Sitting on cold concrete

You may think of piles as those dreaded things your mum said you’d get if you kept sitting on cold concrete. But actually, every healthy person has piles, or haemorrhoids.

They are columns of cushioned tissue and blood vessels found close to the opening of the anus. And they help you maintain bowel continence or, to put it simply, keep your poo in.

Haemorrhoids can be either external (when they grow very close to the anus opening) or internal (when they grow further away in the anus).

Internal haemorrhoids (which we all have) can become a problem when they are swollen or inflamed.

External haemorrhoids are covered by a rich supply of pain fibres and are more likely to be associated with pain. External haemorrhoids can develop clots due to blood in them becoming stagnant and from trauma to blood vessels from straining. This can make them tender and swollen.

The exact cause of haemorrhoids isn’t entirely clear. But they are certainly common; around 50% of people have experienced symptomatic haemorrhoids at some point in their lives.

Who is most likely to get them?

Haemorrhoids can be internal or external. from .com

Many people think constipation is the main reason for haemorrhoids. Constipation means hard stools and more straining on the toilet, which can weaken the supportive tissue in the anal canal and push the haemorrhoids downwards.

Constipation does contribute to the risk of getting haemorrhoids, although one study looking at veterans in the US found diarrhoea, rather than constipation, was associated with haemorrhoids. This could also be due to straining and prolonged sitting in the bathroom.

Other factors such as sex and ethnicity affect risk. One US study found they were more common among those aged between 45-65 and reduced after the age of 65. Caucasians were found to be affected more frequently than African-Americans.

People on higher incomes are also more likely to suffer from haemorrhoids. A suggestion for why this might be the case comes from a study where a majority of patients with haemorrhoids were noted to be in occupations that involve prolonged sitting rather than manual labour.

À lire aussi : What the consistency of your poo says about your health

Haemorrhoids often occur during pregnancy and are most common in the second and third trimesters. It’s thought hormonal changes, pressure from the growing uterus, alterations in blood flow and constipation contribute to their development.

For the majority of women, haemorrhoids and their symptoms will gradually resolve after giving birth.

How do you know you have them?

We classify problematic internal haemorrhoids as fitting into four grades. Grade one haemorrhoids have no prolapse (which refers to them protruding out of the anus) and are usually painless. Bleeding may be the only symptom.

Grade two are more uncomfortable and do prolapse. But this resolves on its own. Grade three are more severe, with a prolapse that will not resolve on its own but can be manually pushed back inside.

Grade four haemorrhoids have prolapsed and cannot be pushed back manually. They are usually the most painful type.

Haemorrhoids can often be confused with anal skin tags, which are benign growths of excess skin around the anal canal.

It’s advised to not spend more than three to four minutes on the toilet. from .com

The only way to know for sure if you have haemorrhoids is to have a rectal examination by your doctor, which involves inspection of the anus at rest and during straining. An instrument that visually inspects the rectum such as a proctoscope or a colonoscope can confirm internal haemorrhoids.

How do you avoid them?

Diet and lifestyle play an important role in preventing and managing haemorrhoids. Fibre can be beneficial, mainly due to reducing constipation and straining. Combined data of seven clinical trials on haemorrhoids has shown supplementary fibre relieves symptoms and reduces risk of bleeding by around 50%.

General advice to increase oral fluid consumption, adopt regular exercise, minimise straining and the use of constipation-inducing medications (such as opioids) are sensible measures, even though there is little evidence in the medical literature to support them.

À lire aussi : Busted myths: what spiders, chewing gum and haemorrhoids have in common

A study of 100 patients in England with confirmed haemorrhoids found they spent more time defecating and reading on the toilet than age and sex matched controls (a group who didn’t have haemorrhoids). This led to a recommendation that the amount of time spent on the toilet defecating be no more than three minutes once a day.

Hygiene may be important too, as a German study found people who had more frequent baths or showers were less likely to develop external haemorrhoids with blood clots.

People who take more showers may have fewer haemorrhoids. from .com

How do you treat them?

The grade of the haemorrhoid, along with symptom severity, plays a role in medical decision making. Dietary and lifestyle changes should be introduced for all patients and can be helpful in managing symptoms for patients with grade one haemorrhoids.

A number of drugs, suppositories, creams and wipes are available too. Analgesic (pain relieving) topical creams would be a reasonable option to manage pain associated with haemorrhoids. But there is a lack of strong evidence to support a benefit for topical treatment in symptomatic haemorrhoids.

Flavonoids, a large class of plant pigments, have been shown to improve symptoms of bleeding, discharge and itch. They are taken in tablet form.

In cases where symptoms persist and for those with grade two haemorrhoids, a gatroenterologist or surgeon can use rubber band ligation, which seems to be the most effective therapy. This is where a rubber band is applied to the base of a haemorrhoid via a proctoscope or colonoscope. The band cuts off the blood supply to the haemorrhoid causing it to slough off in around one to two weeks.

If this fails, or for grade three to four haemorrhoids, the most effective therapy appears to be surgical excision or haemorrhoidectomy. There are variations in surgical techniques and it would be worth consulting a colorectal surgeon for advice on the best approach for a particular patient.


Black pepper and spicy foods can cause them: False.

Everyone has piles: True…piles are normal bodily structures, it is only when they swell that they cause problems.

Pregnancy can cause them: True… pressure from an expanding womb and a general relaxing of the pelvic muscles can cause them to swell painfully, and prolapse so they protrude from the bottom.

Napoleon had piles during the Battle of Waterloo: True, Napoleon may have done better at Waterloo had an attack of the piles not prevented him from riding his horse into battle.

