What should I know about Hemorrhoids?

Hemorrhoids are dilated or enlarged veins in the area of the anal canal. Sometimes hemorrhoids are referred to as piles. This swelling of tissue can be classified as internal or external depending upon the exact location of the area that is affected. Hemorrhoids are further classified as either prolapsing or non-prolapsing.

Both types of hemorrhoids are very common and may be associated with straining at stool, pregnancy, or with cirrhosis. When internal hemorrhoids enlarge, they are generally not associated with pain. The most common complaint is bright red blood on the toilet tissue or coating the stool, and the individual may have a vague feeling of anal discomfort. It is not until an internal hemorrhoid is thrombosed, infected, or when there has been erosion of the mucosal surface that pain is a feature.

Internal hemorrhoids may be classified additionally by degree of severity. First-degree internal hemorrhoids enlarge but do not prolapse. (1) Second-degree hemorrhoids bleed and prolapse with defecation, but return spontaneously. (2) Third-degree hemorrhoids prolapse with each bowel movement and sometimes with exertion related to work or simply when standing. They can be replaced with manual manipulation. (3) Fourth-degree hemorrhoids prolapse with profuse bleeding, and great pain. (4) When prolapse is not treated, hemorrhoids will usually becomes chronic as the tissue stays stretched.


Everhart, J. E. (Ed.). (1994). Digestive diseases in the United States: Epidemiology and impact. (NIH Publication No. 94-1447).

    Incidence: 1 million new cases. Prevalence: 10.4 million people. Mortality: 17 deaths. Hospitalizations: 316,000. Physician office visits: 3.5 million. Prescriptions: 1.5 million. Disability: 52,000 people.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

The most common complaint indicating the presence of an internal hemorrhoid is bright red blood on the toilet tissue or coating the stool along with a vague feeling of discomfort around the anus. Pain generally does not occur until an internal hemorrhoid is either clotted, become infected, or when there has been a breakdown of the surface membrane. Internal hemorrhoids may bleed and temporarily slip out of place with bowel movements and sometimes with strain related to work or simply when standing. Fourth-degree hemorrhoids may slip down and not go back, may "break" and bleed extensively, and cause a lot of pain.

External hemorrhoids, because they lie under the skin, are quite often painful, particularly if there is a sudden increase in their size. These episodes result in a tender, blue swelling at the anus.

Internal hemorrhoids

  • Bright red blood on toilet paper or coating stool
  • Soft tissue that protrudes from the anus with bowel movements, but returns by itself
  • More severe cases include severe pain, bleeding
  • Protruding tissue that will not go back

External hemorrhoids

  • Pain or itching
  • Tenderness, particularly during a bowel movement
  • Tender, bluish swelling at the opening of the anus

Treatment Options


Most treatment is conservative, such as sitz baths or other forms of moist heat, suppositories, stool softeners, and bed rest. Permanently prolapsed hemorrhoids are best treated surgically, with milder degrees of prolapse being treated by banding or injection of with a drug which the physician recommends. External hemorrhoids that become acutely thrombosed are treated by incision, extraction of the clot, and compression of the incised area following clot removal. (5)

Nutritional Suplementation


Studies report an inverse relationship between dietary fiber and the incidence of hemorrhoids. (6) , (7) One double-blind study reported that increasing the amount of dietary fiber in the form of psyllium seed powder decreased both pain and bleeding in patients with hemorrhoids. (8)


In a 90-day, double-blind study, 100 patients with acutely bleeding internal hemorrhoids were randomly divided into two groups and treated with a micronized bioflavonoid product or a placebo. The primary endpoint was cessation of bleeding on the third day of treatment. Acute bleeding stopped by the third day in 40 patients (80%) who received the bioflavonoids compared with 19 (38%) who took the placebo. The treatment group had a cessation of bleeding 2.1 days faster than the patients receiving placebo. Also, continued treatment in patients with no bleeding prevented a relapse in 30 of 47 patients, compared with 12 of 30 receiving placebo. (9)

