Hemorrhoids are common, affecting 20 to 50%¹ people and accounting for approximately four million office and emergency visits each year. If you notice blood in the toilet or on the tissue when you use the bathroom and you have pain and itching in the anal region, you may have hemorrhoids. There are two types of hemorrhoids, internal and external.
Internal hemorrhoids are usually painless, but occasionally, they prolapse and protrude through the anus outside the body. On the other hand, external hemorrhoids cause discomfort and can become thrombosed (where a blood clot forms in the hemorrhoid vein, cutting off blood supply and causing painful swelling).
An internal hemorrhoid forms inside the anal canal, in the cushiony, veiny area of the rectum that constrict the sphincter muscles when you're not going to the bathroom. While bleeding is often the only sign of internal hemorrhoids, they can cause significant discomfort if they prolapse.
External hemorrhoids are lumps of tissue that form outside the anus in response to excess pressure on the blood vessels in the region.
Infected hemorrhoids are rare, but when an infection does develop, it’s most often in a prolapsed internal hemorrhoid.
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Hemorrhoids can get infected when the blood flow to the tissue is reduced or cut off. Over time, as a hemorrhoid prolapse, clots can form that block blood flow, leading to a painful condition called a strangulated internal hemorrhoid. When blood can’t flow freely, the white blood cells that are essential for immune function can't reach the affected area, resulting in infection.
Any person with hemorrhoids can develop an infection. Similarly, anyone can get hemorrhoids. However, certain groups of people are more likely to develop the condition. Risk factors for hemorrhoids include:
As a condition that increases pressure on many parts of the body, obesity is thought to increase a person’s risk of developing hemorrhoids. However, the connections are unclear.
One study² with over 2,800 participants found no connection between increased weight and hemorrhoids when using body mass index (BMI — a number calculated using height and weight).
However, in a more extensive study³ of nearly 200,000 adults using various measurement techniques, researchers found that specific measures were associated with a higher risk in certain groups. For example, they found that higher waist circumference was associated with hemorrhoids, but only in women who’d given birth.
More research is needed to understand the relationship (or lack thereof) between obesity and hemorrhoids.
There’s less debate when it comes to constipation and hemorrhoids. Constipation can cause hemorrhoids by increasing intra-abdominal pressure and through excess force on anal cushions linked to straining.
In their review of relevant literature,⁴ one research duo identified numerous studies showing connections between constipation and hemorrhoid risk. Additionally, hard and dry stool can worsen symptoms associated with a prolapsed internal hemorrhoid.
Conventional wisdom holds that a sedentary lifestyle contributes to all sorts of ailments, including hemorrhoids, but the research presents a more complex story.
There’s evidence that a low-activity lifestyle could actually reduce the risk. However, given the multitude of benefits associated with physical activity, leading a sedentary lifestyle is far from ideal. Instead, people at risk of developing hemorrhoids should favor aerobic exercises, such as walking and swimming, that don’t place excessive pressure on sensitive areas.
Similarly, they could consider avoiding or limiting cycling, horseback riding, and weight-lifting activities that involve the Valsalva maneuver⁵ (a breathing technique associated with increased pressure comparable to straining during a bowel movement). Finally, exercises that improve abdominal and rectal muscle strength, such as yoga, may benefit people at risk of developing hemorrhoids.
Up to 35%⁶ of pregnant women, mostly in their last trimester, develop hemorrhoids. If you've ever been pregnant, you’re familiar with the constant pressure on your pelvis and constipation as your body prepares for delivery.
More blood pumping through your body means more pressure on the blood vessels. Beyond that, progesterone causes the blood vessels to relax, and a heavy uterus places exceptional pressure on rectal veins.
Additionally, emotional stress, prenatal iron supplements, and hormone fluctuation leading to digestive troubles can all increase the risk of hemorrhoids.
It’s not all bad news, though. In most cases, hemorrhoids caused by pregnancy typically resolve soon after giving birth.
People with certain health conditions may be more likely to develop hemorrhoids. For example, in their assessment of nearly 200,000 adults, researchers found that participants with high blood pressure, diabetes, and dyslipidemia (poorly-balanced lipid levels in the blood) had higher rates of hemorrhoids.
While the mechanisms are unclear, nearly 19.7%⁷ of people with HIV have perianal diseases, including hemorrhoids.
While anyone with hemorrhoids may develop an infection, it’s essential to note that infections may also result from hemorrhoid removal surgery. However, the risk is low, and doctors typically only recommend surgery when other treatment methods have failed. If your doctor suggests surgery for your hemorrhoids, the benefits likely outweigh the risks.
If you’re worried about the risk of post-surgery infection, discuss your concerns with your doctor.
Internal hemorrhoids (unless they prolapse) rarely cause discomfort. External hemorrhoids, in contrast, are usually associated with itching and burning. Other signs may include:
Swelling and redness around the rectal area
Painful bowel movements
Small amounts of blood in the toilet bowl or on the toilet paper
If you have hemorrhoids and you experience other symptoms, such as pain or a fever, your hemorrhoids may be infected. Likewise, you may have an infection if you have hemorrhoids that don’t resolve with home treatments. Consult your healthcare provider if you develop a fever, experience significant pain in the rectal area, or have hemorrhoids that aren’t healing with at-home care. An untreated infection can spread and worsen. Typical hemorrhoids rarely cause complications.
Your doctor can definitively diagnose an infected (or non-infected) hemorrhoid. They'll review your medical history and current symptoms before deciding which tests are necessary.
Your doctor feels around your rectum, internally and externally, for any unusual lumps or swelling.
A thin, lighted tube with a tiny camera is inserted into the anus to look at the anal and rectal linings.
If they suspect an infection, your doctor will confirm the diagnosis with a white blood cell count test. If they’re worried the infection has spread, they may order imaging tests or urine analysis to be sure.
There are many different treatments for hemorrhoids, and in most cases, the condition resolves with home management. Over-the-counter painkillers and topical ointments can help ease discomfort while your hemorrhoids heal. Taking a sitz bath (a warm, shallow bath with just water) a few times each day can help.
In contrast, if you suspect your hemorrhoid is infected, you should seek treatment from your doctor. If you have an infection, your doctor may recommend antibiotics and surgery to remove hemorrhoids.
Antibiotics will fight the bacteria causing the infection but won't alleviate the pain that comes with infected hemorrhoids. Home remedies that may improve comfort include:
Cold compresses or ice packs (wrapped in cloth) in the area
Over-the-counter pain relievers
Adding more fiber to your diet
The best way to prevent infected hemorrhoids is to prevent hemorrhoids from forming. The following steps can reduce your risk of developing hemorrhoids:
Don't sit on the toilet too long
Don't push too hard or strain (speak with your doctor before taking laxatives if you feel they’re necessary)
Eat well, and be sure to consume plenty of fiber
See your doctor if your hemorrhoids are exceptionally painful and don’t resolve with over-the-counter treatments and home remedies. Additionally, if you suspect you have infected hemorrhoid, a doctor can prescribe the necessary treatments to encourage healing and prevent complications.
Hemorrhoids rarely require treatment with a doctor. However, hemorrhoids can become infected, and left untreated, the infection can spread. If you have hemorrhoids that are exceptionally painful or long-lasting, or if you have symptoms of an infection, see your doctor to prevent complications and improve your comfort.
Valsalva maneuver (2022)