External and internal hemorrhoids

Hemorrhoids are thickened blood vessels in the anus and rectum (rectum).
There are two types of hemorrhoids: external and internal, depending on their location.

External hemorrhoids develop near the anus and are covered by very sensitive skin. Usually they are painless, only when a blood clot (thrombus) forms in the hemorrhoids, they become a painful and hard thickening. External hemorrhoids can bleed if they tear.

Internal hemorrhoids develop inside the anus under the wall. Painless bleeding and protrusion during bowel movements are the most common symptoms. However, internal hemorrhoids can cause severe pain if they are completely “prolapsed”, that is, they protrude from the opening and can no longer be pushed back inside.

The duration is variable; often they heal on their own when the diet is changed, in other cases they become chronic.



  1. First degree: The hemorrhoids bleed, but are not prolapsed.
  2. Second degree. The hemorrhoids have exited through the anus, but spontaneously retract again.
  3. Third degree: The hemorrhoids prolapse through the anus during the exertion of force, but it takes a handle to push them back into the canal;
  4. Fourth degree: The prolapse remains on the outside and cannot be pushed back again.

What are hemorrhoids?

The arteries that supply blood to the anus descend from the rectum, forming a dense network of blood vessels connected around the anus.
Due to the dense arterial network, the hemorrhoidal blood vessels have a large supply of arterial blood.
This explains why bright red (arterial) instead of dark red (venous) blood flows from hemorrhoids and why hemorrhoid bleeding is severe in rare cases.

The veins drain blood from the canal and hemorrhoidal veins. These veins have two directions.
The first direction goes upwards to the rectum, while the second direction goes down under the skin that surrounds the anus.

How common are hemorrhoids?

About 75 percent of people have hemorrhoids at some point in their lives. Hemorrhoids are more common in adults from 45 to 65 years of age, often they affect pregnant women, but they can also occur in young children.

Why do hemorrhoids occur more often in pregnancy?
In pregnancy, for various reasons, the likelihood of getting hemorrhoids, varicose veins on the legs, and sometimes on the external genital organs, increases.
The growth of the uterus increases the pressure on the pelvic veins and the inferior vena cava (inferior vena cava), a large vein to the right side of the body that receives blood from the lower limbs. This can slow down the return of blood from the lower half of the body, increasing pressure on the veins below the uterus, and thus leading to dilation and swelling.
Constipation is another common problem in pregnancy and can cause or worsen hemorrhoids. This happens because strong abdominal efforts during bowel movements lead to hemorrhoids.
In addition, an increased progesterone level during pregnancy causes a relaxation of the vein walls, so that they expand more easily.
Progesterone also contributes to constipation due to a slowing of intestinal peristalsis (rhythmic muscular contractions of the intestinal muscles).

How to avoid hemorrhoids?

The formation of hemorrhoids during pregnancy can be prevented.
Here are a few ways to prevent or cure hemorrhoids:

Above all, you need to prevent constipation: eat a high-fiber diet (lots of whole grains, beans, fruits and vegetables), drink plenty of water (2 liters a day) and regular exercise, even if there is only time for a short, quick walk.
Anyone suffering from constipation should ask the doctor about supplemental fiber or be prescribed a product that softens the stool.

Do not wait until the urge to defecate is urgent, do not press too hard during bowel movements, do not sit too long on the toilet, because this increases the pressure in this area

Perform daily bowling exercises (pelvic floor exercises). Perineal rehabilitation exercises promote blood circulation in the rectal area and strengthen the muscles surrounding the anus. This reduces the likelihood of hemorrhoid formation.
Strengthening muscle tone around the vagina and urethra helps the body recover after childbirth.

Avoid sitting positions and standing for long periods of time. During work, you usually have to sit, but you should get up every hour and move for a few minutes.
At home when sleeping, reading and watching TV, lie on the left side to reduce pressure in the rectal veins and support the return flow of blood from the lower part of the body.

Symptoms of hemorrhoids

The most common symptom of hemorrhoids is painless bleeding.
The blood in the stool can be bright red, you can also see it on the toilet paper or watch a light dripping into the toilet.
The bleeding usually stops on its own.
Blood in the stool during bowel movements is never normal, so you should consult the doctor.
While hemorrhoids are the most common reason for bleeding during bowel movements, other causes may also be responsible, including tumors, infections, rhagades, and inflammatory bowel diseases (ulcerative colitis and Crohn’s disease).

