Pain and bleeding are caused by hemorrhoids, sometimes referred to as piles, which are enlarged and irritated vessels in the anus and rectum. They might be external, developing beneath the skin surrounding the exterior of the anal hole, or internal, taking place inside the rectum. 

Several factors can contribute to the development of hemorrhoids, including: 

• Straining during bowel movements: Among the most frequent causes is this one. The act of straining causes edema and inflammation by applying pressure to the vein in the rectum. 
• Chronic constipation or diarrhea: Both disorders have the potential to strain the rectal region and hasten the onset of the hemorrhoids. 
• Pregnancy: Hormonal changes and increased pelvic vein pressure during pregnancy might aggravate or start hemorrhoids. 
• Sitting for long periods: Extended periods of sitting, particularly when using the restroom, might exacerbate venous pressure in the rectal region. 
• Obesity: Being obese can increase the pressure on rectal veins, leading to hemorrhoids. 
• Aging: The tissues in the rectal region that support the veins may degenerate with age, increasing the risk of hemorrhoids. 

Prevalence: 

• Hemorrhoids are a widespread condition, affecting people of all ages and backgrounds. 
• Prevalence tends to increase with age, with a higher incidence in older adults. 
• An estimated 50% of persons over 50 may at a point in their life have symptoms associated with hemorrhoids. 

Gender Differences: 

• Hemorrhoids are slightly more prevalent in men than in women. 
• Pregnancy and childbirth, which can contribute to the development of hemorrhoids, make women more susceptible during certain life stages. 

Age Distribution: 

• While hemorrhoids can occur at any age, the risk increases with advancing age. 
• Older adults are more likely to experience weakened vein walls and increased pressure in the rectal area, contributing to the development of hemorrhoids. 

Pregnancy-Related Hemorrhoids: 

• Due to the hormonal changes and increased strain on the pelvic veins, hemorrhoids are frequent during pregnancy. 
• It is estimated that up to 50% of pregnant women may develop hemorrhoids. 

Occupational Factors: 

• Individuals with occupations that involve prolonged sitting or standing may be at a higher risk of developing hemorrhoids. 

Geographical Variation: 

• Hemorrhoids are a global health concern, with prevalence rates varying across different regions. 
• Factors such as dietary habits, lifestyle, and genetic predisposition may contribute to regional differences. 

Increased Venous Pressure: 

• One of the key elements in the pathophysiology of hemorrhoids is elevated pressure in the veins of the rectum and anus. 
• Straining during bowel movements, chronic constipation, and prolonged sitting on the toilet can all contribute to increased pressure. 

Weakened Vein Walls and Valves: 

• The veins in the rectum and anus have small valves that help regulate blood flow. 
• Weakened vein walls, possibly due to aging or genetic factors, can result in inefficient valve function, allowing blood to accumulate in the veins and leading to their enlargement. 

Congestion and Stasis: 

• Increased pressure and weakened vein walls can cause congestion and stasis (slowed blood flow) in the hemorrhoidal plexus, a network of veins in the anal canal. 
• Stasis can result in engorgement of the veins and the formation of hemorrhoids. 

Straining During Bowel Movements: 

• Straining to pass hard stools or constipation increases intra-abdominal pressure, which is transmitted to the veins in the rectum. 
• This pressure can cause the veins to dilate and become inflamed. 

Pregnancy-Related Changes: 

• Because of the hormonal changes and increased strain on the pelvic veins, pregnancy might exacerbate the development of hemorrhoids. 
• The pressure of the expanding uterus on the pelvic arteries affects the flow of blood to the lower abdomen. 

Inflammation and Swelling: 

• Prolonged exposure to increased pressure, congestion, and stasis leads to inflammation and swelling of the hemorrhoidal veins and surrounding tissues. 
• Inflamed hemorrhoids may become symptomatic, causing pain, itching, bleeding, or the formation of external lumps. 

Thrombosis: 

• In some cases, hemorrhoids may develop blood clots (thrombosis), leading to further swelling and pain. 
• Thrombosed external hemorrhoids can be particularly uncomfortable and may require medical intervention. 

Increased Pressure in the Rectum: The primary factor leading to hemorrhoids is an increase in pressure in the rectum. This pressure can result from various conditions, including: 

• Straining during bowel movements, often due to constipation. 
• Prolonged sitting on the toilet. 
• Chronic diarrhea. 

Weakened Vein Walls: The veins in the rectum and anus have small valves that help regulate blood flow. If these valves weaken, blood may accumulate and cause the veins to swell. Factors contributing to weakened vein walls include: 

• Aging, as the tissues supporting the veins may become less elastic over time. 
• Genetic predisposition, as some individuals may inherit a tendency to develop weak vein walls. 