Bleeding from the bottom can be a symptom: True..this is usually seen as small amounts of bright red blood on the toilet paper or surface of the motions. Occasionally, they cause severe bleeding. It is always advised to see your doctor if you experience any symptoms at all.

Piles affect at least half of the population: True.. piles are a common problem that affect at least 50% of people in the UK and Ireland, at some point in their life.

For more information on piles, including symptoms and treatment see our page: About Piles.

Useful links:

NHS choices.

Daily Express.

‘Can I Get Hemorrhoids From Sitting On a Cold Surface?’ — Ask Dr. Harry Fisch

Can I get hemorrhoids from sitting on a cold surface? If so, how can I reduce the swelling? — Lester, 39, Green Bay, WI

No, you can’t get hemorrhoids by sitting on a cold surface—although sitting for extended periods of time on any kind of surface may make hemorrhoids more likely. Hemorrhoids are swollen veins in your anus and lower rectum. They may be located inside the rectum (internal hemorrhoids) or under the skin around the anus (external hemorrhoids). Your risk of hemorrhoids is higher if you: strain during bowel movements; have chronic diarrhea or constipation; are obese; are pregnant; or engage in receptive anal intercourse.

Over-the-counter creams, ointments, suppositories or pads may provide temporary relief, but they shouldn’t be used long-term because they can be irritating or cause a rash. Since hemorrhoids are unlikely to disappear on their own, the best bet is to see a doctor. There are many quick, minimally invasive techniques for eliminating hemorrhoids, which can provide permanent relief and reduce the chances of further problems.

Dr. Harry Fisch is a board certified urologist. He’s here to answer reader questions in an effort to get guys to “man up about health.”

Hemorrhoids: FAQs for a Common Medical Condition

Medically reviewed by L. Anderson, PharmD Last updated on Jan 8, 2019.

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Introduction | Symptoms | Types | Diagnosis | Treatments and Home Remedies | Procedures | Prevention | Compare Products

What are hemorrhoids?

Talking about hemorrhoids may seem embarrassing, but it’s a common problem encountered by millions of people. Plus, it’s been one of the top medical Internet searches in years past. So let’s clear up the frequent question of what exactly are hemorrhoids?

  • Hemorrhoids are swollen and inflamed veins in the rectum or anus. Common symptoms are rectal bleeding, itching and pain. An increased pressure in the veins of the anus (such as with pregnancy or obesity) may cause or worsen the condition.
  • Hemorrhoids can occur inside the rectum (internal hemorrhoids) or near the anal opening (external hemorrhoids).
  • When a hemorrhoid pushes through the anal opening, it is known as a protruding or prolapsed hemorrhoid. External hemorrhoids can form swollen and painful blood clots.

Learn More: Common Anorectal Preparations

Are hemorrhoids serious?

Although hemorrhoids can be painful and irritating, they are not usually serious. Nonetheless, they can dramatically affect your quality of life. Today, there are many medical options to help relieve the discomfort from this condition.

  • Hemorrhoids, also called piles, have been reported to occur in roughly 1 in 20 people in the U.S. About 50% of people over the age of 50 have hemorrhoids.
  • Straining during bowel movements, usually due to constipation, is the most common cause of hemorrhoids with rectal bleeding as the most common symptom.
  • Increased anal pressure in pregnancy, diarrhea, constipation and straining during a bowel movement, those with pelvic tumors, excessive sitting or inactivity (for example: long hours at the computer), and being overweight can all increase the risk for hemorrhoids.

Typical hemorrhoid symptoms

Common symptoms of hemorrhoids can include:

  • painful bowel movements
  • rectal bleeding
  • anal itching
  • swelling of rectal tissue
  • stool leakage

Internal hemorrhoids can lead to bleeding from straining and constipation, and may push through the anal opening.

  • If you see blood after a bowel movement or have severe pain, contact your doctor to rule out a more serious condition.
  • Blood clots may also form in hemorrhoids. Bleeding hemorrhoids usually leave a bright red color on the toilet paper, in the stool or in the toilet bowl.

Types of hemorrhoids

There are two basic type of hemorrhoids. Hemorrhoids may occur on the inside or outside of the body.

  • Internal hemorrhoids occur just inside the anus at the beginning of the rectum and cannot usually be seen or felt by a doctor. These internal hemorrhoids may push through the anus and result in external hemorrhoids.
  • External hemorrhoids occur at the anal opening and may protrude outside of the anus. Both hemorrhoid types can occur at the same time. Be sure to visit your healthcare provider for a diagnosis, especially if bleeding occurs.

Hemorrhoid diagnosis

A hemorrhoid diagnosis involves a visit to the doctor, who will examine your anus and rectum. A rectal exam using a gloved finger may be conducted. If blood is seen, a procedure may be scheduled to look inside the anus (anoscopy) or the colon (sigmoidoscopy or colonoscopy).

Treatments and home remedies for hemorrhoids

Treatments for hemorrhoids such as hemorrhoid creams, ointments, sprays and suppositories can be purchased at the pharmacy. These products may contain a local anesthetic for pain, a corticosteroid for itching, or a topical vasoconstrictor to decrease swelling. Creams and ointments are used on external and internal hemorrhoids, and suppositories are used inside the rectum to treat internal hemorrhoids.

  • Talk to your healthcare provider if you need creams or suppositories for longer than one week.
  • Common OTC brands include Preparation H, Americaine, and Tronolane – although many other brands and generics are available and may cost less. Prescription products are available, too.
  • These remedies won’t cure hemorrhoids, but can offer relief.
  • Hemorrhoids may shrink and subside over time, but are always at risk of a flare-up. Preventing constipation and regular exercise is the best way to avoid flare-ups.

