Hemorrhoids (piles)

Everyone has hemorrhoids. They are simply normal “cushions” of tissue filled with blood vessels, found in the anal canal at the end of the rectum. They only cause symptoms when they enlarge. Many people have enlarged hemorrhoids. It is estimated that about one in two adults over the age of 30 is affected.

At a glance

  • Hemorrhoids are a normal part of the human body – they are simply natural “cushions” of tissue filled with blood vessels, found in the anal canal at the end of the rectum, just inside the anus.
  • Symptoms only occur if the hemorrhoids become enlarged.
  • Typical symptoms are itching, mucus discharge or a burning sensation in or around the anus.
  • Many people have enlarged hemorrhoids. It is estimated that about one in two adults over the age of 30 is affected.
  • The choice of treatment will depend on the size of the hemorrhoids and the severity of symptoms.

Note: The information in this article cannot and should not replace a medical consultation and must not be used for self-diagnosis or treatment.

Hemorrhoids: man sitting in a bath looking at a toilet with the seat up and holding a roll of toilet paper in his right hand.

What are hemorrhoids?

Everyone has hemorrhoids. Hemorrhoids are pads or cushions of tissue filled with blood vessels, which are arranged in a ring just inside the anus at the end of the rectum. Together with the sphincter muscle, they ensure that the anus closes properly. For example, they ensure that no stool leaks out when a person is passing wind.

When people say they “have hemorrhoids”, they usually mean enlarged hemorrhoids. Typical symptoms include itching in the anal area and bleeding during or after a bowel movement. Doctors call these problems hemorrhoidal disease.

Many people are ashamed of having enlarged hemorrhoids. They don’t feel comfortable talking about their symptoms, and may be reluctant to go to the doctor.

Some might be afraid of having a physical examination or finding out that they have a serious illness. In most cases, however, the symptoms have a harmless cause. But seeing a doctor is important in order to get the right treatment.

What are the symptoms of hemorrhoids?

Hemorrhoid problems can cause various symptoms. These typically include itching, mucus discharge or a burning sensation in the anus. Painless bleeding is common too. The main symptom is painless bleeding during or shortly after having a bowel movement.

This can happen if the thin walls of the blood vessels in hemorrhoids are damaged by hard stool or by straining too hard to pass a stool. Bleeding from hemorrhoids is usually visible as bright red or red blood, on toilet paper or in the stool. If a person has blood in their stool, it’s important for them to see a doctor rather than try to diagnose the problem themselves.

Enlarged hemorrhoids may also protrude out of the anus and can then be seen as soft lumps of tissue. This is called a protruding or prolapsed hemorrhoid. Sometimes hemorrhoids are confused with anal skin tags. Anal skin tags are small, harmless flaps of skin that grow around the anus and usually do not cause any symptoms.

Usually, pain only occurs if the hemorrhoidal disease is already very advanced. Often, however, the pain may be caused by other skin injuries in the anal area (e.g. small tears).

Larger hemorrhoids generally lead to more severe symptoms. They often cause a feeling of pressure or a sensation that there is something in the anal area. Hemorrhoids may also make sitting down very uncomfortable. People often feel that their bowel isn’t really empty, although they have just gone to the toilet.

Mucus or stool can sometimes come out by accident too, particularly when passing wind. More severe hemorrhoids can be very painful.

What are hemorrhoids?

The video below explains more about the symptoms and causes of hemorrhoid problems.

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What causes hemorrhoids?

The causes of enlarged hemorrhoids and the risk factors involved are not well understood. Research to date has failed to produce any clear answers.

It is likely that hemorrhoidal disease develops when the tissue that supports the hemorrhoids becomes weaker with age. It is also possible that enlarged hemorrhoids have a genetic component and run in families.

Various factors can make hemorrhoidal disease more likely to occur. These include:

  • hard stool
  • chronic constipation
  • frequent diarrhea
  • pregnancy and childbirth
  • being overweight/obese
Factors that increase the likelihood of developing hemorrhoidal disease include hard stool, chronic constipation, frequent diarrhea, pregnancy and childbirth, and being overweight/obese.

How common are hemorrhoids?

Hemorrhoidal disease is very common – it is estimated that over half of all adults will experience symptoms over the course of their lives.

However, many of these won’t seek medical help. Every year, about 4 out of 100 adults in Germany go to a doctor because of enlarged hemorrhoids.

Around 4% of adults in Germany see their doctor about enlarged hemorrhoids.

