Hemorrhoids are swollen, enlarged veins that form either inside the lower rectum or underneath the skin around the anus. For many people, symptoms such as minor bleeding, discomfort, and itching resolve on their own within a few days to a week with simple changes to diet and toilet habits. When these swollen cushions persist beyond that typical self-care window, they are considered chronic and can cause escalating physical complications.
If symptomatic hemorrhoids persist beyond a few weeks, they become a chronic disease that may require medical intervention. If underlying causes, such as chronic straining or prolonged sitting, are not addressed, the continued pressure prevents the veins from shrinking back to their normal size. This chronic inflammation and stretching of the tissue can lead to more serious physical issues.
Common Complications of Persistent Hemorrhoids
Acute thrombosis occurs when a blood clot forms inside a hemorrhoidal vein. This is most often seen in external hemorrhoids, presenting as a hard, tender, and often bluish lump near the anal opening. The sudden swelling and inflammation can cause severe pain that peaks within the first 48 hours.
Chronic, low-grade bleeding from internal hemorrhoids can eventually lead to anemia. The slow, ongoing loss of blood depletes the body’s iron stores, resulting in a reduction of healthy red blood cells. Patients may experience fatigue, weakness, and lightheadedness due to the reduced capacity to carry oxygen.
Strangulation is a severe mechanical complication affecting prolapsed internal hemorrhoids. This happens when the anal sphincter muscles involuntarily clamp down on the tissue outside the anus, cutting off the blood supply. Strangulation causes extreme pain and requires immediate medical attention, as the lack of blood flow can lead to tissue death.
After a thrombosed external hemorrhoid resolves, a residual issue can be the formation of skin tags. These benign, painless flaps of excess skin are left behind after the swelling and clot dissipate. While they do not cause medical harm, they can complicate perianal hygiene and cause persistent irritation or itching.
When to Seek Professional Evaluation
Home care measures, including increased fiber and fluid intake, are the standard first-line treatment for hemorrhoids. If symptoms of bleeding, pain, or discomfort do not improve after one to two weeks of consistent self-management, a professional evaluation is warranted. Persistent symptoms suggest the disease has progressed beyond what simple lifestyle adjustments can correct.
Sudden, severe pain, especially accompanied by a hard lump, should prompt an immediate medical visit, as this indicates a likely thrombosed hemorrhoid. Excessive or continuous rectal bleeding, or any bleeding accompanied by dizziness or faintness, is a medical emergency. Any rectal bleeding, even if minor, should always be evaluated by a healthcare provider to rule out other serious conditions, such as colorectal cancer.
Other concerning signs include a change in the color or consistency of stool, which may suggest bleeding higher in the digestive tract. The inability to manually push a prolapsed internal hemorrhoid back into the anal canal is another indication of an advanced state requiring professional intervention. A full evaluation often involves a physical exam, including an anoscopy, to grade the internal hemorrhoids and exclude other anorectal diseases that mimic symptoms.
Minimally Invasive Procedures for Chronic Hemorrhoids
For chronic hemorrhoids (Grade I, Grade II, or early Grade III) that have failed conservative management, office-based procedures are often the next step. These procedures aim to reduce the blood flow to the hemorrhoidal tissue, causing it to shrink or fall off. They are typically performed in an outpatient setting without the need for general anesthesia.
Rubber Band Ligation (RBL) is one of the most common and effective office procedures, particularly for Grade II hemorrhoids. During RBL, a small elastic band is placed around the base of the internal hemorrhoid, cutting off its blood supply. The deprived tissue then withers and falls off, typically within a week, often unnoticed by the patient.
Sclerotherapy involves injecting a chemical solution directly into the submucosal tissue surrounding the hemorrhoid. This agent causes a localized inflammatory reaction that leads to fibrosis, which shrinks the hemorrhoid and fixes the surrounding tissue to the underlying muscle layer. It is reserved for smaller, non-prolapsing Grade I and Grade II internal hemorrhoids.
Infrared Coagulation (IRC) uses a specialized device to apply short bursts of infrared light to the tissue above the hemorrhoid. This focused heat energy coagulates the vessels supplying the hemorrhoid, leading to scar tissue formation and shrinkage. IRC is a quick procedure often used for bleeding Grade I and Grade II hemorrhoids, and it can be repeated over several sessions.
Surgical Options for Recurrent Severe Cases
When chronic hemorrhoidal disease progresses to advanced Grade III or Grade IV, or when minimally invasive procedures have failed, surgical intervention is required. These procedures are reserved for the most severe cases and are performed to permanently remove or reposition the tissue.
Excisional hemorrhoidectomy involves the surgical removal of the excess hemorrhoidal tissue. This method, which can be performed using various techniques, is considered the most effective way to treat severe or recurring hemorrhoids. However, because it involves the removal of tissue in a highly sensitive area, it is associated with considerable postoperative pain and a recovery period that can last two to four weeks.
An alternative surgical approach is Stapled Hemorrhoidopexy, also known as the Procedure for Prolapse and Hemorrhoids (PPH). This technique uses a circular stapling device to excise a ring of redundant rectal mucosa above the hemorrhoidal tissue. This action lifts the hemorrhoidal cushions back into position and simultaneously interrupts the blood supply, causing the hemorrhoids to shrink. PPH is associated with less postoperative pain and a quicker return to normal activities compared to excisional hemorrhoidectomy, though it carries a slightly higher risk of recurrence and rectal prolapse.