Treatment options: Medications for Hemorrhoids

Other options include soaking in a warm sitz bath of water only (no bubbles or oils). Moist toilettes specifically made for hemorrhoids can be used after a bowel movement. Avoid straining during a bowel movement; adding fiber and plenty of water to the diet can help alleviate constipation and straining.

Table 1: Common Hemorrhoid Treatments

Examples Treatment Type Drug Action
  • Citrucel (methylcellulose)
  • Fibercon polycarbophil)
  • Metamucil (psyllium)
  • Benefiber (wheat dextrin)
Fiber supplements and bulk-forming laxatives (OTC*) Softens hard stools; take with plenty of water; can help to prevent hemorrhoid formation.
  • docusate (Colace, Dulcolax, Surfak, generics)
Stool softeners (OTC) Softens stool and eases bowel movement; can help to prevent hemorrhoid formation.
  • pramoxine (Pramox, Tronolane)
  • dibucaine 1% (Nupercainal)
  • benzocaine 20% (Americaine)
  • lidocaine 5% (RectiCare)
  • pramoxine and zinc oxide (Tucks, Tronolane Anesthetic for Hemorrhoids)
Topical anesthetics; numbing ointment or cream for hemorrhoid pain relief (OTC) Temporarily numbs the area; use infrequently unless directed by your doctor.
  • hydrocortisone (Preparation H, Anucort-HC)

Anti-inflammatory (OTC, Rx*)

Decreases swelling, pain, itching; limit use to one week or less unless directed by your doctor.
  • hydrocortisone and pramoxine topical (Analpram, Proctofoam HC, Procort, Zypram, Pramasone, others)
Combo anti-inflammatory and pain relief medication (Rx) Decreases hemorrhoid swelling and pain, relieves itching.
  • phenylephrine rectal (Preparation H Cooling Gel, Preparation H Suppositories, others)
A decongestant used to shrink blood vessels and hemorrhoids (OTC) Relief from pain, burning, itching and discomfort, shrinks swollen hemorrhoidal tissue; clean and dry area before application.
  • witch hazel wipes, zinc oxide cream
witch hazel wipes, zinc oxide cream Helps to dry the skin, protect from irritation.

*OTC=over-the-counter; Rx=by prescription

Also avoid taking medications that can lead to constipation. Ask your pharmacist to review your medications with you to screen for this side effect. Drugs that are known as “anticholinergic” drugs can often cause or worsen constipation.

Related information:

  • Anticholinergic Drugs to Avoid in the Elderly
  • Medications for Constipation

If these actions do not seem to relieve your symptoms, it may be time to visit with your healthcare provider to discuss other options.

Hemorrhoid procedures

If an over-the-counter (OTC) hemorrhoid treatment is not effective, and the hemorrhoid causes significant pain or bleeding, you may need a minimally invasive procedure to shrink or remove the hemorrhoid.

  • Clot removal, rubber band ligation, and sclerotherapy are all options.
  • These procedures are usually performed as an outpatient in the clinic or as day surgery, and may only require a local anesthetic.

Which surgical procedures are used for the remedy of hemorrhoids? Your physician will be able to examine you and tell you about your best options. Be sure to discuss the benefits and risks and each procedure with your doctor.

Rubber band ligation

  • Rubber band ligation is the most common procedure for internal hemorrhoids and is effective in about 75% of patients.
  • A rubber band is placed on the hemorrhoid to cut off the blood supply, and in a few days the hemorrhoid dies and falls off. This procedure is usually done in the clinic.
  • Complications may include a raw area, bleeding, pain, infection, or thrombosis; however, serious complications are rare.

Laser light, infrared light, sclerotherapy

  • Laser or infrared light may be used to destroy internal hemorrhoids.
  • Another option is sclerotherapy, when a chemical injection may help the tissue to die and form a scar.

Hemorrhoid surgery

  • A hemorrhoidectomy, where excess tissue is surgically removed, can be effective in up to 95% of patients for treatment of internal and external hemorrhoids, but is usually reserved for those that do not respond to other procedures. You may receive local or general anesthesia for this surgery.
  • Pain and bleeding from your incision may occur for a few days after surgery. You will be given medication to help control pain. You may have bleeding with bowel movements for several weeks after the procedure.

Other options for internal hemorrhoids include hemorrhoid stapling and and arterial ligation.

Can hemorrhoids be prevented?

Lifestyle changes can help to prevent hemorrhoids and lessen their impact, if they do occur:

  • Avoid constipation, straining, and pushing during a bowel movement.
  • Avoid sitting for prolonged periods of time; take a break or a short walk at least every one to two hours.
  • Eat foods high in fiber, such as fresh fruits, vegetables and whole grains, or use a fiber supplement. Aim for 20 to 35 grams of fiber per day. Fiber supplements, such as Benefiber, FiberCon, or Metamucil may be needed.
  • Drink plenty of water (6 to 8 glasses of water daily) and get regular exercise, at least 20 minutes per day of brisk walking or other aerobic exercise. Talk to your doctor about the best exercise program for you.
  • When you feel an urge to have a bowel movement, do not postpone using the restroom.
  • If needed, stool softeners or laxatives can be used for constipation and may help to prevent the development of hemorrhoids. Safe, over-the-counter options are now commercially available for constipation. Ask your pharmacist for recommendations.
  • If constipation is an ongoing problem, see your doctor.
  • A lukewarm sitz bath may be used to relieve the anal area and improve blood flow.

Learn More: Look at Over the Counter (OTC) Drugs to find remedies for constipation.

What’s the bottom line on hemorrhoids?

