Everything You Never Wanted to Know About Hemorrhoids

If there’s one topic that never comes up in conversation yet afflicts a large proportion of Americans, it’s hemorrhoids. At least half of U.S. adults over 50 have endured unpleasant symptoms from these swollen clusters of blood vessels in their butts. Yet even colorectal surgeons were shocked when I asked them to talk to me about the issue.

“I laughed when I got this request,” said Dr. Robert Cima, a colorectal surgeon at the Mayo Clinic in Rochester, Minn., in response to my asking if he would talk to me for this newsletter. “I was like, is this a punk call? The New York Times wants to know about hemorrhoids?”

Yes, I wanted to know about hemorrhoids. For a friend, of course. I’ll admit, however, that I should have thought twice about my decision to eat a brown lentil stew during some of my interviews.

Here’s what I learned about preventing and treating hemorrhoids after conversations with four physicians.

Understand the anatomy of hemorrhoids and look out for the symptoms.

I was surprised to learn that everyone is, in fact, born with hemorrhoidal tissue. Actually, these blood vessels that line the anus have a useful job: They help us sense what’s in the rectum, Dr. Cima said. They’re the reason that you can (usually) tell whether the pressure you’re feeling down below is gas or diarrhea or a normal bowel movement. Hemorrhoids also help to form a seal within the anus that keeps it closed, kind of like weather stripping on a door, Dr. Cima explained.

It’s only when hemorrhoids become engorged and inflamed that they cause unpleasant symptoms. Those symptoms can include itching, burning, bleeding and, sometimes, protrusion of the hemorrhoid outside of the body. Hemorrhoids get inflamed typically because of straining during bowel movements, which puts pressure on them, said Dr. Rahul Narang, a colorectal surgeon at N.Y.U. Langone Health.

Most hemorrhoids are called internal hemorrhoids, meaning that they develop inside the anus, even if they sometimes protrude. People can, more rarely, get external hemorrhoids, which affect blood vessels outside the anus. These tend to occur suddenly, and are acutely painful, Dr. Cima said — but usually go away by themselves within a week.

Even if you have hemorrhoid symptoms, you shouldn’t assume that you have hemorrhoids, said Dr. Karen Zaghiyan, a colorectal surgeon at Cedars-Sinai Medical Center in Los Angeles. Symptoms such as rectal bleeding and pain can also be caused by other problems, including anal fissures (tears in the anus), anal fistulas (infected tunnels between the anus and the skin) and rectal cancer. Doctors should conduct a rectal exam with their finger to rule out other issues, she said. If yours doesn’t, consider seeking out a specialist, such as a gastroenterologist or colorectal surgeon, who might also order an endoscopic exam such as a colonoscopy to properly diagnose the problem, Dr. Cima said.

To prevent hemorrhoids, eat fiber, drink water and don’t sit too long.

When it comes to preventing hemorrhoids, eating a high-fiber diet will almost certainly help, said Dr. Neha Mathur, a gastroenterologist at Houston Methodist Hospital. She recommended consuming 20 to 30 grams of fiber a day. My lentil stew was a wise choice for my bowels, even if I was dining at an inopportune time.

Staying hydrated can make a big difference, too, Dr. Narang said. The fiber and water make it easier to pass bowel movements, which then reduces the chances hemorrhoids will become inflamed, he explained.

Activities that increase the risk that you could become dehydrated — such as drinking lots of coffee or alcohol or engaging in vigorous exercise — can worsen symptoms, Dr. Cima said. (He highlighted bicycle riding as a particular problem, since it puts lots of pressure on the perineum, the area between the anus and the scrotum or vulva.)

It may also help to sit on the toilet for less than five minutes at a time, Dr. Zaghiyan said. “If you feel like you’ve got more to go and it’s not coming, get up and go do something else, and come back again later when you feel the urge once again,” she suggested. How you sit on the toilet matters, too: Products like the Squatty Potty — a footstool placed under your feet while sitting on the toilet — change the angle at which you sit in a way that may reduce strain, Dr. Mathur added.