Pelvic Congestion: Conditions that cause congestion in the pelvic area can contribute to the development of hemorrhoids. This congestion may result from: 

• Pregnancy: Hormonal changes and increased pelvic vein pressure during pregnancy might aggravate or start hemorrhoids. 
•  Obesity: Being obese can increase the pressure on rectal veins, leading to hemorrhoids. 

Liver Disease: Liver cirrhosis can lead to portal hypertension, increasing pressure in the veins around the rectum and anus and potentially causing hemorrhoids. 

Lifestyle Factors: The chance of getting hemorrhoids might be raised by certain lifestyle decisions and practices. These include: 

• Lack of physical activity. 
• Poor dietary habits, including a low-fiber diet. 
• Prolonged sitting or standing. 

• Severity of Symptoms: The prognosis may be affected by the intensity of symptoms, such as pain, bleeding, and discomfort. Mild symptoms may respond well to conservative measures, while more severe symptoms may require medical interventions. 
• Chronicity of Symptoms: Chronic or recurrent symptoms may suggest an ongoing issue that requires ongoing management. Addressing the underlying causes and making lifestyle modifications can improve long-term outcomes. 
• Response to Treatment: The response to conservative measures, such as dietary changes, increased fiber intake, and topical treatments, can impact the prognosis. If symptoms improve with these interventions, the prognosis is generally more favorable. 
• Presence of Complications: Complications, such as thrombosis (formation of blood clots in hemorrhoids) or prolapse (protrusion of internal hemorrhoids through the anal opening), may influence the prognosis. Complicated cases may require more intensive management. 
• Underlying Health Conditions: Certain underlying health conditions, such as liver disease leading to portal hypertension, may contribute to the development of hemorrhoids. Managing these conditions can positively impact the prognosis. 
• Compliance with Treatment: Patient compliance with recommended treatments and lifestyle modifications is crucial. Adhering to a high-fiber diet, staying hydrated, and avoiding straining during bowel movements can improve outcomes. 
• Timing of Medical Intervention: Early recognition and treatment of symptomatic hemorrhoids can prevent the progression of the condition and improve outcomes. Delayed intervention may lead to more severe symptoms and complications. 
• Recurrence: Hemorrhoids tend to recur, especially in individuals with predisposing factors. Managing underlying causes and adopting preventive measures can reduce the risk of recurrence. 

Age Group: 

• Younger Adults (20s-30s): Hemorrhoids can occur at any age, but they are less common in younger adults. When present, they are often associated with factors like a sedentary lifestyle, low-fiber diet, or straining during bowel movements. 
• Middle-aged Adults (40s-50s): This age group may experience an increased incidence of hemorrhoids. Factors such as chronic constipation, prolonged sitting (especially in desk jobs), and dietary habits may contribute. 
• Older Adults (60s and above): The risk of hemorrhoids tends to increase with age. Hemorrhoids in elderly persons can be caused by weakened walls of veins and connective tissues, as well as a history of extended exposure to risk factors. 

History Taking: 

• The medical professional will begin by obtaining a thorough medical history that includes the symptoms, length of time they have been present, and any prior operations or treatments for hemorrhoids. 
• Specific questions may be asked about bowel habits, dietary habits, presence of constipation or diarrhea, and any factors that exacerbate or alleviate symptoms. 

Visual Inspection: 

• The healthcare provider will visually inspect the anal and perianal area for signs of external hemorrhoids or any other abnormalities. 
• External hemorrhoids may appear as swollen, bluish lumps around the anal opening. 

Digital Rectal Examination (DRE): 

• To find internal hemorrhoids, rectal tumors, or other anomalies, a gloved, lubricated finger is placed into the rectum. 
• During the examination, the healthcare provider can palpate the rectal wall and assess for the presence of internal hemorrhoids, their size, and any associated tenderness or bleeding. 

Anoscopy or Proctoscopy: 

• Anoscopy or proctoscopy may be performed to obtain a closer view of the anal canal and lower rectum. 
• Proctoscopy is similar but allows for a more extensive examination of the rectum using a longer instrument called a proctoscope. 

Assessment of Hemorrhoid Characteristics: 

• The healthcare provider will determine the characteristics of hemorrhoids, including size, degree of prolapse (if present), and any signs of inflammation, thrombosis, or ulceration. 
• Internal hemorrhoids may be graded based on their degree of prolapse: 

• Grade I: Hemorrhoids that do not prolapse. 
• Grade II: Hemorrhoids that prolapse with straining but spontaneously reduce. 
• Grade III: Hemorrhoids that prolapse with straining and require manual reduction. 
• Grade IV: Irreducible hemorrhoids that are prolapsed and thrombosed. 

