Hemorrhoids are swollen cushions of blood vessels in and around the anus and lower rectum. Everyone has these vascular cushions naturally; they only become a problem when they enlarge, bleed, or cause pain. Roughly 1 in 4 adults worldwide will deal with hemorrhoids at some point, with the average age of onset in the early 50s, though they can appear much earlier.
What Happens Inside the Body
The anal canal contains clusters of tiny blood vessels arranged in a spongy network. Under normal conditions, these cushions help with stool control and stay neatly tucked inside. When pressure in the abdomen rises repeatedly or blood flow out of the area is restricted, these vessels become engorged and swollen. The connective tissue that normally holds them in place stretches and weakens over time, allowing the cushions to bulge or slide downward.
The veins in the rectum lack internal valves, which means blood can pool there more easily than in other parts of the body. Anything that chronically raises abdominal pressure, from straining during bowel movements to pregnancy, obesity, heavy lifting, or even sitting on the toilet for extended periods, can push blood into these vessels and keep it there. Constipation makes things worse in two ways: the straining itself increases pressure, and hard stool physically compresses the surrounding veins as it passes through.
Interestingly, the modern sitting position on a toilet plays a role too. Sitting doesn’t straighten the angle between the rectum and the anal canal the way squatting does, which means you need more effort to push stool through, generating even more pressure on those vulnerable blood vessels.
Internal vs. External Hemorrhoids
The distinction comes down to location. Internal hemorrhoids form inside the rectum, above a dividing line in the anal canal. You typically can’t see or feel them, and they rarely hurt because the tissue in that area has few pain-sensing nerves. The most common sign is painless bleeding: small amounts of bright red blood on toilet paper or in the bowl after a bowel movement. If an internal hemorrhoid swells enough, it can push through the anal opening (called prolapse), which may then cause discomfort.
External hemorrhoids develop under the skin around the anus, where there are plenty of nerve endings. They tend to cause itching, swelling, and pain. Sometimes blood pools inside an external hemorrhoid and forms a clot, creating what’s known as a thrombosed hemorrhoid. This produces a hard, discolored lump near the anus along with severe pain, swelling, and inflammation. Thrombosed hemorrhoids are not dangerous, but they can be intensely uncomfortable.
Grades of Internal Hemorrhoids
Doctors classify internal hemorrhoids into four grades based on how far they’ve slipped from their normal position:
- Grade I: The hemorrhoid bulges into the anal canal during a bowel movement but doesn’t come out of the opening.
- Grade II: The hemorrhoid pushes out during straining but slides back in on its own once you stop.
- Grade III: The hemorrhoid comes out and stays out until you push it back in manually.
- Grade IV: The hemorrhoid is permanently outside the anus and cannot be pushed back in.
This grading system guides treatment decisions. Lower grades usually respond well to home care and minor office procedures, while grades III and IV may eventually need surgery.
Common Risk Factors
Chronic constipation and prolonged straining are the most direct triggers, but several other factors raise your risk:
- Pregnancy: The growing uterus puts pressure on pelvic veins, and hormonal changes loosen connective tissue.
- Obesity: Excess weight increases baseline abdominal pressure.
- Aging: The supportive tissue around the anal cushions weakens over time.
- Prolonged sitting: Spending long stretches on the toilet (scrolling your phone, for instance) keeps steady pressure on the anal vessels.
- Heavy lifting or intense exercise: Repeated spikes in abdominal pressure stress the vascular cushions.
How Hemorrhoids Are Diagnosed
A doctor can usually identify external hemorrhoids just by looking at the area around the anus. For internal hemorrhoids, a digital rectal exam is the first step, where the doctor checks for tenderness, lumps, or blood. If more information is needed, they may use a short, lighted tube called an anoscope to see the lining of the lower rectum directly. A longer instrument (proctoscope) can examine further up the rectum and into the lower colon.
These exams are quick and generally cause only mild discomfort. In some cases, hemorrhoids are discovered incidentally during a colonoscopy done for other reasons. Because rectal bleeding can also signal more serious conditions like colorectal polyps, getting an accurate diagnosis matters, especially if you’re over 45 or have a family history of colorectal disease.
Home Care That Works
Most hemorrhoids, particularly grades I and II, improve with straightforward changes at home. A sitz bath is one of the simplest and most effective options: sit in 3 to 4 inches of warm water (around 104°F or 40°C) for 15 to 20 minutes. You can do this three to four times a day to reduce pain, itching, and swelling. A small plastic basin that fits over the toilet rim makes this easier than using a full bathtub.
Over-the-counter creams and suppositories containing ingredients that reduce itching or inflammation can help with symptoms in the short term. Applying a cold pack to the area for 10 to 15 minutes at a time also brings temporary relief from swelling. Avoid sitting on the toilet longer than necessary, and don’t strain or hold your breath during bowel movements.
The Role of Fiber
Dietary fiber is the single most effective long-term strategy for both treating and preventing hemorrhoids. Fiber softens stool and adds bulk, which means less straining and less pressure on the anal cushions. The current dietary guidelines recommend about 28 grams of fiber per day for a 2,000-calorie diet, or roughly 14 grams per 1,000 calories consumed. Most people fall well short of this target.
Good sources include beans, lentils, whole grains, fruits, and vegetables. If your current intake is low, increase it gradually over a week or two to avoid bloating and gas. Drinking plenty of water alongside fiber is important; fiber absorbs water to soften stool, and without enough fluid, it can actually make constipation worse.
Office Procedures
When home measures aren’t enough, rubber band ligation is one of the most common and effective in-office treatments for internal hemorrhoids. A small rubber band is placed around the base of the hemorrhoid, cutting off its blood supply. The tissue shrinks and falls off within a few days. About 89% of patients get significant symptom relief from the procedure. Around 78% report no discomfort afterward, while 13% experience mild discomfort and 9% have moderate discomfort lasting three or more days. Some patients notice anal pain (22%) or minor bleeding (18%) in the days following treatment.
The procedure takes only a few minutes and doesn’t require anesthesia. It works best for grade II and grade III internal hemorrhoids.
When Surgery Is Needed
For large or severe hemorrhoids (typically grade III and IV) that haven’t responded to less invasive options, surgery becomes the most reliable path. The two main approaches are traditional excisional surgery, which removes the hemorrhoid tissue entirely, and stapled surgery, which repositions the tissue and cuts off blood supply.
Stapled surgery causes less pain in the first three weeks of recovery, and patients use fewer pain medications during that window. However, both approaches have similar operating times, hospital stays, and time to return to normal activities (about six weeks). The important trade-off is durability. Traditional excisional surgery has a significantly lower recurrence rate. In a large clinical trial, patients who had stapled surgery reported roughly double the recurrence rate at both 12 and 24 months compared to those who had traditional surgery. For this reason, many surgeons favor excisional surgery when a long-term fix is the priority, despite the slightly rougher early recovery.
Preventing Recurrence
Hemorrhoids tend to come back if the underlying habits don’t change. Keeping your fiber intake at recommended levels and staying well hydrated are the most impactful daily choices. Regular physical activity helps promote consistent bowel movements. Avoid sitting on the toilet for more than a few minutes at a time, and go when you first feel the urge rather than delaying. If you do heavy lifting, exhale during the exertion rather than holding your breath, which spikes abdominal pressure. These adjustments won’t guarantee you never deal with hemorrhoids again, but they substantially reduce the odds.