Sitting for long periods of time in general can worsen hemorrhoid symptoms as well, Dr. Cima said, as can lifting heavy weights with the upper body, as doing so strains the blood vessels around the anus. He said men often come to see him with painful hemorrhoids after becoming dehydrated while doing strenuous physical activity.

Women often develop hemorrhoid symptoms during pregnancy, too, in part because as the uterus grows, it puts additional pressure on the anal region, Dr. Mathur said. Hormonal changes and prenatal vitamins also increase the chance that pregnant women will become constipated, which worsens the problem by causing women to strain while on the toilet, she said.

Again, fiber, hydration and less time spent on the toilet may help, as could a stool softener. Dr. Mathur recommended that pregnant women with hemorrhoids talk to their physicians about safe treatment options.

For mild hemorrhoids, simple treatments may help.

Doctors categorize internal hemorrhoids in stages from one to four, depending on their physical characteristics and severity. For minor hemorrhoids — grade 1 hemorrhoids, which don’t protrude outside the anus at all, and grade 2 hemorrhoids, which may protrude but then go back in by themselves — people can often get relief by following the lifestyle recommendations mentioned above. They also may feel better after sitting in a sitz bath or an Epsom salt bath for 15 minutes, Dr. Narang said. These soaks soothe the tissue and reduce inflammation.

I was surprised to learn from Dr. Cima that over-the-counter hemorrhoid lotions and gels often do not help as much as people expect them to. They might briefly ease symptoms, he said, but they don’t resolve the underlying problem.

If your hemorrhoid symptoms don’t ease, an office-based procedure could help, Dr. Narang said. One popular treatment is rubber band ligation, in which a doctor uses a tool to place a rubber band around the base of the hemorrhoid, which stops blood flow to the inflamed tissue and causes it to die and fall off within one to four days. It is fast, relatively painless and requires very little downtime for the patient, Dr. Mathur said — some people can go right back to work after the procedure. But you may need to come back in for multiple treatments. Another less common office treatment is infrared photocoagulation, in which a physician uses infrared light to cut off blood supply to the bothersome tissue, causing it to shrink.

Serious hemorrhoids can be treated with surgery.

Grade 3 and 4 internal hemorrhoids — grade 3 means the hemorrhoid protrudes outside the anus but can be manually pushed back in, and grade 4 is when it’s constantly outside the anus — sometimes require surgery.

A handful of surgical options are available. One is an excisional hemorrhoidectomy, which is the surgical removal of the hemorrhoid, Dr. Narang explained. Another option is stapled anopexy (also called stapled hemorrhoidopexy), in which a doctor removes part of the hemorrhoid and then staples it back together, reducing it to a normal size, Dr. Cima said. Some doctors instead use Doppler-guided hemorrhoidal artery ligation, which is a good choice for hemorrhoids that bleed a lot, Dr. Narang said. In this procedure, a doctor ties off the main arteries feeding the hemorrhoid, causing it to wither and fall off.

Although surgical procedures often work, they aren’t without potential downsides, Dr. Mathur said. They can have painful and longer recoveries than the office procedures and can cause fecal incontinence. Also, even after surgery, hemorrhoids can return — some surgeries, such as the artery ligation, are associated with up to a 30 percent chance of recurrence, Dr. Narang said. That’s in part because these treatments remove or kill off a portion of the body’s hemorrhoidal tissue, but leave behind the rest, which can then become engorged and inflamed, Dr. Cima said. If people don’t address the lifestyle factors that cause hemorrhoids, they are more likely to see their hemorrhoids return.

I learned quite a lot about hemorrhoids this week, and although I didn’t love the images that came to mind (especially while eating my lunch), I’m grateful to know more about how to prevent and treat them. As Dr. Zaghiyan said to me when we spoke, hemorrhoids are “not a cocktail conversation” — but I am happy that our discussion has made it into The Times.

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