Remember, hemorrhoids are a common topic in healthcare worth discussing with your doctor. Don’t let embarrassment get in the way.

  • Prevention is key. Staying at a normal weight, avoiding long periods of sitting, not straining during a bowel movement, preventing constipation, and adding extra fiber in your diet can help to keep hemorrhoids at bay.
  • If you see blood during a bowel movement, contact your doctor quickly to rule out any complications.
  • Consider using over-the-counter remedies and warm sitz baths for minor symptoms, but don’t hesitate to seek out advice from your doctor, too.
  • Don’t use OTC hydrocortisone hemorrhoid cream for more than one week unless your doctor approves.

Compare Products and Ask Questions

  • Compare hemorrhoidal preparations and see ratings and reviews using the Comparison Tool.
  • Join the Hemorrhoids Support Group to ask questions, review topics and keep up-to-date with the latest news on hemorrhoid diagnosis and treatment.


Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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At-Home Treatments

There are several ways to treat hemorrhoids. The best way may be to relieve the symptoms and prevent the hemorrhoids from becoming problematic. This is best done by:

  • Taking a warm tub or sitz bath several times a day in plain, warm water for about 10 minutes
  • Using ice packs to reduce swelling
  • Ensuring regular, soft bowel movements by eliminating foods that lead to constipation, adding fiber to your diet, drinking lots of fluids and exercising regularly
  • Spending less time on the toilet
  • Trying to have a bowel movement when you get the urge rather than holding it

Hemorrhoid Procedures

If your hemorrhoids do not respond to the above therapies, or are already very problematic, there are a number of other treatments options, including:

Rubber Band Ligation

Also called banding, this involves placing a very small rubber band around the base of the hemorrhoid inside the rectum. The band cuts off circulation and the hemorrhoid withers away within seven to 10 days. This leaves a scar that prevents further bleeding and prolapse. This is usually done in the office but sometimes it is done in surgery.

What to expect from banding:

  • Bleeding in seven to 10 days when the hemorrhoid falls off
  • Bleeding with bowel movements
  • A dull ache and fullness in the rectum – apply an ice pack to help relieve this
  • If you have increased pain, fever and difficulty urinating you must return to the hospital immediately for removal of the rubber band
  • Avoid aspirin and non-steroidals (Ibuprofen-type pain pills) for 10 days
  • You may return to daily activities right away


A chemical solution is injected around the blood vessel to shrink the hemorrhoid. This causes inflammation and scarring. This is done in the office but has a higher chance of only working temporarily. You may return to daily activities right away.


When hemorrhoids are severe, extensive, prolapsing or incarcerated, they may require removal by surgery known as hemorrhoidectomy. This is done under anesthesia. Because there is a risk of causing permanent damage to the sphincter – the muscle that controls your bowel movements – this operation is only done if absolutely necessary.

What to expect from hemorrhoidectomy:

  • You will experience a lot of discomfort from this procedure and you will not be able to return to regular activities for five to 10 days.
  • If you are unable to urinate after the procedure, you must call your doctor.
  • Avoid Aspirin and non-steroidal pain medications (like Ibuprofen) for 10 days.
  • Warm baths will be soothing.
  • The first several bowel movements can cause bleeding and pain. Narcotics for pain control and stool softeners will be necessary.

Thrombosed External Hemorrhoids

When an external hemorrhoid develops, it can be treated with excision, or cutting open, of the hemorrhoid or clot if you are able to be seen within the first 24 hours of pain. After that, the hemorrhoid will begin to go away on its own and cutting it open will not help it heal more quickly. Warm baths are very helpful for this.

Creams and Suppositories

You may have noticed that there is no mention of creams or suppositories in this handout. We believe that these may help but they also can cause problems. The anal area prefers to be dry and because it is a very sensitive area, it can develop allergies to some preparations.


A high-fiber diet will help you have soft, regular bowel movements. Also, the best time to have a bowel movement is when your body gives you an urge to go – this will minimize problems with hemorrhoids, fissures, itching and other common colon, rectal and anal problems.

A diet high in fiber has about 25 to 30 grams of fiber per day. For information on how to increase your fiber through diet, please see Increasing Fiber Intake. For information on using supplements, please see Fiber Supplements.

Are those hemorrhoids? Get to know the anorectal imitators

ESTES PARK, COLO. – As a colorectal surgeon, Michelle Cowan, MD, sees a steady parade of primary care referrals for surgical evaluation of hemorrhoids.

The thing is, most of the time, the referred patients don’t have hemorrhoids. They have one of the other common anorectal disorders, including anal fissure, anoperineal abscess, fistula-in-ano, or an anorectal sexually transmitted infection, according to Dr. Cowan.

Bruce Jancin/Frontline Medical News

Dr. Michelle Cowan

At a conference on internal medicine sponsored by the University of Colorado, the surgeon explained how to tell these common disorders apart, which ones can be treated appropriately in a primary care office, and who needs referral for surgery.

The diagnostic challenge stems from the fact that most common anorectal diseases – whether benign or malignant – present with the same constellation of symptoms: pain, bleeding, itching or burning, swelling, and leakage.

The quality and intensity of the pain “down under” provides a useful clue in differentiating the disorders.

“Hemorrhoids rarely cause legit pain,” said Dr. Cowan, who practices at the University of Colorado at Denver, Aurora. “Excruciating pain, where the patient will only sit on one side, that’s typically an abscess, a fissure, or an STI.”

The exceptions in the hemorrhoid realm are external thrombosed hemorrhoids, which are exceedingly painful but also readily identifiable, and incarcerated hemorrhoids, which are quite rare.

