What are Hemorrhoids?

external and internal hemorrhoidsHemorrhoids commonly called as Piles are symptomatic anal cushions, i.e., dilated blood vessel channels (vascular channels) in the anal canal.{swollen veins}

Hemorrhoids (piles) being the most common cause of bleeding through anus (rectum/anal canal) is due to downward sliding of anal cushions abnormally due to various causes (Most commonly due to straining and loss of elasticity)

It is a common anal disease {pathology}, but many patients are embarrassed to seek medical attention.

Types of Hemorrhoids

Anal Hemorrhoids are commonly classified according to the position and origin

  • Internal piles
  • External piles
  • Mixed (interno external)

Internal Hemorrhoids:

  Pile mass arises inside the anal canal and covered by mucous membrane. Based on the severity, it is graded into

  • 1st degree: piles that may bleed but doesn't come out
  • 2nd degree: piles that prolapsed during defecation (passing stools) but reduces back spontaneously
  • 3rd degree: Piles prolapsed can be reduced/replaced manually
  • 4th degree: Permanently prolapsed piles
I  Only bleeds
II  Prolapsed and reduces spontaneously
III  Requires manual replacement
IV  Permanently  prolapsed

External Hemorrhoids:

Piles that arises at the anal verge and covered by skin. It presents as prolapsed Hemorrhoids but usually asymptomatic unless secondarily thrombosed. It may also Present as a skin tag.

Thrombosed Hemorrhoids :

Any prolapsed or external Hemorrhoids may get thrombosed as a result of straining during defecation/extreme physical activity or any random event.

Patient presents in ER {Emergency room} with acute onset of Anal pain.
(A blood clot can turn ext Hemorrhoids into Purple/ blue with severe pain)

Medically (Theoretically), Hemorrhoids are classified into

  1. Primary
  2. Secondary

Primary piles - Hemorrhoids located at 3, 7, 11 o clock positions inside the anal canal
Secondary piles – one which occurs between the primary sites.

Symptoms & Signs

Majority of patients may be asymptomatic for a long time unless they spot/identify/notice
Bleeding – Most common / maybe the 1st symptom.

  • Splash in the pan (bright red fresh)
  • Dripping in the toilet
  • On wiping after passing stools
  • Bleeding during defecation
  • Pain during bowel Movements / during defecation (pain may be due to prolapse or secondary Infection or spasm)
  • Anal itching (Pruritus)
  • Perianal dermatitis
  • Mass descending per anum (Through anus)
  • Prolapse during walking/straining / extreme physical activity
  • Mucoid discharge through the anus
  • Extreme / Acute Pain when thrombosed

Hemorrhoids are usually PAINLESS if there is pain Think of complications such as Thrombosis / Prolapse or Change the diagnosis
The patient may present with signs and symptoms of anaemia due to constant blood loss (such as easy fatigability/breathlessness/tiredness/palpitations)
They may also present with symptoms of Infection (fever/chills etc.,)

Causes :

Due to pressure inside the anal canal most commonly due to constant straining and constipation

  • Pregnancy [Temporary] (Resolved after delivery – piles of pregnancy)
  • Prolonged sitting
  • Chronic diarrhoea / over purgation
  • Irritable bowel syndrome
  • High socio-economic status
  • Less fibre diet
  • Fatty / fried food intake
  • Portal hypertension (Liver disease)
  • Any mass inside the abdomen (which increases intra abdominal pressure)
  • Familial
  • Colon carcinoma (cancer)
  • Any rectal mass
  • Loss of Rectal Tone
  • Spinal Injury
  • Episiotomy during delivery
  • Rectal surgery
  • Anal sex (Intercourse)

Incidence – Men > Women (Hospital based study)
Incidence Increases with advancing age


Treatment options for Hemorrhoids are mainly based upon the clinical features and degree of Hemorrhoids as diagnosed by your consultant.

Your doctor may treat you conservatively with various lifestyle modifications and Medical methods.

Lifestyle modifications {Mostly for Grade 1st degree}

  • Home remedies - dietary changes such as High fibre diet & Less fatty/fried items
  • Plenty of water intake / Liquid diet often
  • Sitz bath {Warm water sitting}
  • Use of laxatives in case of constipation
  • Use of stool softeners
  • Local analgesic application (suppositories/creams/oils)
  • Changing defecation habits (Avoiding constipation / overpurgation)
  • Proper Anal hygiene

Minimally invasive Procedures

  • Injection sclerotherapy
  • Rubber band ligation
  • Cryotherapy
  • Photocoagulation (Infra red coagulation)
  • Laser therapy
  • Lord's dilatation of anal sphincter

Surgical Treatment for Hemorrhoids

Higher degrees of piles / Prolapsed piles require surgical management

  • Open hemorrhoidectomy
  • Closed hemorrhoidectomy
  • Whitehead hemorrhoidectomy
  • Laser, Electrocautery ablation
  • Radiofrequency ablation

[ Hemorrhoidectomy – Ligation and excision of piles ]

Surgical Treatment for piles are indicated in Third and fourth-degree Piles / second-degree piles that could not be cured by conservative methods / Fibrosed piles

What does Hemorrhoids look like?

One cannot see Internal hemorrhoid (pile mass), but they may experience discomfort in the anus / anal canal mostly during defaecation.

You may experience a mass sliding downwards during defecation which may reduce on its own or manually – Characteristic sign of Hemorrhoids. In both cases, your consultant can feel and diagnose by doing DRE (Digital Rectal Examination) or through Proctoscopy.

Some may identify a Pinkish/reddish mass which prolapsed and reduce (either Painless or painful)

Prolapse (or) lumps protruding through anus are the Real Piles.

Protrusion/prolapse with spontaneous or manual reduction is the characteristic feature of Hemorrhoidal disease.

Note: Hypertrophied anal papillae and Low rectal polyps can also prolapse, and they can also be reduced (Commonly mistaken for piles)

Hemorrhoid stages:

During Onset, Pile mass develops inside the anal canal or @ Anal verge, which presents with above-mentioned signs and symptoms.
which later on causes  Perianal dermatitis   (due to mucoid discharge)
It may get secondarily infected or may get thrombosed à which lan up in complication.

The patient may present in various stages, from minor to major according to their clinical features.

How long?

  • Seeking medical attention at the onset of very 1st symptom may resolve your problem (Following consultant's advice ) in a month or two.
  • Hemorrhoids symptom – usually go on its own
  • Patient landing up with complications or Those who need surgeries – will be improved/cured in a month or more
  • But may recur unless your consultant's advice is followed properly.
  • Doctor's plan will depend on how severe your symptoms are.
  • Simple lifestyle changes often relieve symptoms in a week

When to consult?

 Hemorrhoids are less dangerous unless otherwise thrombosed/incarcerated.

If symptoms don't go away in a week, if bleeding continues or if you have an acute onset of pain à consult to make sure of the diagnosis and further evaluation and Treatment.


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