How do hemorrhoids go on to develop?

It’s not possible to predict the course of enlarged hemorrhoids. Symptoms caused by slightly enlarged hemorrhoids might not get any worse and might improve again. But they might get worse and hemorrhoids that are already enlarged don’t usually get smaller on their own again.

Enlarged hemorrhoids can also irritate the surrounding tissue, which, in turn, increases the risk of anal eczema in some cases. With anal eczema, the skin around the anus is red and inflamed, accompanied by itching and weeping. Small blisters and scabs may also form.

How are hemorrhoids diagnosed?

Some people with hemorrhoids are afraid of having physical examinations and the possible associated pain these may cause. However, the examinations are usually painless, though some people may find them unpleasant or embarrassing. For healthcare professionals, they are a normal part of their daily work.

At the initial consultation, the doctor will ask about the patient’s symptoms and their past medical history.

The doctor will then examine the anus manually to determine whether it is inflamed, and whether enlarged hemorrhoids protrude out of the anus when pressure is applied or are already on the outside.

This is followed by a palpation examination of the rectum, in which the doctor carefully inserts a gloved, lubricated finger into the anus. The doctor then examines the inside of the anal canal by touch. This allows the doctor to examine the sphincter muscles and the condition of the mucus lining of the anus. Various examinations might be done for further clarification. If there’s blood in the person’s stool, the doctor may suggest a colonoscopy (looking inside their bowel with a camera).

If the doctor thinks the person might have enlarged hemorrhoids, a proctoscopy is normally carried out next. This procedure takes a few minutes and is usually not painful. Here the mucus membranes lining the rectum are examined. The rectum needs to be emptied before the procedure is carried out. Laxatives, suppositories or an enema may be used for this purpose.

How are hemorrhoids treated?

The choice of treatment will depend on the size of the hemorrhoids and the severity of the symptoms.

If a person’s hemorrhoids are only slightly enlarged, avoiding constipation and changing their behavior during bowel movements might be enough to make a difference. There’s a lot of advice out there about what people can do to relieve hemorrhoid symptoms themselves – like using creams or sitz baths (shallow warm baths), or changing their diet. While some of these treatments provide temporary relief from symptoms, many have not been well tested in scientific studies.

For more detailed information, e.g., about home remedies for hemorrhoids, see gesundheitsinformation.de.

It’s a good idea to seek medical advice if the symptoms are unpleasant and distressing. Family doctors and proctologists are suitable points of contact. Proctologists are doctors who specialize in the treatment of medical conditions affecting the colon, rectum and anus.

Things to discuss with a doctor include whether surgery might help and what other treatment options are available.

Hemorrhoidal disease is classified into four different grades of severity – from 1 (mild) to 4 (severe). The following treatment options are available, depending on the severity of the hemorrhoids:

  • Grade 1 and grade 2 hemorrhoids: These can be treated using sclerotherapy, for example. Sclerotherapy involves injecting a chemical solution to reduce the blood supply to the hemorrhoids.
  • Grade 2 and grade 3 hemorrhoids: Rubber band ligation may be considered in these cases. In rubber band ligation, the hemorrhoids are tied off at the base, making them fall off after a while.
  • Grade 3 or grade 4 hemorrhoids: Surgery may be required. This involves removing the enlarged vascular cushions. Various surgical procedures can be used depending on the location and severity of the hemorrhoids.

  • Abramowitz L, Weyandt GH, Havlickova B et al. The diagnosis and management of haemorrhoidal disease from a global perspective. Aliment Pharmacol Ther. 2010 May;31 Suppl 1:1-58. doi: 10.1111/j.1365-2036.2010.04278.x. PMID: 20500735.
  • Acheson AG, Scholefield JH. Management of haemorrhoids. BMJ. 2008 Feb 16;336(7640):380-3. doi: 10.1136/bmj.39465.674745.80. PMID: 18276714; PMCID: PMC2244760.
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  • Alonso-Coello P, Guyatt GH, Heels-Ansdell D, Johanson JF, Lopez-Yarto M, Mills E et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004649. doi: 10.1002/14651858.CD004649.pub2. PMID: 16235372.
  • Deutsche Gesellschaft für Koloproktologie e.V. (DGK). Hämorrhoidalleiden. S3-Leitlinie. AWMF-Registernummer 081-007. 2019.
  • Hahn EG, Riemann FJ. Klinische Gastroenterologie. Thieme: Stuttgart 2000.

In cooperation with the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen – IQWiG).

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