What Is Hemorrhoid (Piles)?

Hemorrhoidal tissue is a normal anatomical structure in the human body. In some individuals, these structures enlarge and/or cause various complaints. Located in the anal canal, where the intestine ends and opens outward, hemorrhoidal tissue contains blood vessels, connective tissue, and small muscle fibers.

Hemorrhoids are classified into internal and external types.
Internal hemorrhoids are covered by a mucosal layer and are not sensitive to touch, pressure, or temperature (painless).
External hemorrhoids, on the other hand, are covered by highly sensitive skin and are painful.

Symptoms

Approximately 5% of the general population experience hemorrhoid-related symptoms, and around 10% of these cases require surgical treatment.
Patients may experience symptoms due to internal and/or external hemorrhoids.

Most patients presenting to a colorectal or general surgeon with anal complaints believe their symptoms are caused by hemorrhoids. However, a thorough examination by an experienced surgeon is essential for an accurate diagnosis.
Conditions with similar symptoms — such as anal fissure (tear), anal or rectal cancer, and anal fistula — must be ruled out.
Notably, nearly half of patients who believe they have hemorrhoids are ultimately diagnosed with anal fissure upon examination.

Common Hemorrhoid Symptoms

  • Bleeding during defecation

  • Feeling of tissue protrusion after bowel movements

  • Itching around the anus

  • Anal pain

  • Tender or painful swelling near the anus

Facts About Hemorrhoids

  • One of the most common diseases worldwide

  • Millions of people suffer from hemorrhoids

  • Many delay seeking treatment for years

  • The biggest fear is the “painful surgery” stigma

  • Today, hemorrhoids can be treated with painless and modern techniques

What Causes Hemorrhoids?

The exact cause is not fully known. Standing for long periods and straining during defecation increase pressure in the venous network of the anal region.
In susceptible individuals, this increased pressure causes hemorrhoidal tissue to enlarge and prolapse.

Other contributing factors include:

  • Aging

  • Chronic constipation or diarrhea

  • Pregnancy

  • Genetic predisposition

  • Straining during defecation

  • Excessive use of laxatives or enemas

  • Spending too long on the toilet (e.g., reading)

Do Hemorrhoids Cause Colon Cancer?

Hemorrhoids neither increase the risk of colon cancer nor cause it.
However, since symptoms may overlap (especially bleeding), colonoscopy may be necessary to rule out colorectal cancer.

Internal Hemorrhoids

Painless rectal bleeding or tissue prolapse is often associated with internal hemorrhoids.
Prolapse refers to hemorrhoidal tissue protruding from the anus during defecation or cleaning. It may return on its own or need to be pushed back manually.
Symptoms typically progress gradually over time and may occur intermittently.

Classification of Internal Hemorrhoids:

  • Stage 1: No prolapse

  • Stage 2: Prolapse that resolves spontaneously

  • Stage 3: Prolapse requiring manual reduction

  • Stage 4: Constant prolapse that cannot be reduced manually (often painful)

Bleeding is usually bright red, visible on toilet paper, dripping into the toilet, or streaking the stool.
Not all internal hemorrhoids bleed — some present mainly with prolapse or swelling.
Prolapsed hemorrhoids may cause itching, mucous discharge, or a sensation of incomplete evacuation.

External Hemorrhoids

External hemorrhoids usually present as painful, bluish-purple swellings around the anus that appear suddenly, often after straining.
A blood clot (thrombosis) forms under the skin, causing intense pain and pressure.
In severe cases, the overlying skin may rupture, allowing clotted blood to leak out.
Non-thrombosed external hemorrhoids may cause intermittent swelling, pressure, or discomfort.

Anal Skin Tags

Patients often notice soft, painless skin folds around the anus.
These are usually remnants of old external hemorrhoids but may also appear spontaneously.
They can cause hygiene difficulties after bowel movements but generally do not require treatment.
If large or bothersome, they can be surgically removed.

Examination

A thorough medical history and anal examination are essential for all anorectal complaints.

  • The external anal area and surrounding skin are inspected.

  • The inner rectal wall is examined by digital rectal examination.

  • An anoscopy (a small illuminated instrument inserted into the anus) is performed to evaluate hemorrhoidal structures.

Depending on findings, additional evaluations may be recommended to rule out polyps or cancer — such as sigmoidoscopy (examining the last 30–40 cm of the colon) or colonoscopy (examining the entire colon).

What Is a Hemorrhoid Crisis?

A hemorrhoid crisis occurs when a blood clot forms within an external hemorrhoid, leading to sudden, painful swelling and prolapse.
The swelling may affect a portion or the entire circumference of the anus.
This condition is extremely painful during the first few days and may require surgical intervention.

Can It Be Treated Medically?

Warm sitz baths or showers provide significant relief during symptomatic periods.
Certain medications and topical creams may help control bleeding and alleviate symptoms.

Is Painless Surgery Possible?

Yes. Early-stage hemorrhoids can be treated with non-surgical procedures.
Although some can be performed in an office setting, optimal results are achieved under surgical conditions with proper lighting and equipment.
These methods work by cutting off blood supply to hemorrhoidal tissue, allowing veins to drain and shrink.
Minimally invasive, painless techniques such as THD (Transanal Hemorrhoidal Dearterialization) and Longo (Stapled Hemorrhoidopexy) reposition prolapsed hemorrhoids and secure them in place.

When Is Open Surgery Performed?

Open hemorrhoidectomy — surgical removal of hemorrhoidal tissue — is typically reserved for advanced cases.
Since the outer anal skin is highly sensitive, pain is more common compared to non-surgical methods.
In rare cases, scarring or anal narrowing may occur after healing.
Using skin-sparing techniques reduces both pain and the risk of narrowing.

Does Surgery Really Take “Five Minutes”?

The success of any surgical procedure depends on accurate assessment, knowledge of anatomy, and selecting the appropriate technique.
While hemorrhoid surgeries are usually short, adequate time must be taken under proper conditions to ensure safe and effective treatment.

Can Hemorrhoids Be Prevented?

Yes. Eating a diet rich in fiber (especially green vegetables) and drinking 8–10 glasses of water daily can help prevent the development or progression of hemorrhoidal symptoms.
The goal is to maintain soft, well-formed stools to prevent both constipation and diarrhea, enabling comfortable bowel movements without straining.