Evaluation for Complications: 

• The healthcare provider will assess for the signs of complications such as thrombosis (clot formation within hemorrhoids), strangulation (loss of blood supply to prolapsed hemorrhoids), or infection. 
• Signs of complications may include severe pain, rapid enlargement of hemorrhoids, fever, or signs of sepsis. 

• Pregnancy: Pregnant women are at the higher risk of developing hemorrhoids due to the pressure exerted by the growing uterus on pelvic vessels.  
• Obesity: Excess weight can contribute to increased intra-abdominal pressure and pelvic congestion, increasing the risk of hemorrhoids. 
• Chronic Constipation or Diarrhea: Individuals with bowel habits that involve straining (constipation) or frequent bowel movements (diarrhea) may be more prone to developing hemorrhoids. 
• Liver Disease: Liver cirrhosis can lead to portal hypertension, increasing pressure in the veins around the rectum and anus, potentially causing hemorrhoids. 

• Acute Presentation: Some individuals may experience sudden and severe symptoms, often associated with complications such as thrombosis (formation of blood clots in hemorrhoids) or strangulation (loss of blood supply to prolapsed hemorrhoids). Acute symptoms may include intense pain, swelling, and bleeding. 
• Chronic Presentation: In other cases, individuals may have a more chronic and gradual onset of symptoms. This can include intermittent bleeding during bowel movements, discomfort, itching, or a feeling of incomplete evacuation. 

Lifestyle and Dietary Modifications: 

• Increasing dietary fiber intake: Eating a diet rich in fiber can help prevent straining and constipation by softening stools and facilitating bowel movements. 
• Drinking plenty of fluids: Staying hydrated helps maintain soft stools. 
• Avoiding prolonged straining or sitting during bowel movements. 
• Regular exercise: Physical activity can promote regular bowel movements and improve overall bowel function. 

Topical Treatments: 

• Hemorrhoid symptoms including itching, soreness, and swelling can be lessened using over-the-counter (OTC) lotions, ointments, or suppositories that contain witch hazel, hydrocortisone, or phenylephrine. Some topical treatments may also contain ingredients with a cooling or numbing effect to provide additional relief. 

Sitz Baths: 

• Sitting in warm water baths (sitz baths) for ten to fifteen minutes several times a day can help soothe symptoms, reduce the swelling, and promote healing of hemorrhoids. 

Bulk Laxatives or Stool Softeners: 

• Bulk-forming laxatives or stool softeners may be recommended to help prevent constipation and reduce straining during bowel movements. 

Minimally Invasive Procedures: 

• Rubber band ligation: An external hemorrhoid’s blood supply is severed by wrapping a rubber band around its base; the hemorrhoids shrink and fall out in a few days because of this frequently done outpatient surgery. 
• Sclerotherapy: To reduce internal hemorrhoids, a chemical solution is injected into their base. 
• Infrared coagulation (IRC) or bipolar diathermy: Application of heat to internal hemorrhoids to cause coagulation and scarring, reducing blood flow to the hemorrhoids. 

Surgical Interventions: 

• Hemorrhoidectomy: Hemorrhoids can be surgically removed; this procedure is often saved for severe instances or after all other options have been exhausted. 
• Stapled hemorrhoidopexy: A surgical procedure that involves stapling the hemorrhoids to reduce their blood supply and repositioning prolapsed tissue. 
• Surgical interventions: They are generally reserved for individuals with large or symptomatic hemorrhoids that do not respond to conservative or minimally invasive treatments. 

Home Remedies: 

• Some individuals find relief from hemorrhoid symptoms with home remedies such as applying cold packs, using witch hazel pads, or using over-the-counter analgesics (e.g., acetaminophen or ibuprofen) for pain relief. 

Gastroenterology

Internal Medicine

Dietary Modifications: 

• Increasing dietary fiber intake: Eating a diet rich in fiber can help prevent straining and constipation by softening stools and facilitating bowel movements. 
• Adequate hydration: Drinking plenty of fluids, especially water, helps prevent dehydration and maintains soft stools. 
• Avoiding irritants: Limiting consumption of spicy foods, caffeine, alcohol, and foods that can exacerbate symptoms or irritate the gastrointestinal tract. 