Other symptoms include:

  • Thin stool
  • burning
  • itching
  • Anaemia

Internal hemorrhoids

Prolapse of internal hemorrhoids occurs when the veins swell and expand from their position in the rectum through the anus.

Prolapse of internal hemorrhoids has the following characteristics:

  • you can feel a kind of lump in front of the anus;
  • the hemorrhoids can be carefully pushed back inside through the anus, this could correct their position, but does not cure the disease;
  • the hemorrhoids may continue to enlarge and swell if they cannot be pushed back inwards;
  • the prolapse can become trapped, requiring urgent medical attention.

Hemorrhoids can also cause itching or itching around the anus and a constant feeling of urge to defecate (tenesmus).

External hemorrhoids with thrombotic phenomena

External hemorrhoids with thrombotic phenomena are a very painful disease. It occurs when blood clots form in a hemorrhoidal vein, causing swelling and inflammation.
When a blood clot forms in hemorrhoids, they swell even more. The swelling leads to an increase in pain.

Usually, pain increases in the following situations:

  • during bowel movements,
  • while sitting,
  • on the bike.

A thrombosis of external hemorrhoids (thrombotic hemorrhoids) can heal on its own, but therapy is usually required for this disease.
Inflamed hemorrhoids have a bright red color, while thrombotic are bluish or purple in color.

Complications of hemorrhoids

Complications of hemorrhoids are rare, they include:

Anemia. Chronic blood loss from hemorrhoids can lead to anemia, in which there are not enough healthy red blood cells to transport oxygen to cells. Anemia can lead to exhaustion and weakness.

Strangulated hemorrhoids. If the blood supply to the internal hemorrhoids decreases, the hemorrhoids can be “strangled”. The consequences are extreme pain and tissue death (gangrene).

Causes of hemorrhoids

Common causes
Hemorrhoidal swelling and stretching of the diameter of the canal is a consequence of the death of connective tissue that supports the hemorrhoids. This is part of the normal aging process.
Diseases that increase intra-abdominal pressure can accelerate the death of connective tissue and prolapse of the canal. The vessels swell and lose their grip.

Rare causes
It is a misconception that rectal varicose veins are the cause of hemorrhoids. In patients with liver problems, varicose veins may occur because of the double blood supply to the rectum.
On endoscopic examination, it can be seen that the rectal varicose veins appear in the rectum, while the hemorrhoids are found in the anus.

Serious causes
Any cause of portal hypertension (for example, cirrhosis) can aggravate the pressure of the hemorrhoidal vein.

Predisposing factors are:

  • strain during bowel movements and constipation (constipation);
  • increase in pressure in the abdomen due to ascites and pregnancy;
  • diarrhoea (diarrhea);
  • in the premenstrual period until the onset of menstruation, there may be an exacerbation of hemorrhoids;
  • childbirth – associated with thrombosis and hemorrhoidal prolapse;
  • lifting heavy loads;
  • long sitting;
  • chronic cough;
  • Prostatitis;
  • Anal sex.

Diagnosis of hemorrhoids

The doctor can see if a patient has external hemorrhoids by simply looking at it.

Examinations and procedures for diagnosing internal hemorrhoids are:

Examination of the canal and rectum for abnormalities
In a digital rectal examination, the doctor palpates the greased rectum with his finger, which is stuck in a glove. The doctor feels for unusual changes such as protrusions. The examination can give the doctor an indication of what further examinations need to be carried out.

Visual inspection of canal and rectum
Because internal hemorrhoids are often too soft to be detected on palpation, the doctor may examine the lower parts of the colon and rectum with an anoscope, proctoscope, or sigmoidoscope.

These are instruments that allow the doctor to look at the anus and rectum.

External hemorrhoids appear like a strand and/or a dark area surrounding the anus. If the lump is painful, it means that it is a thrombosed hemorrhoid. Any type of swelling must be carefully controlled. One should not assume that it is always hemorrhoids, because there are tumors and polyps in the perianal zone that can resemble external hemorrhoids.

Diagnosis of internal hemorrhoids is easy when these hemorrhoids emerge from the anus.

Even if rectal examination with the finger can detect high internal hemorrhoids in the canal, rectal inspection is more useful to exclude rare tumors that begin in the canal and adjacent rectum.

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