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You may be surprised to learn that hemorrhoids are a normal part of our anatomy. We have both internal and external hemorrhoids, located inside the anal canal and around the anal opening, respectively. The internal hemorrhoids are a part of the blood supply to the anus and are made up of small arterial branches. External hemorrhoids are veins.

We are not aware of our hemorrhoids when they are in their normal state. They cause no symptoms. But sometimes we can develop problems because of our internal hemorrhoids. This is known as "internal hemorrhoidal disease." Such symptoms can occur occasionally ("flare ups") or may be chronic (long-term).

External hemorrhoids cause symptoms when a blood clot suddenly forms in one of the veins at the anus opening; this is known as a "thrombosed external hemorrhoid”. This blood clot results in a firm external lump that may cause anal pain and, at times, bleeding between bowel movements.

Both internal and external hemorrhoidal problems are common. There are treatment options.

What are the symptoms of internal hemorrhoidal disease?

The symptoms of internal hemorrhoidal disease include:

  • Rectal bleeding, usually bright red, during and occasionally between bowel movements
  • Anal pain, especially during or after bowel movements
  • Anal itching or burning
  • Anal area is hard to clean
  • Bulging (prolapse) of the internal hemorrhoids during bowel movements. The hemorrhoids may go back in on their own, or can be pushed back inside the anus by hand.
  • Drainage

Factors that can lead to the development of hemorrhoid problems include:

  • Straining during bowel movements or heavy lifting or vigorous activity
  • Hard or watery bowel movements
  • Sitting on the toilet for a long time (for example, while reading or playing video games)
  • A low-fiber diet
  • Pregnancy and vaginal deliveries
  • Aging

How are hemorrhoids diagnosed?

A diagnosis of a hemorrhoidal problem begins with a visit to your doctor. The doctor will ask about your symptoms and perform a physical examination of the anal area.

During an anal examination, the doctor will:

  • look at skin around the anus;
  • do a digital rectal examination, in which a gloved, lubricated finger is gently inserted into the anus; and
  • check the inside of the anal canal—where the internal hemorrhoids are located—with a short lighted probe called an anoscope.

In some cases you may need another, more extensive exam, like a colonoscopy, to make sure your symptoms are not due to any other disease in your colon or rectum.

How is internal hemorrhoidal disease treated?

Various treatments are available for internal hemorrhoidal disease. Not all people will require an office procedure or surgery.

For milder or occasional symptoms, the following treatments can help:

  • Keep stool soft and regular by increasing the amount of fiber in your diet to 30 grams/day and, if needed, by starting a fiber supplement.
  • Develop good toilet habits, such as not straining or sitting on the toilet for a long period of time. If you are constipated, a stool softener or laxative may be added after talking with your doctor.
  • Take a warm tub or sitz bath to relieve more severe pain from bowel movements.

For more severe or chronic symptoms, other options are available. The best procedure for you depends on the size of the internal hemorrhoids and how severe your symptoms are.

Techniques for treating internal hemorrhoidal disease include:

  • Rubber band ligation: Usually performed in the office without sedation, rubber band ligation involves placing rubber bands at the base of the internal hemorrhoid to cut off its blood supply, allowing it to fall off.
  • Sclerotherapy: In an office setting, a sclerosing (chemical) agent is injected into the internal hemorrhoid to create scar tissue to fix it in place.
  • Doppler-guided hemorrhoidal artery ligation: This surgical procedure, done in the operating room under general anesthesia, uses a special anal probe equipped with a Doppler device. Blood vessels leading to the internal hemorrhoids are identified and then tied off (ligated), causing them to shrink. The internal hemorrhoids can also be fixed in place with stitches.
  • Stapled hemorrhoidopexy, or Procedure for Prolapse and Hemorrhoids (PPH): Also done in the operating room, a special stapling device removes a donut of the rectal lining, which then pulls the bulging internal hemorrhoids back into the anus.
  • Excisional hemorrhoidectomy: The internal and, if appropriate, external hemorrhoids are removed by cutting them out.
  • Infrared coagulation: Coagulation of the veins feeding the hemorrhoids can be done as an outpatient procedure in the office.

In most cases, a thrombosed external hemorrhoid does not need surgery. As the blood clot dissolves, the thrombosed external hemorrhoid shrinks. If needed, the clot can be removed or the thrombosed external hemorrhoid completely cut out. This minor procedure can usually be done in the office.

How can I prevent internal hemorrhoidal disease?

Here are some ways to prevent internal hemorrhoidal disease:

  • Try to keep your stool soft and regular. Make sure you get enough fiber in your diet, about 30 grams/day, by eating fruits, vegetables, and whole grains. A fiber supplement may help you reach your fiber goal. Your doctor may suggest a stool softener or laxative.
  • Exercise regularly to help prevent constipation.
  • Maintain good toilet habits. Don't strain or sit too long on the toilet.
  • Do not delay bowel movements. Go to the toilet when you feel the urge.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 5/18/2016...#15120

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