The pain associated with an anal fissure is distinct from that of an abscess or thrombosed hemorrhoid – it’s a throbbing pain lasting minutes to hours per episode.

“These are the people who won’t sit down in your office,” Dr. Cowan said.

Anal fissure is a common condition in young and middle-aged adults, and especially in peripartum women. The pathophysiology involves microtrauma, typically either because of passing rock-hard stools, diarrhea, or the rigors of childbirth, any of which can cause a break in the anal mucosa. That break causes the internal sphincter muscle to go into spasm, temporarily choking off the blood supply to the area of the fissure. Those wounds won’t heal on their own. Close to 90% of the fissures are located in the posterior midline; if the fissure is ectopic, it’s time to consider Crohn’s disease, HIV infection, tuberculosis, cancer, and other possibilities.

The patient with an anoperineal abscess presents with extreme pain, a sensation of fullness in the anus and rectum, erythema, fullness of the perineum, drainage, and sometimes fever.

“This is legit pain, like with a fissure or thrombosed hemorrhoids,” she explained. “Patients with any of these conditions can tell you exactly when they went from feeling normal to when the pain started.”

The abscess is caused by an infected anal gland. The location is most commonly perianal or ischioanal. If that’s not the suppuration site, the abscess is intersphincteric or supralevator, in which case a confirmatory CT scan is called for before proceeding with treatment.

Regardless of the suspected cause of a patient’s anorectal symptoms, any GI bleeding needs to be taken seriously. Young adults are the only segment of the population in whom the incidence of colorectal cancer is going up. In response, the American Society for Gastrointestinal Endoscopy and other groups now recommend colonoscopy for all patients older than age 40 years with GI bleeding, even if their family histories for colorectal cancer are negative and they lack other high-risk factors. For those younger than age 40 years, flexible sigmoidoscopy is recommended, even if it’s obvious that the patient has external thrombosed hemorrhoids that are bleeding.

“I tell people that I will not do hemorrhoid surgery until they have the scope,” Dr. Cowan said.

Office-based treatment of common anorectal disorders

Nonoperative treatment of anal fissures and internal hemorrhoids is all about encouraging patient adherence.

“Patient expectations are often overlooked,” according to the surgeon. “It’s rare that these patients actually need to go to surgery, but they oftentimes don’t do what we tell them to do, which is why they end up in my office.”

With anal fissure, the goal is to relax the spastic sphincter muscle, allowing the fissure to heal. That can be accomplished medically or surgically.

Medically, treatment consists of increased water intake, incorporation of more fiber in the diet, undertaking warm sitz baths a couple times a day, and application of a pea-sized amount of topical 2% diltiazem three times daily on the outside of the anus for 6-8 weeks.

“Compliance is huge. This whole thing is about consistency. Oftentimes, the reason treatment fails is people can’t do this. They feel good after about a week, so they stop before the fissure is completely healed,” she said.

The topical diltiazem must be prepared at a compounding pharmacy. It’s usually covered by insurance. Even if it’s not, an 8-week prescription costs only about $25. The drug is effective in up to 95% of patients who follow the instructions.

Topical 0.2% nitroglycerin, an alternative treatment, is less attractive because 30% of patients experience often-disabling headaches as a side effect. Topical diltiazem has a much better side effect profile, Dr. Cowan noted. If a patient shows a partial response to 6-8 weeks of topical diltiazem, it’s worth prescribing a second round. If the fissure still hasn’t healed after that, it’s time for referral to a surgeon. The options are onabotulinumtoxinA (Botox) and lateral internal sphincterotomy.

Botox is effective in 60%-80% of patients, she explained, providing temporary benefit lasting up to 3 months with a much lower risk of incontinence than with lateral internal sphincterotomy. Open and closed sphincterotomy techniques yield a similar success rate, with healing in 93% of cases.

For internal hemorrhoids, stool softeners, 25-30 g of fiber supplements per day, warm sitz baths, avoiding straining during defecation, and not loitering on the toilet are key elements in achieving symptomatic control nonoperatively.

Patients who don’t have a bathtub in which to take sitz baths can accomplish the same thing using an easily removable, commercially available device that fits over a toilet bowl.

Disposable baby wipes for adults have become the No. 1 cause of anal itching and are to be shunned by patients with internal hemorrhoids or other anorectal disorders.

“Patients often engage in excessive wiping because of the poor consistency of their bowel movements,” Dr. Cowan explained. “If they’re pasty and not coming out in one fell swoop, it leads to residue that patients appropriately feel they need to wipe multiple times to keep clean. The majority of these dipe wipes for adults are alcohol based, and even though on your exam you may see nothing, the dipe wipes cause microexcoriations of the skin. The patient itches and doesn’t know why.”

Primary care physicians can readily learn to do mucosal banding for grade II and III prolapsing hemorrhoids in the office, she noted. However, banding should never be attempted on external thrombosed hemorrhoids, though.

Surgical excisional hemorrhoidectomy is a lasting solution for such hemorrhoids, but patients need to understand that even though it’s only a 10- to 15-minute procedure performed in an outpatient setting, it’s excruciatingly painful for a week – and that’s not the end of the story.

“I tell patients to take a week off work,” the surgeon said. “And don’t sit on a donut; it pulls on the suture line. Pillows are okay. But it takes 6-8 weeks to heal, so even though they’re only in excruciating pain for about a week, they have to poop past the suture line, so they’ve got to avoid rock-hard stools.”

With an anoperineal abscess, first-line treatment is incision of the abscess as close as possible to the anus, followed by placement of a drain to be left in place for 7-10 days. Prophylactic antibiotics are reserved for immunosuppressed patients.