Herbal Suplementation

Gotu Kola

Gotu kola is reported to have a positive effect on tissues, specifically skin, connective tissue, lymph and mucous membranes. (10) , (11) , (12) It does not contain any caffeine and is not related in any way to kola nut. Gotu kola has been used primarily for venous insufficiency, soft tissue inflammation and infection, and for postsurgical wound healing. (13) , (14) Gotu kola has been traditionally used both topically and internally for skin conditions including psoriasis and eczema as well as hemorrhoids. (15) , (16)


Bilberry is claimed to exert a collagen stabilizing activity. (17) Collagen is responsible for the integrity of tendons, ligaments, and cartilage. In conditions such as arthritis, where the connective tissue is attacked and vascularized, bilberry may be helpful. Bilberry reportedly strengthens the cross-linking of the collagen matrix and stimulates the production of collagen. (18)


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  3. Dennison AR, et al. The management of Hemorrhoids. Am J Gastroenterol. 1989;84:475.
  4. Pray WS. Hemorrhoids. In: Nonprescription Product Therapeutics. Philadelphia: Lippincott, Williams & Wilkins; 1999:177-187.
  5. Isselbacher KJ, Epstein A. Anorectal Problems. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:1653.
  6. View Abstract: Burkitt DP. A deficiency of dietary fiber may be one cause of certain colonic and venous disorders. Am J Dig Dis. Feb1976;21(2):104-8.
  7. View Abstract: Perez-Miranda M. Effect of fiber supplements on internal bleeding hemorrhoids. Hepatogastroenterology. Nov1996;43(12):1504-7.
  8. Moesgaard F, et al. High-fiber diet reduces bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum. Jul1982;25(5):454-6.
  9. View Abstract: Misra MC, Parshad R. Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids. Br J Surg. Jul2000;87(7):868-72.
  10. View Abstract: Suguna L, et al. Effects of Centella asiatica Extract on Dermal Wound Healing in Rats. Indian J Exp Biol. 1996;34(12):1208-11.
  11. View Abstract: Hausen M. Centella asiatica (Indian Pennywort), an Effective Therapeutic But a Weak Sensitizer. Contact Dermatitis. 1993;29(4):175-79.
  12. View Abstract: Tenni R, et al. Effect of the Triterpenoid Fraction of Centella asiatica on Macromolecules of the Connective Matrix in Human Skin Fibroblast Cultures. Ital J Biochem. 1988;37(2):69-77.
  13. View Abstract: Maquart FX, et al. Stimulation of Collagen Synthesis in Fibroblast Cultures by a Triterpene Extracted from Centella asiatica. Connect Tissue Res. 1990;24(2):107-20.
  14. View Abstract: Cesarone MR, et al. The Microcirculatory Activity of Centella asiatica in Venous Insufficiency. A Double-blind Study. Minerva Cardioangiol. 1994;42(6):299-304.
  15. Natarajan S, et al. Effect of topical Hydrocotyle Asiatica in psoriasis. Indian J Dermatol. Jul1973;18(4):82-5.
  16. View Abstract: MacKay D. Hemorrhoids and varicose veins: a review of treatment options. Altern Med Rev. Apr2001;6(2):126-40.
  17. Jonadet M, et al. Anthocyanosides Extracted from Vitis vinifera, Vaccinium myrtillus and Pinus maritimus, I. Elastase-inhibiting Activities in Vitro, II. Compared Angioprotective Activities in Vivo. J Pharm Belg. 1983;38(1):41-46.
  18. Jonadet M, et al. Anthocyanosides Extracted from Vitis vinifera, Vaccinium myrtillus and Pinus maritimus, I. Elastase-inhibiting Activities in Vitro, II. Compared Angioprotective Activities in Vivo. J Pharm Belg. 1983;38(1):41-46.