What causes hemorrhoids, and when should you see a doctor?

toilet paper

If you're experiencing discomfort in your anal area, one of the first things that come to mind for many of us is hemorrhoids. 

That's the big misnomer.

"Hemorrhoids are the great scapegoats for all sorts of anal issues and discomfort," says Sean Langenfeld, MD, Nebraska Medicine colon and rectal surgeon. "Because of their location, it's very difficult for most people to know what's going on with their anus so they assume it's hemorrhoids. Less than 50% of people who complain of hemorrhoids actually have hemorrhoids that cause symptoms. More often, they have other diagnoses ranging from small issues such as pruritus ani (anal itching), anal warts, or anal fissures to large issues such as abscesses, fistulas and cancers."  

If you do experience new onset bleeding, it's better to get it checked early with your primary care doctor than to wait. This will allow your doctor to rule out other alternative competing diagnoses and get you the appropriate treatment.

What are hemorrhoids?

Hemorrhoids are vascular cushions that live inside the anal canal. They are a part of normal human anatomy. Everyone is born with three of them. These internal hemorrhoids help keep the anus closed at rest, which helps with continence. Hemorrhoids can become uncomfortable when they are swollen and inflamed. Common causes include constipation and straining, prolonged sitting on the toilet, pregnancy and strenuous exercise.

Hemorrhoids fall into two categories.

Internal hemorrhoids

Internal hemorrhoids are the most common type. Despite commonly-held beliefs, hemorrhoids are not usually painful. They can cause painless, bright red bleeding and may bulge outside the anal opening, also known as prolapse, during bowel movements. If they get large enough, patients may see or feel a soft, pink bulge of tissue prolapsing out of their anus. This tissue goes back inside on its own, but sometimes it needs to be pushed back in.

External hemorrhoids

An external hemorrhoid is a soft cushion of skin-covered vascular tissue that lives just outside the anal opening. Severe straining and strenuous exercise can cause these tiny vessels to rupture, which is similar to a blood blister. The ruptured or thrombosed hemorrhoid can grow under the skin and become firm and painful. It is usually dark blue in color and often ruptures producing small dark blood clots.

While thrombosed hemorrhoids are very painful, they are not dangerous to your health and improve over time similar to a skin bruise. If the pain is severe, they can often be removed in the office by a colorectal surgeon. 

Home remedies to relieve hemorrhoids

If you suspect you may have hemorrhoids, Dr. Langenfeld suggests making the following lifestyle changes that can help relieve your symptoms usually within two to seven days:

  1. Add more fiber to your diet such as fruits, vegetables, grains and beans.
  2. Drink more water.
  3. Refrain from straining or prolonged sitting during bowel movements.
  4. Over-the-counter creams for hemorrhoids are of little benefit overall but may help temporarily ease pain and swelling.
  5. A sitz bath, which involves sitting in warm salt water for 15 to 30 minutes, can help relieve pain and swelling. 

"In many cases, a suspected case of hemorrhoids ends up being a different issue," notes Dr. Langenfeld. "If the anal symptoms do not get better in a short period of time, a visit with your doctor can help determine if another issue exists. People who are searching hemorrhoids on the Internet should try to find a reliable online resource, such as the American Society of Colon & Rectal Surgeons website. They should also be searching anal fissure since this is a much more common cause of anal complaints."

Other possible causes of hemorrhoid-like symptoms

Anal itching (pruritus ani) – itching near the anal opening due to irritation to the skin in the area. 

Anal warts – caused by the human papilloma virus (HPV), anal warts are caused from direct sexual contact with an infected person. 

Anal abscess – an infected cavity of puss near the anal opening usually caused by an infection of one of the anal glands usually inside the anal opening. 

Anal fissure – a tear in the skin just inside the anal opening usually caused by trauma to the anal canal such as a large, hard bowel movement.

Anal fistula – a small tunnel connecting a previously infected anal gland with the skin outside the anal opening usually caused by a previous anal abscess. 

When to call your doctor

"Hemorrhoids are not dangerous and typically don't turn into more severe problems, but they can be distressing and uncomfortable," says Dr. Langenfeld. "The important thing is to rule out other causes if they do not go away on their own within one to two weeks after trying some simple lifestyle changes."

If you continue to have rectal bleeding, depending on your age and risk factors, your doctor may recommend a colonoscopy to rule out other possible sources of blood loss, says Dr. Langenfeld.  

Who treats hemorrhoids

"Your primary care doctor can determine your diagnosis and help you implement lifestyle changes to alleviate your symptoms," says Dr. Langenfeld. "If symptoms linger, your primary care doctor may refer you to a gastroenterologist or colorectal surgeon for treatment."

Surgery for hemorrhoids

Hemorrhoids that cause moderate or severe symptoms may require surgery. "The most common office procedure for hemorrhoids is rubber band ligation. 

"Rubber band ligation is a safe, effective and pain-free procedure that can be performed in your doctor's office that involves placing a rubber ligature tightly around the internal hemorrhoid to cut off the blood supply," explains Dr. Langenfeld. "This will cause the hemorrhoid to shrink and eventually slough off over one to two weeks."
A severe thrombosed hemorrhoid may require excision, which can often be performed in your doctor's office. This involves making a small incision to drain the clot and usually brings significant relief, notes Dr. Langenfeld.

Need an evaluation?
Suspect you may have hemorrhoids or another type of anal issue?  Call 800.922.000 to schedule an appointment with one of our doctors.