Patients need to understand up front that, 30%-50% of the time, a fistula can develop after drainage of an abscess. Indeed, abscessed anoperineal fistula is one of the most common conditions Dr. Cowan sees in the emergency department and clinic. The telltale symptoms are recurrent abscess and/or persistent drainage. Those patients need referral to a colorectal surgeon.

“Fistula-in-ano is a frustrating disease for the patient and the surgeon. As surgeons, we like to fix – and there’s really no good option,” according to Dr. Cowan.

Among the surgical treatment options are debridement followed by fibrin glue injection, an anal fistula plug, an endorectal flap closure, and ligation of the intersphincteric fistula tract, or LIFT, procedure.

Dr. Cowan reported serving as a consultant to Applied Medical.


The Facts

Hemorrhoids, also called “piles,” are swollen tissues that contain veins. They are located in the wall of the rectum and anus and may cause minor bleeding or develop small blood clots. Hemorrhoids occur when the tissues enlarge, weaken, and come free of their supporting structure. This results in a sac-like bulge that extends into the anal area.

Hemorrhoids are unique to humans – no other animal develops them. They are very common – up to 86% of people will report they have had hemorrhoids at some time in their life, though people often use this as a catch-all label for any ano-rectal problem including itching. They can occur at any age but are more common between the ages of 45 and 65. Among younger people, they are most common in women who are pregnant.

Although they can be embarrassing to talk about, anyone can get hemorrhoids, even healthy young people in good shape. They can be painful and annoying but aren’t usually serious. Hemorrhoids differ depending on their location and the amount of pain, discomfort, or aggravation they cause.

Internal hemorrhoids are located up inside the rectum. They rarely cause any pain, as this tissue doesn’t have any sensory nerves. These hemorrhoids are graded for severity according to how far and how often they protrude into the anal passage or protrude out of the anus (prolapse):

  • Grade I is small without protrusion. Painless, minor bleeding occurs from time to time after a bowel movement.
  • A grade II hemorrhoid may protrude during a bowel movement but returns spontaneously to its place afterwards.
  • In grade III, the hemorrhoid must be put back in place manually.
  • A grade IV hemorrhoid has prolapsed – it protrudes constantly and will fall out again if pushed back into the rectum. There may or may not be bleeding. Prolapsed hemorrhoids can be painful.

External hemorrhoids develop under the skin just inside the opening of the anus. The hemorrhoids may swell and the area around it may become firm and sore, turning blue or purple in colour when they get thrombosed. A thrombosed hemorrhoid is one that has formed a clot inside. This clot is not dangerous and will not spread through the body, but does cause pain and should be drained. External hemorrhoids may itch and can be very painful, especially during a bowel movement. They can also prolapse.


Hemorrhoids are caused by repeated or constant pressure on the rectal or anal veins. The most common cause of pressure usually results from straining or prolonged sitting during a bowel movement. Other factors that increase the risk for getting hemorrhoids include constipation, diarrhea, lifting heavy objects, poor posture, prolonged sitting or standing, pregnancy, anal intercourse, and being overweight. Liver damage and some food allergies can also add stress to the rectal veins.

Symptoms and Complications

External hemorrhoids most often itch, burn, or bleed, and they can be painful and swollen. They’re the most common cause of bleeding during bowel movements.

A small, painless emission of very bright red blood in the stool or on the toilet paper just after a bowel movement is a sign of an internal hemorrhoid. The blood will be on the surface of the stool only, not mixed in. In small amounts, it’s not a serious issue. If this is the first occurrence, see your doctor to confirm that hemorrhoids are the source. Visit your doctor if bleeding continues, as a constant loss of blood may lead to anemia ( a condition where there are not enough red blood cells to bring oxygen to your tissues).

Watch for pain that lasts longer than a week, blood loss along with weakness or dizziness, or infection – these are all situations that should be brought to your doctor’s attention. Your doctor should also be consulted about bleeding not brought on by a bowel movement, blood that’s dark in colour, or bleeding that is recurrent. This can signal more serious problems higher in the colon, unrelated to hemorrhoids.

Also, children under 12 should be referred to a doctor if symptoms of hemorrhoids are present.

Making the Diagnosis

No examination for hemorrhoids is complete without a digital rectal examination, where the doctor will insert a gloved finger into the rectum to examine the hemorrhoids. This helps to determine if the hemorrhoid is external or internal, and to assess the grade of internal hemorrhoids. Blood does not usually need to be drawn.

An instrument called an anoscope or a proctoscope lets the doctor see internal hemorrhoids. The examination should also include questions about lifestyle. The doctor will probably try to isolate risk factors and suggest changes.

Be sure to tell your doctor the following:

  • your health history and any family history of hemorrhoids or intestinal disease
  • your medication history, especially if it includes any blood thinning ones (e.g., clopidogrel, warfarin)*

Treatment and Prevention

A high-fibre diet with large amounts of water is the answer for grade I internal hemorrhoids and painless external hemorrhoids. This will soften the stool, decreasing constipation and straining. It will also allow the inflamed veins to decrease in size. There are also a number of creams, ointments, suppositories and wipes available without prescription that can help reduce pain and inflammation around the anus. Some of these include topical hemorrhoidal preparations that contain local anesthetics for their soothing properties. Your pharmacist can help you choose a topical application that is appropriate for your circumstances. Prescription medications can include anti-inflammatory cortisone creams.

Other useful measures include stool softeners or bulking agents to help prevent constipation. A sitz bath, used 3 or 4 times daily for 15 minutes at a time, can help to sooth symptoms. A sitz bath is a container filled with warm water that fits over a toilet bowl. Ice packs alternated with warm packs on the affected area can help dissolve a blood clot in an external hemorrhoid.

