

In depth

Everyone has hemorrhoids. They are cushions of blood vessels and supporting tissue in the anal canal that help seal it and contribute to continence. They only become a problem when they swell, slip down or bleed. Internal hemorrhoids lie higher in the anal canal, where there are few pain nerves, so they usually cause painless bleeding. External hemorrhoids lie under the sensitive skin around the anus and can cause pain, swelling and itching.

Repeated straining, hard stools and long periods on the toilet raise the pressure in these vessels and stretch the tissue that anchors them, allowing hemorrhoids to enlarge and slide downward. Internal hemorrhoids are graded by how far they prolapse, from those that stay inside, to those that come out with a bowel movement and go back on their own, to those that stay out. This grading helps guide treatment. Lower grades usually respond to home care, while higher grades more often need a procedure.

Sometimes a blood clot forms in an external hemorrhoid, causing a sudden, painful, bluish lump called a thrombosed hemorrhoid. The pain is usually worst in the first two to three days and then gradually eases as the body absorbs the clot. Being seen within the first few days gives you the option of having the clot removed for faster relief. Otherwise, home care usually allows it to settle on its own, sometimes leaving a small skin tag behind.

Signs and symptoms

• Bright red blood on toilet paper or in the toilet bowl
• Itching or irritation around the anus
• A lump near the anus that may be painful
• Tissue that protrudes during bowel movements
• Mucus leakage or difficulty keeping the area clean
• Sudden severe pain with a hard lump from a thrombosed hemorrhoid

Causes and risk factors

• Constipation and straining
• Chronic diarrhea
• Long periods sitting on the toilet
• Pregnancy and childbirth
• Low fiber intake
• Heavy lifting and obesity, which raise pressure within the abdomen
• Aging, which weakens supporting tissues

How it is checked

Your doctor will ask about your symptoms and bowel habits and examine the area. A gentle digital rectal exam and anoscopy, which uses a short tube with a light to look inside the anal canal, can show internal hemorrhoids. These checks are quick and usually not painful, and they help rule out other causes of bleeding or pain, such as an anal fissure.

Because rectal bleeding can come from other conditions, your doctor may recommend a colonoscopy or flexible sigmoidoscopy, especially if you are 45 or older, have a family history of colorectal cancer, or have symptoms such as a change in bowel habits, weight loss or anemia. Anal fissures, small tears that cause sharp pain during bowel movements, are another common cause of bleeding and are treated differently.

Treatment and support options

Home care

Treating constipation is the foundation. Increase fiber and fluids, use a fiber supplement or stool softener if needed, and avoid straining. Warm sitz baths for 10 to 15 minutes several times a day can ease pain and itching. Over-the-counter creams, ointments and medicated pads can soothe symptoms, but use steroid-containing products only for a short time unless your doctor advises otherwise. Products containing a numbing agent can ease pain for a short time.

Office procedures

For internal hemorrhoids that keep bleeding or prolapsing despite home care, rubber band ligation is the most common procedure. A small band is placed around the base of the hemorrhoid, cutting off its blood supply so it shrinks and falls off within about a week. Other office options include sclerotherapy injections and infrared coagulation. These are usually done without anesthesia and need little time off.

Surgery

Surgery such as hemorrhoidectomy is reserved for large or recurrent hemorrhoids or those that do not respond to other treatments. It removes the swollen tissue and has the lowest chance of the problem returning, but recovery can be painful and usually takes a few weeks. Other operations reduce blood flow to the hemorrhoids or lift them back into place, with less pain but a higher chance of recurrence.

Treating a thrombosed hemorrhoid

If a painful clotted external hemorrhoid is seen within the first few days, a doctor can often remove the clot through a small cut under local anesthetic, which gives rapid relief. After that window, the pain is usually already easing, so warm baths, pain relief and stool softeners are generally recommended while it settles on its own over a week or two.

Prevention

• Eat a fiber-rich diet and drink plenty of fluids
• Go when you feel the urge and avoid straining
• Limit time on the toilet to a few minutes
• Stay active to keep bowels moving
• Use proper lifting technique and avoid holding your breath when lifting

Day to day

Most hemorrhoid flares improve within a week or two with simple measures. Keep the area clean with gentle washing using plain water, and pat dry rather than rubbing. Avoid scented soaps, wipes and toilet paper that can irritate the skin. Sitting on a soft cushion may help, and breaking up long periods of sitting reduces pressure on the area.