Lifestyle Changes: 

• Regular exercise: Engaging in the regular physical activity, such as swimming,walking, or cycling, can promote bowel regularity and improve overall bowel function. 

• Avoiding prolonged sitting or straining: Sitting for long periods on the toilet or straining during bowel movements can exacerbate hemorrhoid symptoms. Encouraging prompt bowel movements and avoiding unnecessary straining is important. 

Sitz Baths: 

• Sitting in warm water baths, known as sitz baths, for 10-15 minutes several times a day can provide relief from pain,itching, and discomfort associated with hemorrhoids. The warm water helps to relax the anal sphincter muscles, reduce swelling, and promote healing of hemorrhoids. 

Topical Applications: 

• Witch hazel compresses: Applying witch hazel-soaked pads or compresses to the affected area which provide relief from itching, inflammation, and discomfort. 
• Cold packs: Applying ice packs or cold packs to external hemorrhoids can help reduce swelling and numb pain. 

Good Hygiene Practices: 

• Gentle cleansing: Maintaining good hygiene by gently cleaning the anal area with mild soap and water after bowel movements can help prevent irritation and reduce the risk of infection. 
• Avoiding harsh or scented hygiene products: Using gentle, unscented wipes or toilet paper can help prevent irritation and discomfort. 

Optimizing Bowel Habits: 

• Establishing a regular bowel routine: Encouraging regular bowel movements and avoiding delaying or holding in bowel movements can help prevent constipation and straining. 
• Avoiding excessive wiping: Excessive wiping or harsh wiping can irritate the anal area and worsen symptoms. Patting or gently wiping with soft, unscented toilet paper can help minimize irritation. 

Internal Medicine

Stool softeners are often recommended as part of the treatment approach for hemorrhoids, particularly when constipation is a contributing factor to the development or exacerbation of hemorrhoidal symptoms. They work by increasing the water content and softening the stool, making the bowel movements easier and less straining. Constipation is a common factor in the development and worsening of hemorrhoids. Straining during bowel movements can exacerbate symptoms and contribute to the formation of hemorrhoids. 

Hemorrhoids can cause discomfort and pain, especially during bowel movements. Softening the stool with the use of stool softeners can make the process of passing stool more comfortable for individuals with hemorrhoids. 

Docusate Sodium: Stool softeners are sometimes recommended to prevent the constipation and make bowel movements more comfortable. They are available in oral formulations. 

Anesthesiology

Internal Medicine

Topical anesthetics are occasionally used in the treatment of hemorrhoids to provide temporary relief from pain and discomfort associated with the condition. These agents work by numbing the affected area, thereby reducing the sensation of pain. The use of topical anesthetics offers temporary relief and is generally recommended for short-term use.It can be particularly helpful during acute episodes of pain or after certain procedures, such as rubber band ligation. 

Lidocaine 5% Ointment: Lidocaine is a local anesthetic which work by blocking the nerve signals in the treated area, leading to temporary numbness and pain relief. When applied topically, lidocaine can help alleviate the pain and discomfort associated with hemorrhoids. 

Gastroenterology

Internal Medicine

Mild astringents are sometimes used in the treatment of hemorrhoids to help reduce swelling and soothe irritation. Astringents work by causing the contraction of tissues, which can lead to a tightening effect.  

Witch Hazel: 

• It is a naturally occurring astringent that is made from the plant’s bark and leaves. 
• It is often used topically for its anti-inflammatory and soothing properties. 
• Witch hazel is available in various forms, including pads,wipes, creams, and liquid solutions for external application. 

Calamine Lotion: 

• Calamine lotion is a mild astringent that contains zinc oxide and ferric oxide. 
• It has soothing properties and may help alleviate itching and irritation associated with hemorrhoids. 
• Calamine lotion is typically applied externally to the affected area. 

Chamomile: 

• It is known for its soothing and anti-inflammatory properties. 
• Chamomile preparations, such as chamomile-infused wipes or ointments, may be used topically to relieve discomfort. 

Gastroenterology

Internal Medicine

Topical analgesics, which include agents designed to provide pain relief, can be used in the treatment of hemorrhoids to alleviate discomfort and improve the overall well-being of individuals experiencing pain. Topical analgesics offer temporary relief and are generally used for short-term symptom management, particularly during acute episodes of pain. They do not address the underlying causes of hemorrhoids but can improve the comfort of individuals experiencing pain. 

Acetaminophen: It is commonly known by its brand name, Tylenol, is an over-the-counter pain reliever and fever reducer. While acetaminophen can help manage pain associated with various conditions, it is not specifically indicated for the treatment of hemorrhoids. It also has antipyretic properties, which means it can help reduce fever. 

