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Understanding Hemorrhoids: Causes, Symptoms, and Treatment Options

Writer: MaytaMayta
Apr 14, 20241 min read

Updated: May 27, 2024

Aspect

Internal Hemorrhoids

External Hemorrhoids

Pathophysiology

Swollen/inflamed vascular structures in the anal canal.

It is the same as internal but can be externally visible.


"Sliding theory": Downward displacement of anal cushions due to weakened connective tissues.

Increased venous pressure and swelling in the inferior hemorrhoidal veins, rather than the downward displacement of anal cushions seen in internal hemorrhoids.

Signs & Symptoms

- Grade 1: Bleeds, no prolapse.

Typically painful if thrombosed.


- Grade 2: Prolapse during bowel movements, reduces spontaneously.

It may cause swelling and irritation.


- Grade 3: Requires manual reduction.



- Grade 4: Cannot be reduced.


Conservative Management

High-fiber diet, increased fluids, stool softeners, hydrocortisone suppositories.

Warm sitz baths, topical creams.

Specific Treatments

- Grade 1 & 2: Sclerotherapy, Rubber band ligation.

Thrombosed Hemorrhoids:


- Grade 3 &4:  Hemorrhoidectomy, Stapled hemorrhoidopexy.

- Within 72 hours: Excision.



- After 72 hours: Conservative management.


Image source: Padmavathi Gastroenterology Clinic. Available at: padmavathigastro.com

Pathophysiology of Hemorrhoids

Hemorrhoids, commonly referred to as piles, are vascular structures in the anal canal that help with stool control. They become an issue when swollen or inflamed, classified as hemorrhoidal disease. The "sliding theory" suggests that hemorrhoids develop when the anchoring connective tissues of the anal cushions deteriorate. This leads to the downward displacement of the anal cushions, which disrupts the vascular flow, causing venous dilation and the formation of hemorrhoids.


Signs and Symptoms

Internal Hemorrhoids:

  • Grade 1: May bleed but do not prolapse.

  • Grade 2: Prolapse during bowel movements but reduces spontaneously.

  • Grade 3: Prolapse during bowel movements and requires manual reduction.

  • Grade 4: Prolapse and cannot be manually reduced.

External Hemorrhoids:

  • Typically painful if thrombosed.

  • It may cause swelling and irritation around the anus.

Management of Hemorrhoids

Internal Hemorrhoids:

  • Conservative Treatment: Includes high-fiber diets, increased fluid intake, stool softeners, and topical treatments (e.g., suppositories containing hydrocortisone).

  • Grade 1 & 2 Treatments:

  • Sclerotherapy: In Grade 1, only Injection of a solution that causes the hemorrhoid to shrink.

  • Rubber Band Ligation: Placement of a tight band around the base of the hemorrhoid to cut off blood supply, causing it to fall off.

  • Grade 3 & 4 Treatments:

  • Hemorrhoidectomy: Surgical removal of excessive tissue causing bleeding and prolapse.

  • Stapled Hemorrhoidopexy: Re-sectioning of the prolapsed hemorrhoidal tissue and repositioning back to the original anatomical position.

External Hemorrhoids:

  • Conservative Treatment: Includes warm sitz baths and topical creams to ease symptoms.

  • Thrombosed External Hemorrhoids:

  • If presented within 72 hours, excision under local anesthesia can be considered to relieve pain rapidly.

  • After 72 hours, conservative management is recommended as the body gradually reabsorbs the clotted blood.

 
 
 

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Message for International Readers
Understanding My Medical Context in Thailand

By Uniqcret, M.D.
 

Dear readers,
 

My name is Uniqcret, which is my pen name used in all my medical writings. I am a Doctor of Medicine trained and currently practicing in Thailand, a developing country in Southeast Asia.
 

The medical training environment in Thailand is vastly different from that of Western countries. Our education system heavily emphasizes rote memorization—those who excel are often seen as "walking encyclopedias." Unfortunately, those who question, critically analyze, or solve problems efficiently may sometimes be overlooked, despite having exceptional clinical thinking skills.
 

One key difference is in patient access. In Thailand, patients can walk directly into tertiary care centers without going through a referral system or primary care gatekeeping. This creates an intense clinical workload for doctors and trainees alike. From the age of 20, I was already seeing real patients, performing procedures, and assisting in operations—not in simulations, but in live clinical situations. Long work hours, sometimes exceeding 48 hours without sleep, are considered normal for young doctors here.
 

Many of the insights I share are based on first-hand experiences, feedback from attending physicians, and real clinical practice. In our culture, teaching often involves intense feedback—what we call "โดนซอย" (being sliced). While this may seem harsh, it pushes us to grow stronger, think faster, and become more capable under pressure. You could say our motto is “no pain, no gain.”
 

Please be aware that while my articles may contain clinically accurate insights, they are not always suitable as direct references for academic papers, as some content is generated through AI support based on my knowledge and clinical exposure. If you wish to use the content for academic or clinical reference, I strongly recommend cross-verifying it with high-quality sources or databases. You may even copy sections of my articles into AI tools or search engines to find original sources for further reading.
 

I believe that my knowledge—built from real clinical experience in a high-intensity, under-resourced healthcare system—can offer valuable perspectives that are hard to find in textbooks. Whether you're a student, clinician, or educator, I hope my content adds insight and value to your journey.
 

With respect and solidarity,

Uniqcret, M.D.

Physician | Educator | Writer
Thailand

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