If symptoms keep returning, talk to your doctor about longer-term options rather than relying on creams indefinitely. Do not assume new bleeding is from hemorrhoids, even if you have had them before. A change in the color or amount of bleeding, or in your bowel habits, should always be checked.

For specific groups

Pregnancy

Hemorrhoids are common in pregnancy and after childbirth because of pressure from the uterus, hormonal changes, constipation and straining during delivery. Fiber, fluids, sitz baths and topical treatments your doctor approves usually help. Most improve within weeks to months after delivery, and procedures are rarely needed.

Adults 45 and older

Rectal bleeding at this age should prompt a conversation about colorectal cancer screening and possibly colonoscopy, even if hemorrhoids are found on examination, since both can be present at once. Screening is recommended for average-risk adults from age 45, and earlier for those with a strong family history.

People on blood thinners

Blood thinners can make bleeding from hemorrhoids heavier or more frequent. Do not stop these medicines on your own, as that can be dangerous. Talk to your doctor if bleeding is frequent or heavy, and seek urgent care for bleeding with dizziness, fainting or a racing heart.

Questions to ask your doctor

• Are my symptoms definitely from hemorrhoids?
• Do I need a colonoscopy?
• Which home treatments are best for me?
• How long can I use an over-the-counter cream?
• Would rubber band ligation be an option?
• What should I do if bleeding becomes heavier?

More questions, answered

Do hemorrhoids go away on their own?

Many mild hemorrhoids improve within days to a couple of weeks with simple measures such as treating constipation and avoiding straining. Larger or prolapsing internal hemorrhoids are more likely to persist or keep coming back, and these may need an office procedure or, occasionally, surgery.

Can hemorrhoids turn into cancer?

No. Hemorrhoids do not turn into cancer. However, colorectal and anal cancers can cause similar symptoms, including bleeding and a lump, so rectal bleeding should be evaluated rather than assumed to be hemorrhoids, especially if it is new or you are due for screening.

Is it safe to push a hemorrhoid back in?

Gently pushing a prolapsed internal hemorrhoid back in with a clean, lubricated finger is usually safe and can ease discomfort. If it will not go back, is very painful, or looks dark purple or black, see a doctor promptly, as the blood supply may be affected.

Why are hemorrhoids itchy?

Swollen tissue can leak mucus and make it harder to clean the area completely, and both irritate the skin around the anus. Keeping the area clean and dry, wearing cotton underwear and using a soothing cream for a short time can help. Persistent itching should be checked for other skin causes.

Can sitting on a hard surface cause hemorrhoids?

Not directly. Long periods of sitting, especially on the toilet where the anal area is unsupported, increase pressure on the veins. If you sit for work, taking short breaks to stand and move around helps, and so does keeping bowel movements soft and regular.

Is it normal to bleed after a bowel movement?

Small amounts of bright red blood on the paper are common with hemorrhoids or fissures, but any rectal bleeding should be checked by a doctor at least once, particularly if it is new, darker, mixed into the stool or comes with other changes. Heavy bleeding needs urgent care.

Related topics

• Colorectal Cancer: Sorting the Evidence From the Noise (Cancer Awareness)
• Severe Bleeding: What the Evidence Actually Says (Emergency Care)
• Bruising and Bleeding: Sorting the Evidence From the Noise (Blood Health)
• Swollen Ankles: What Published Guidance Supports (Foot Health)

Where to go next

• Starting Out With Hemorrhoids
• Your Questions About Hemorrhoids, Answered
• Hemorrhoids — the reference entry
• Digestive Health: The Complete Guide
• Food Intolerance: What the Evidence Actually Says
• What the Guidance Really Says About Probiotics

When to speak to a doctor

See your doctor for any rectal bleeding, particularly if it is dark, mixed with stool, persistent, or accompanied by a change in bowel habits, weight loss or abdominal pain — colorectal cancer can cause the same symptoms. Guidelines recommend colorectal cancer screening from age 45. Go to the emergency room or call 911 for heavy bleeding with dizziness or fainting, and seek prompt care for severe anal pain with a hard lump.

Where this comes from

• National Institute of Diabetes and Digestive and Kidney Diseases — Hemorrhoids
• US Preventive Services Task Force — Colorectal Cancer: Screening

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.