Gastroenterology

Internal Medicine

Rubber Band Ligation (RBL): 

• Rubber band ligation is a widely used and effective outpatient procedure for treating internal hemorrhoids. 
• Cutting off the hemorrhoid’s blood supply involves wrapping a rubber band around its base. The hemorrhoid shrinks as a result and eventually falls off. 
• RBL is typically used for grade II and grade III internal hemorrhoids. 

Sclerotherapy: 

• Sclerotherapy involves injecting a chemical solution (sclerosant) into the hemorrhoid, causing it to shrink. 
• If a rubber band ligation has not produced satisfactory results, this treatment is frequently done for minor internal hemorrhoids. 

Infrared Coagulation (IRC): 

• By coagulating the blood arteries supplying the hemorrhoid with infrared light, infrared coagulation causes the hemorrhoid to contract. 
• It is commonly used for treating small to medium-sized internal hemorrhoids. 

Hemorrhoidectomy: 

• It is a surgical procedure which involves the removal of hemorrhoids, typically used for larger or more severe cases. 
• It is effective for both the external and internal hemorrhoids. 
• Recovery time may be longer compared to less invasive procedures. 

Stapled Hemorrhoidopexy: 

• Stapled hemorrhoidopexy involves using a circular stapling device to remove the excess tissue and reposition the remaining tissue. 
• It is often used for treating prolapsed internal hemorrhoids. 

• This procedure may be associated with a shorter recovery time compared to traditional hemorrhoidectomy. 

Doppler-Guided Hemorrhoidal Artery Ligation (DG-HAL): 

• DG-HAL involves using a Doppler ultrasound to locate the arteries supplying blood to the hemorrhoids. These arteries are then ligated, reducing blood flow to the hemorrhoids. 
• This procedure is less invasive than traditional hemorrhoidectomy. 

Laser Coagulation: 

• Laser coagulation uses laser energy to shrink and coagulate the blood vessels supplying the hemorrhoids. 
• It is often used for treating smaller internal hemorrhoids. 

Cryotherapy: 

• Cryotherapy involves freezing the hemorrhoid using liquid nitrogen or a cryoprobe, leading to its destruction. 
• It is a less commonly used procedure but may be considered in certain cases. 

Gastroenterology

Internal Medicine

Phase 1: Lifestyle Modifications and Conservative Measures: 

• Dietary Changes: It is possible to soften stools and avoid constipation by increasing your diet of fiber through whole grains, legumes, fruits, and vegetables. 
• Hydration: Drinking plenty of water helps maintain soft stools and supports overall digestive health. 
• Regular Exercise: Physical activity promotes regular bowel movements and reduces the risk of constipation. 
• Avoiding Straining: Encouraging proper bowel habits, avoiding prolonged sitting, and minimizing straining during bowel movements are crucial. 

Phase 2: Over-the-Counter (OTC) Medications and Topical Treatments: 

• Topical Analgesics and Anti-Inflammatory Agents: Over-the-counter creams, ointments, or wipes containing ingredients like hydrocortisone, witch hazel, or lidocaine can provide relief from pain, itching, and inflammation. 

• Stool Softeners: Over-the-counter stool softeners, such as docusate sodium, can help prevent constipation and reduce straining during bowel movements. 
• Sitz Baths: Warm water baths, also known as sitz baths, applied to the anal region many times a day for ten to fifteen minutes will help reduce feelings of discomfort. 

Phase 3: Prescription Medications and Procedures: 

• Prescription-Strength Medications: For more severe symptoms, prescription medications, including stronger corticosteroids or vasoconstrictors, may be considered under the guidance of a healthcare professional. 
• Minimally Invasive Procedures: If conservative measures and medications do not provide sufficient relief, procedures such as rubber band ligation, sclerotherapy, or infrared coagulation may be recommended. 
• Surgical Interventions: In cases of severe hemorrhoids or when other treatments have failed, surgical interventions like hemorrhoidectomy or stapled hemorrhoidopexy may be considered. 

Phase 4: Post-Treatment Management and Prevention: 

• Follow-up Care: It’s critical to schedule routine check-ups with a healthcare professional to assess treatment efficacy and manage any persistent problems. 
• Preventive Measures: Continuing with a high-fiber diet, maintaining good hydration, and adopting healthy bowel habits can help prevent recurrence. 
• Lifestyle Maintenance: Long-term lifestyle changes, including regular exercise and avoiding factors that contribute to hemorrhoids, are essential for preventing future episodes.