Hemorrhoids

Disease Description (Causes and Symptoms)

• Definition summary: A condition caused by enlargement and prolapse of the vascular cushioning tissue around the anus (hemorrhoidal tissue) or venous congestion. It is classified into internal hemorrhoids (arising on the rectal side and prolapsing during bowel movements or causing bleeding) and external hemorrhoids (located beneath the skin outside the anus and causing a lump or pain).
• Main causes and pathophysiology: Repeated excessive pressure during bowel movements (straining), chronic constipation or diarrhea, prolonged toilet use, pelvic venous congestion caused by pregnancy and childbirth, obesity, a sedentary lifestyle, and genetic predisposition can combine to increase vascular pressure and weaken connective tissue, causing hemorrhoids to form or worsen. Internal hemorrhoids prolapse because the supporting tissue of the submucosal vascular cushions stretches and slips downward.
• Main symptoms: Bright-red bleeding during bowel movements, a foreign-body sensation or feeling of prolapse around the anus (especially after bowel movements), anal pain (particularly severe in cases of thrombosis in external hemorrhoids), itching, discharge, and discomfort that improves after a sitz bath. Symptoms range from mild bleeding to severe pain, necrosis, and anemia.

Treatment Methods

• Conservative treatment (first-line treatment)
  • Diet and lifestyle: Dietary fiber (20–30 g per day), adequate fluid intake, regular bowel habits (avoiding excessive straining), avoiding sitting on the toilet for a long time, and regular exercise.
  • Topical and medication therapy: Warm sitz baths (10–15 minutes per day), topical analgesic and anti-inflammatory ointments (limited short-term use of topical steroids), topical anesthetics (for symptom relief), suppositories/stool softeners (starch, emulsifier [docusate], or laxatives), and oral analgesics (for temporary use).
  • Medications for constipation and bowel regulation: Bulk-forming laxatives, polyoxyl (PEG), etc.
• Outpatient (non-surgical) procedures
  • Rubber band ligation: Commonly used for grade 1–2 to grade 3 internal hemorrhoids.
  • Sclerotherapy and infrared coagulation: Effective for small internal hemorrhoids.
  • Hemorrhoidal artery ligation (HAL/Doppler-guided ligation): Selectively used to reduce bleeding and prolapse.
• Emergency and surgical treatment
  • Thrombosed external hemorrhoid: If symptoms are severe, removal of the thrombus (incision and drainage/excision) within 72 hours of onset may be considered.
  • Hemorrhoidectomy (Milligan–Morgan or Ferguson, etc.): Standard treatment for severe cases (severe prolapse, recurrent bleeding, or pain) or when non-surgical treatment fails.
  • Stapled hemorrhoidopexy / PPH: Selectively used for prolapsing internal hemorrhoids, taking into account the advantages of reduced pain during bowel movements and reduced bleeding, as well as possible complications.
• Special situations
  • Pregnancy and breastfeeding: Conservative treatment is generally recommended (dietary fiber, sitz baths, and topical treatment); surgery is considered after childbirth.
• Complications and precautions
  • Complications: Excessive bleeding, infection, anal stenosis (with excessive excision or treatment), fecal incontinence (with muscle damage), and recurrence.
  • Medication and procedure-related adverse effects: Long-term use of topical steroids can cause skin atrophy; pain and bleeding may occur after band ligation. People taking anticoagulants have an increased risk of bleeding — consultation with a doctor is necessary before a procedure.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare (recommended to bring)
  • List of medications currently being taken (including anticoagulants and antiplatelet agents) and allergy history
  • History of previous surgeries and childbirth (especially recent delivery)
  • Recent test results or colonoscopy report (a copy, if available)
  • Symptom records: frequency and amount of bleeding (whether bright red), pain intensity (onset date and duration), frequency of prolapse and whether it can be reduced, and patterns of constipation or diarrhea
  • Photographs (when an external hemorrhoid frequently protrudes and is visible) — showing them with the patient’s consent may help with diagnosis
• Key items the doctor may ask about during the visit (organizing these in advance can improve consultation efficiency)
  • When the symptoms began and how they have changed
  • Bowel habits (frequency, stool form, and degree of straining)
  • Whether there is weight loss, nighttime pain, or a sudden change in bowel habits apart from the bleeding (active differential diagnosis is necessary)
  • Whether anticoagulants are being taken and other chronic diseases (such as liver disease or heart failure)

General Example Questions to Ask the Doctor

• "What is the severity of my hemorrhoids (internal/external hemorrhoids and grade), and what treatment do you recommend?"
• "In my case, how likely is it that conservative treatment alone will improve the condition?"
• "What are the advantages, disadvantages, and side effects of each treatment (topical medication, band ligation, and surgery)?"
• "What is the expected recovery period after the procedure or surgery, and when can I return to daily activities?"
• "Do I need to stop taking anticoagulants because of my hemorrhoids? What are the risks of stopping them?"

Examples of Disease-Specific Questions

• "My hemorrhoids prolapse during bowel movements. In this case, could rubber band ligation be effective, or would you recommend surgery?"
• "My hemorrhoid symptoms are severe during pregnancy. What treatment do you recommend before and after delivery? If surgery is necessary, when should it be performed?"