More severe hemorrhoids may require a doctor’s intervention. External hemorrhoids can be removed or drained with local anaesthetic and a scalpel by a doctor if they have developed a clot within the previous 72 hours.

Internal hemorrhoids, depending on the hemorrhoid grade, may require procedures that can either be done in the doctor’s office or require an operation. Sometimes, a hardening agent is injected into internal hemorrhoids to make them smaller and firmer. Grade I through III internal hemorrhoids may be tied off with a rubber band via rubber band ligation. This stops the blood flow and the hemorrhoids eventually die and drop off within 5 to 7 days. Electricity, lasers, heat, cold, or infrared light are also used to destroy hemorrhoids. These procedures can involve some discomfort.

A hemorrhoidectomy is a type of surgery done under anesthesia. It involves complete removal of internal hemorrhoids. It’s reserved for severe cases: those where other treatments have failed or can’t be tolerated. Hemorrhoidectomy has the lowest rate of recurrence (hemorrhoids coming back) but has the highest rate of post-surgery pain.

Here are a few tips on preventing hemorrhoids:

  • Don’t delay bowel movements, because the stool can harden.
  • Avoid straining to have a bowel movement, and don’t stay sitting on the toilet for long periods.
  • Drink at least 8 glasses of water a day.
  • Eat foods that are high in fibre and bulk, such as whole-grain foods, fresh vegetables, and fruit ­– especially prunes and bran.
  • Get plenty of exercise and don’t sit for prolonged periods of time. Try to go for walks.
  • Lose excess weight.

*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For more information on brand names, speak with your doctor or pharmacist.

All material copyright MediResource Inc. 1996 – 2020. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source:

For instance, people with fissures also experience bleeding and often mistake the condition as a problematic hemorrhoid. But fissures are associated with a sharp, severe pain during bowel movements, unlike hemorrhoids, which are associated with feelings of pressure, Husain said.


Over-the-counter remedies, such as stool softeners and anti-inflammatory ointments, can provide short-term local relief from discomfort, pain and bleeding caused by external hemorrhoids. People can also eat more fiber, drink more water and avoid straining while they’re going to the bathroom, Husain said. These measures often help enlarged hemorrhoids go away on their own, he said.

There are a few nonsurgical treatment options for internal hemorrhoids. Rubber band ligation is the most common treatment, Husain said. It involves placing a small rubber band around the base of the hemorrhoid and stopping the flow of blood to the area until it shrinks and falls off. It is more effective than other methods, though it is also associated with more post-treatment pain and complications.

Sclerotherapy, where the hemorrhoid is injected with chemicals in order shrink it, is the oldest therapy. Infrared or electrocoagulation targets the hemorrhoid by burning it and letting it slough off. It’s found to be less effective than banding and usually requires more treatments. However, it also has significantly less postoperative pain and fewer complications.

Surgical removal or stapling of the hemorrhoids may be needed if internal hemorrhoids have prolapsed or are very large, according to a review published in the Journal of American College of Surgeons. But stapling has become less popular recently, as long-term data shows that it has an increased rate of problematic recurrence, Husain said.

Doctors may also use Doppler-guided hemorrhoidal artery ligation, an ultrasound technique that identifies blood vessels feeding the hemorrhoid and cuts them off, Husain said.

“There are many techniques and procedures for the same problem,” he said. “From a patient’s perspective, the best thing is what your surgeon feels comfortable with.”


One can maintain regular bowel movement and lessen the risk of hemorrhoids by including more fiber in his or her diet, about 30 grams per day, Husain said. Laxatives, aside from bulk-forming laxatives like Fiberall and Metamucil, can lead to diarrhea, and should be avoided because they can worsen hemorrhoids. Also, one should avoid exerting too much pressure during bowel movement, according to the Mayo Clinic.

Try not sit on the toilet for too long when waiting for bowel movement and also avoid straining too hard when trying to pass a stool.

“Time yourself when you feel urge to move your bowels,” Husain said. “The cut off should be five to 10 minutes. If nothing is happening during that period, go out and come back later.”

Additional resources

  • Learn about ways to treat hemorrhoids at Medline Plus, a part of the U.S. National Institutes of Health.
  • Read about dietary and lifestyle changes for people with hemorrhoids, posted by the American Society of Colon & Rectal Surgeons.
  • Find out more about surgical procedures for hemorrhoids at The Washington Post.

This article was updated on Feb. 5, 2015 by Live Science Senior Writer, Laura Geggel, and again on Oct. 4, 2018 by Live Science Senior Writer, Mindy Weisberger.

Rectal Cancer Symptoms vs. Hemorrhoids

What Is the Treatment for Rectal Cancer?

Surgery is likely to be the only necessary step in treatment if stage I rectal cancer is diagnosed.

The risk of the cancer coming back after surgery is low, and therefore, chemotherapy is not usually offered. Sometimes, after the removal of a tumor, the doctor discovers that the tumor penetrated into the mesorectum (stage II) or that the lymph nodes contained cancer cells (stage III). In these individuals, chemotherapy and radiation therapy are offered after recovery from the surgery to reduce the chance of the cancer returning. Chemotherapy and radiation therapy given after surgery is called adjuvant therapy.

If the initial exams and tests show a person to have stage II or III rectal cancer, then chemotherapy and radiation therapy should be considered before surgery. Chemotherapy and radiation given before surgery is called neoadjuvant therapy. This therapy lasts approximately six weeks. Neoadjuvant therapy is performed to shrink the tumor so it can be more completely removed by surgery. In addition, a person is likely to tolerate the side effects of combined chemotherapy and radiation therapy better if this therapy is administered before surgery rather than afterward.

