This fact sheet is for people who have hemorrhoids.

Hemorrhoids are areas in the anal canal where the tissue, which contains lots of blood vessels, has become swollen. Around half the population of the UK will have suffered from hemorrhoids at some point.  They are common in all age groups from mid-teens onwards and particularly common in pregnant women.


Hemorrhoids look like round pink swellings, the size of a pea or a grape. Sometimes they are a blue color.

Hemorrhoids can be internal, inside the anus, or external, and be seen and felt on the outside of the anus. You can have internal and external hemorrhoids at the same time.

Internal hemorrhoids
Internal hemorrhoids are classified according to their position.

* First-degree (or grade 1) hemorrhoids are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the anus.
* Second-degree (or grade 2) hemorrhoids are larger and stick out (or prolapse) from the anus when you go to the toilet, but return afterwards.
* Third-degree (or grade 3) hemorrhoids are similar, but hang out from the anus and only return inside when pushed back with a finger.
* Fourth-degree (or grade 4) hemorrhoids permanently hang down from the anus and you cannot push them back inside.

External hemorrhoids

An external hemorrhoid (perianal hematoma) is a small lump that develops on the outside edge of the anus. They are less common than internal haemorrhoids.

Symptom.
Common symptoms include:

* blood from the anus, which you may notice on toilet paper, coating the stool or in the toilet after you have opened your bowels
* itchiness around your anal area
* pain and discomfort after you have opened your bowels
* a slimy discharge of mucus
* a feeling that your bowels have not completely emptied

There are conditions other than hemorrhoids that can cause bleeding from the anus. If you notice bleeding for more than six weeks then you should get medical advice.
Possible complications

If you have pain in your anus, this may mean that a complication has occurred and you should get medical advice. Complications include:

* strangulation - when a pile that sticks out of the body (prolapsed pile) swells considerably and the blood flowing into it cannot return to the body.
* thrombosis - if the blood in the swollen pile clots, forming a thrombosed pile.
* gangrene (tissue death) - if there is a lack of blood supply to a pile.
* infection - where an abscess may form around the rectum and anus causing pain and swelling.

Causes
The exact way hemorrhoids form is controversial but it may be linked to excess pressure in the anus and lower rectum. The rectum is at the end of your colon and is where feces collect before they are expelled through your anus as a bowel movement.

You have an increased risk of getting hemorrhoids if you:

* strain to empty your bowels when constipated
* have chronic diarrhea
* are pregnant - as the weight of the fetus on your abdomen and the increased blood flow, as well as the effect of hormones on the blood vessels, can increase pressure
* have a family history of hemorrhoids - hemorrhoids can run in families and are potentially hereditary, perhaps because of weak veins in the anal area
* have varicose veins - many people with these also develop hemorrhoids, although hemorrhoids are not varicose veins
* have cancer or growths in the pelvis or bowel, which may exert pressure in a similar way to a pregnancy

Hemorrhoids are not caused by sitting on cold hard surfaces, prolonged standing or sedentary work.

Diagnosis
Your doctor will ask you about your symptoms and will examine you.

Your doctor may also carry out a rectal examination, where he or she will gently insert a gloved finger into your anus. Internal hemorrhoids cannot normally be felt in this way, but the examination can reveal other problems which will need to be excluded before a diagnosis can be made.

One of the main investigations is a proctoscopy. A small telescope known as a proctoscope will be passed into your anus. This allows your doctor to see any internal hemorrhoids. Some GPs may be trained to use a proctoscope, but it may be necessary to see a hospital specialist (usually a general or colorectal surgeon).

Another test that may be performed by either your GP or a hospital specialist is a sigmoidoscopy. A thin telescope will be inserted into your anus, so your doctor can examine your rectum and the lower part of your large bowel (sigmoid colon).

Occasionally, a test called a barium enema may be performed in a hospital. Liquid dye is passed into your large bowel, which makes your bowel show up on X-ray pictures taken of your lower abdomen.

Relieving symptoms
There are a number of treatments that aim to relieve the symptoms of hemorrhoids. They do not cure hemorrhoids.

* Regular warm baths may relieve irritation.1
* Ice packs may help reduce swelling, but do not apply ice directly to your skin.
* Soothing creams may ease symptoms such as discomfort and itchiness. These often contain agents such as bismuth subgallate and zinc oxide. These are available over-the-counter from pharmacies.
* Creams, such as lignocaine (lidocaine), contain a local anesthetic to provide short-term relief from any discomfort. These products should only be used for a few days. They are not recommended for long-term use or for children. Ask your pharmacist for advice.
* Products containing corticosteroids, such as Anugesic-HC and Proctosedyl, may reduce inflammation and pain. They should only be used for up to seven days as they may be harmful if used long-term.

Treatment
To encourage hemorrhoids to clear up, it's important to avoid constipation. If you have regular bowel movements and avoid straining, stools will pass easily and will not put pressure on the blood vessels in the anal area. The hemorrhoids will then eventually go away without treatment after about six weeks.

Eating plenty of fiber-rich foods such as fruit, vegetables and wholegrain cereals (eg brown rice, wholemeal bread and wholemeal pasta), and drinking plenty of fluids, especially water, should keep bowel movements soft.

It may help to take a fiber supplement such as ispaghula husk (eg Fybogel) or mild laxatives such as lactulose solution (eg Regulose), which soften bowel motions. Do not use strong laxatives, such as the stimulant laxative senna, on a routine basis unless your doctor advises you to because long-term use can be harmful.

If these self-help measures do not work, you may need to be treated in a hospital with the following procedures.
Non-surgical treatments

Banding
Banding is a common treatment for second and third-degree hemorrhoids. It can also be used for first-degree hemorrhoids that have not cleared up with self-help treatment.

An elastic band is placed at the base of the pile so the blood supply to the pile is reduced. The pile then shrinks and drops off after a few days. The pile is passed with a stool and the bands fall off with time.

Up to three hemorrhoids can be treated during each procedure. It is generally successful but if it fails you can have further banding treatment.

Sclerotherapy
This is an injection of a chemical solution known as a sclerosant (which usually has phenol in it) into the hemorrhoids, which causes them to shrink. The solution is usually based on a nut oil, so always tell your doctor if you have a nut allergy. This treatment may have to be repeated once or twice.

Cryosurgery
Cryosurgery is a surgical procedure that freezes the hemorrhoids, causing them to shrink and drop off.
Light coagulation

This treatment can be used for hemorrhoids that do not stick out of the body (non-prolapsing hemorrhoids). Infrared rays are used to restrict blood flow to the hemorrhoids, causing them to shrink and drop off.
Surgical treatments
Hemorrhoidectomy

A hemorrhoidectomy is usually reserved for fourth-degree hemorrhoids or if the procedures mentioned above fail.

There are a number of techniques. The most common involves placing a tight stitch around the base of the pile to control any bleeding during the operation. Then, your surgeon will make a cut on the outer part of the pile and remove any excess tissue. The wound may be closed with dissolvable stitches. Most of the stitches will be inside your body and don't need removing.

Another technique is called circular stapled hemorrhoidectomy. A circular stapler is placed inside the rectum. It removes a ring of the rectal tissue above the hemorrhoids. This blocks the blood supply to the hemorrhoids so that they shrink.

Anal dilatation
An anal dilatation procedure to stretch the sphincter was an operation that was tried in some patients in the past. However it is rarely done as there is a high risk of fecal incontinence.

Your doctor will discuss with you which treatment is most suitable.

Prevention
A good intake of dietary fiber, plenty of fluids, especially water, and regular exercise can keep the bowel movements soft and regular, making hemorrhoids less likely.