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What Causes Hemorrhoids?

Written by: Simon Spichak, M.Sc

Updated: February 2nd, 2023

Hemorrhoids can be a painful and embarrassing condition that affect about two in every five people^[¹^]. While more than half of people who get hemorrhoids don’t report any symptoms, for others it causes severe itching and discomfort.

Hemorrhoids form when constipation and excessive straining lead to stretching and swelling of the cluster of veins in the rectum and anus ^[2]. While the exact cause of hemorrhoids is unknown, there are several modifiable lifestyle factors that can help you stay healthy. Fortunately, most hemorrhoids are painless and likely to resolve on their own.

What causes hemorrhoids?

There are plenty of factors that make it more likely for hemorrhoids to occur. Some are related to nutrition and the gastrointestinal tract while other factors are closely linked to metabolism and other physiological conditions. These risk factors include^[3]:

Straining and constipation^[2]: While blood vessels are elastic enough to accommodate some stretching and distention, they might not always be able to return to their original shape. The excess pressure placed on the veins in the anus and rectum could lead to them stretching permanently, causing swelling and hemorrhoids.
Low-fibre diet^[4]: Without sufficient fibre intake, stool is unable to collect water, bulk up, and become soft enough to slip and slide through the colon. Fibre is also important for feeding gut bacteria, which produces molecules called short-chain fatty acids that play an important role in gut motility and inflammation^[5].
Pregnancy^[6]: More than one in four women will experience hemorrhoids during pregnancy due to extra abdominal pressure and hormonal changes.
Obesity: This condition can cause extra abdominal pressure and is often associated with a low-fiber diet, prolonged periods of sitting and other gastrointestinal issues.
Chronic diarrhea^[²^]^,^[⁴^]: This can cause inflammation in the cells lining the anus or rectum.
Age^[2]: Hemorrhoids are more likely to develop in people between the ages of 45 to 65.

When should I see a doctor?

If you regularly notice blood in your stool, prolapse, itching, or pain, it might be time to check in with your doctor. The doctor may perform a physical examination of the anus and rectum to look for signs of hemorrhoids or prolapse^[3]. In addition to suggesting lifestyle changes and treatments, this initial appointment can rule out more severe conditions like colorectal cancer ^[3].

What’s the difference between internal and external hemorrhoids?

There are two types of hemorrhoids, categorized by their location. Internal hemorrhoids occur in the lower rectum, the terminal section of the large intestine and are usually painless.

External hemorrhoids form under the skin around the anus, causing irritation and damage to the skin. If a blood clot begins forming inside this type of hemorrhoid, it can cause significant pain. Fortunately, the clot typically dissolves and leaves behind a flap of excess skin.

Common symptoms of hemorrhoids:

When this condition is symptomatic, it may cause^[7]:

Bleeding
Pain
Anal protrusion
Itching

Classifying internal hemorrhoids

Internal hemorrhoids are further graded based on their appearance and the degree of prolapse^[2]. Prolapse is a medical term to describe when internal organs like the blood vessels beneath the anus, push out of their usual position. These grades, known as Goligher’s classification help determine the severity of the hemorrhoid.

Grade I: Internal bleeding but no prolapse
Grade II: Prolapse only occurs during straining, but goes away on its own
Grade III: Prolapse occurs during straining but requires it to be manually placed back into position
Grade IV: The blood vessels beneath the anus always remain prolapsed

Treating hemorrhoids

The initial treatment of hemorrhoids involves lifestyle changes including:

Eating more fibre: A diet containing at least 25 grams of fibre will promote healthy bowel movements and prevent constipation. If this is not possible through diet, over-the-counter fibre supplements can increase intake.
Drinking more water: This will help make stools easier to pass and prevent excess straining and constipation.
Stool softeners: This will also make stools easier to pass and prevent straining.
Warm water bath^[³^]: Also called a sitz bath, submerging the butt and hips in warm water for 20 minutes after bowel movements, and two or three additional times per day can help reduce irritation and soothe pain and swelling.

There are also many over-the-counter remedies that provide temporary relief. These preparations often include two or more of the following^[2]^,^[3]^,^[8]:

Astringents (witch hazel): Protect irritated areas and relieve sense of discomfort or burning.
Protectants (zinc oxide): Protect the skin and irritated areas to prevent dryness and provide soothing relief.
Decongestants (phenylephrine): Shrinks blood vessels to relieve burning and swelling.
Steroids: Lower swelling, redness, and itching.
Topical anesthetics: Provided targeted pain relief.

Flavonoids (diosmin for example Hemovel®): These bioactive compounds are used to reduce the pain, swelling and bleeding that come with hemorrhoids.

These products may not be right for you. Always read and follow the label.

Conclusion

Hemorrhoids are an extremely common condition characterized by the stretching or swelling of blood vessels in the anus or rectum. While this condition is often asymptomatic, it sometimes causes pain, irritation, and bleeding in the stool.

A doctor can help rule out more serious conditions and help provide you with a strategy to manage hemorrhoids: eating more fibre, drinking more water, warm baths, and stool softeners. In addition, over-the-counter treatments can provide you with the relief you need.

Hemovel® is a registered trademark owned by Norwell Consumer Healthcare Inc.

References

Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. International Journal of Colorectal Disease. 2011;27(2):215-220. doi:10.1007/s00384-011-1316-3

Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management. World Journal of Gastroenterology. 2012;18(17):2009. doi:10.3748/wjg.v18.i17.2009

Mott, T., Latimer, K., & Edwards, C. (2018). Hemorrhoids: diagnosis and treatment options. American family physician, 97(3), 172-179.

Jacobs D. Hemorrhoids. New England Journal of Medicine. 2014;371(10):944-951. doi:10.1056/nejmcp1204188 5.

Priyadarshini, Medha, et al. “Role of short chain fatty acid receptors in intestinal physiology and pathophysiology.” Comprehensive Physiology 8.3 (2018): 1091.

Staroselsky, A., Nava-Ocampo, A. A., Vohra, S., & Koren, G. (2008). Hemorrhoids in pregnancy. Canadian Family Physician, 54(2), 189-190.

American Gastroenterological Association Medical Position statement: Diagnosis and treatment of hemorrhoids . Gastroenterology. 2004;126(5):1461-1462. doi:10.1053/j.gastro.2004.03.001

Hemorrhoid cream overview, uses and alternatives – goodrx. https://www.goodrx.com/conditions/hemorrhoids/what-works-for-hemorrhoids. Accessed June 21, 2022.