After recovery from the surgery, a person who has undergone neoadjuvant therapy should meet with the oncologist to discuss the need for more chemotherapy. If the rectal cancer is metastatic, then surgery and radiation therapy would only be performed if persistent bleeding or bowel obstruction from the rectal mass exist. Otherwise, chemotherapy alone is the standard treatment of metastatic rectal cancer. At this time, metastatic rectal cancer is not curable. However, average survival times for people with metastatic rectal cancer have lengthened over the past several years because of the introduction of new medications.


The following chemotherapy drugs may be used at various points during therapy:

  • 5-Fluorouracil (5-FU): This drug is given intravenously either as a continuous infusion using a medication pump or as quick injections on a routine schedule. This drug has direct effects on the cancer cells and is often used in combination with radiation therapy because it makes cancer cells more sensitive to the effects of radiation. Side effects include fatigue, diarrhea, mouth sores, and hand, foot, and mouth syndrome (redness, peeling, and pain in the palms of the hands and the soles of the feet).
  • Capecitabine (Xeloda): This drug is given orally and is converted by the body to a compound similar to 5-FU. Capecitabine has similar effects on cancer cells as 5-FU and can be used either alone or in combination with radiation therapy. Side effects are similar to intravenous 5-FU.
  • Leucovorin (Wellcovorin): This drug increases the effects of 5-FU and is usually administered just prior to 5-FU administration.
  • Oxaliplatin (Eloxatin): This drug is given intravenously once every two or three weeks. Oxaliplatin has recently become the most common drug to use in combination with 5-FU for the treatment of metastatic rectal cancer. Side effects include fatigue, nausea, increased risk of infection, anemia, and peripheral neuropathy (tingling or numbness of the fingers and toes). This drug may also cause a temporary sensitivity to cold temperatures up to two days after administration. Inhaling cold air or drinking cold liquids should be avoided if possible after receiving oxaliplatin.
  • Irinotecan (Camptosar, CPT-11): This drug is given intravenously once every one to two weeks. Irinotecan is also commonly combined with 5-FU. Side effects include fatigue, diarrhea, increased risk of infection, and anemia. Because both irinotecan and 5-FU cause diarrhea, this symptom can be severe and should be reported immediately to a doctor.
  • Bevacizumab (Avastin): This drug is given intravenously once every two to three weeks. Bevacizumab is an antibody to vascular endothelial growth factor (VEGF) and is given to reduce blood flow to the cancer. Bevacizumab is used in combination with 5-FU and irinotecan or oxaliplatin for the treatment of metastatic rectal cancer. Side effects include high blood pressure, nose bleeding, blood clots, and bowel perforation.
  • Cetuximab (Erbitux): This drug is given intravenously once every week. Cetuximab is an antibody to epidermal growth factor receptor (EGFR) and is given because rectal cancer has large amounts of EGFR on the cell surface. Cetuximab is used alone or in combination with irinotecan for the treatment of metastatic rectal cancer. Side effects include an allergic reaction to the medication and an acne-like rash on the skin. Clinical trials are underway to evaluate this antibody for the treatment of localized rectal cancer.
  • Vincristine (Vincasar PFS, Oncovin): The mechanism of action of this drug is not fully known; is known to inhibit cell division.
  • Panitumumab (Vectibix): This recombinant monoclonal antibody binds to human epidermal growth factor receptor (EGFR) and is used to treat colorectal cancer that has metastasized after chemotherapy treatment.

Medications are available to alleviate the side effects of chemotherapy and antibody treatments. If side effects occur, an oncologist should be notified so that they can be addressed promptly.

Home remedies do not treat rectal cancers, but some may help a patient manage side effects of the disease and treatment. For example, ginger tea may help reduce nausea and vomiting while salty crackers and sips of water may reduce diarrhea. However, patients are urged to discuss any home remedies with their doctors before using them.


Surgical removal of a tumor and/or rectum removal is the cornerstone of curative therapy for localized rectal cancer. In addition to removing the rectal tumor, removing the fat and lymph nodes in the area of a rectal tumor is also necessary to minimize the chance that any cancer cells might be left behind.

However, rectal surgery can be difficult because the rectum is in the pelvis and is close to the anal sphincter (the muscle that controls the ability to hold stool in the rectum). With more deeply invading tumors and when the lymph nodes are involved, chemotherapy and radiation therapy are usually included in the treatment course to increase the chance that all microscopic cancer cells are removed or killed.

Four types of surgeries are possible, depending on the location of the tumor in relation to the anus.

  • Transanal excision: If the tumor is small, located close to the anus, and confined only to the mucosa (innermost layer), then performing a transanal excision, where the tumor is removed through the anus, may be possible. No lymph nodes are removed with this procedure. No incisions are made in the skin.
  • Mesorectal surgery: This surgical procedure involves the careful dissection of the tumor from the healthy tissue. Mesorectal surgery is being performed mostly in Europe.
  • Low anterior resection (LAR): When the cancer is in the upper part of the rectum, then a low anterior resection is performed. This surgical procedure requires an abdominal incision, and the lymph nodes are typically removed along with the segment of the rectum containing the tumor. The two ends of the colon and rectum that are left behind can be joined, and normal bowel function can resume after surgery.
  • Abdominoperineal resection (APR): If the tumor is located close to the anus (usually within 5 cm), performing an abdominoperineal resection and removing the anal sphincter may be necessary. Lymph nodes are also removed (lymphadenectomy) during this procedure. With an abdominoperineal resection, a colostomy is necessary. A colostomy is an opening of the colon to the front of the abdomen, where feces are eliminated into a bag.

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