Story
Hemorrhoids
Last updated
In one pass Everyone has a few blood-rich pads inside the anal canal, called anal cushions, three of them main ones.
Educational content, not medical advice — consult a clinician.
Story path
Chapter 1
A normal structure that slipped
Everyone has a few blood-rich pads inside the anal canal, called anal cushions, three of them main ones. They are not a disease but part of the sealing system: the ring of sphincter muscle cannot close completely on its own, and the cushions fill the gap so that the anus stays tightly sealed at rest.
When the connective tissue holding the cushions in place loosens and breaks down, they swell with blood, enlarge and slide downward, and start to bleed or come out. Only then are they called hemorrhoids (piles). So hemorrhoids are not something extra that has grown; they are a structure you already had, out of place.
Their most typical sign is painless bright red bleeding with a bowel movement, dripping into the toilet or on the paper. But you can't decide on your own that bleeding is from hemorrhoids, especially over 50, or if the blood is dark, your bowel habits change, or you lose weight or become anemic: have a doctor check your bowel.
If the bleeding won't stop, there is a lot of blood or large clots, or the pain is severe, go to the emergency department now, and don't drive yourself.
When the connective tissue holding the cushions in place loosens and breaks down, they swell with blood, enlarge and slide downward, and start to bleed or come out. Only then are they called hemorrhoids (piles). So hemorrhoids are not something extra that has grown; they are a structure you already had, out of place.
Their most typical sign is painless bright red bleeding with a bowel movement, dripping into the toilet or on the paper. But you can't decide on your own that bleeding is from hemorrhoids, especially over 50, or if the blood is dark, your bowel habits change, or you lose weight or become anemic: have a doctor check your bowel.
If the bleeding won't stop, there is a lot of blood or large clots, or the pain is severe, go to the emergency department now, and don't drive yourself.
Mechanism · The cushions belong there
A study of 21 people with normal anal function broke down where resting anal pressure comes from: about 30% from steady contraction of the external sphincter (skeletal muscle), about 45% from nerve-driven internal sphincter activity, about 10% from the internal sphincter's own tone, and about 15% from the blood-filled cushions.The share looks small, but the job cannot be replaced: even when the sphincter ring tightens, a gap remains in the middle, and the cushions have to fill it for the anus to seal. Perfect continence depends on them.
That is also why the aim of treating hemorrhoids has never been to remove the cushions altogether, but to get slipped cushions back in place so they stop bleeding and prolapsing. The three main cushions sit at the right front, right back and left side of the anal canal.
lestar-1989-anal-cushions
Clinical · Internal, external, and four grades
Inside the anal canal runs a boundary called the dentate line.Internal hemorrhoids form above it, under a mucous lining with few pain nerves, so they mostly cause painless bleeding.External hemorrhoids form below it, under skin-like squamous lining with sensitive nerves, so they hurt when something goes wrong.Having both is called mixed hemorrhoids.
Internal hemorrhoids are graded by how far they come out:
Grade I: bleed but don't come out.Grade II: come out when straining and go back on their own.Grade III: come out and have to be pushed back by hand.Grade IV: stay out and can't be pushed back.
Most hemorrhoids are controlled by changing bowel habits and diet plus small office procedures (rubber band ligation is the preferred non-surgical option); surgery comes in when these fail or complications occur. Which method to use is for a doctor to decide for your situation.
Chapter 2
What makes the cushions slip
The cushions slide down under repeated downward force and slowly loosening support.
The usual suspects are constipation and long periods of straining. In the widely accepted sliding-lining theory, pushing down again and again gradually loosens the tissue that holds the cushions in place, and they slide down bit by bit. Other things that make hemorrhoids more likely: frequent heavy lifting, pregnancy, getting older, and being overweight.
There is also a modern habit: scrolling your phone on the toilet, which keeps people sitting far longer than they realize. A survey of adults having a screening colonoscopy found that people who used phones on the toilet were much more likely to sit for over 5 minutes at a time, and after adjusting for age, weight, exercise, straining and fiber intake, their risk of hemorrhoids was still about 46% higher. This was a cross-sectional study, so it shows an association, not cause and effect; but sitting less costs nothing.
What you can do: go when you feel the urge instead of holding it; don't strain; leave the phone outside, and get up when you're done.
The usual suspects are constipation and long periods of straining. In the widely accepted sliding-lining theory, pushing down again and again gradually loosens the tissue that holds the cushions in place, and they slide down bit by bit. Other things that make hemorrhoids more likely: frequent heavy lifting, pregnancy, getting older, and being overweight.
There is also a modern habit: scrolling your phone on the toilet, which keeps people sitting far longer than they realize. A survey of adults having a screening colonoscopy found that people who used phones on the toilet were much more likely to sit for over 5 minutes at a time, and after adjusting for age, weight, exercise, straining and fiber intake, their risk of hemorrhoids was still about 46% higher. This was a cross-sectional study, so it shows an association, not cause and effect; but sitting less costs nothing.
What you can do: go when you feel the urge instead of holding it; don't strain; leave the phone outside, and get up when you're done.
Numbers · A study of phones on the toilet
Researchers in Boston, US, surveyed 125 adults coming for a screening colonoscopy about their phone habits on the toilet, straining, fiber intake and exercise; hemorrhoids were judged at colonoscopy by two doctors who didn't know the survey answers.43% had hemorrhoids on colonoscopy.66% used phones on the toilet, and they were younger than non-users.37.3% of phone users sat for over 5 minutes per visit, versus 7.1% of non-users.In the adjusted analysis, phone use on the toilet was linked to about a 46% higher risk of hemorrhoids.The most common thing people read was news, then social media.
How to read it: a small, single-hospital, cross-sectional study cannot prove that phones cause hemorrhoids, and the more likely explanation is sitting longer. It points the same way as standard advice: don't read on the toilet, and don't sit there longer than you need to.
Chapter 3
Don't assume bleeding is piles
Bleeding from hemorrhoids has a typical look: during or after a bowel movement, bright red blood drips into the toilet or shows on the paper, without pain. It is bright red because hemorrhoid tissue has arteries connecting directly into veins.
But that is only typical, not a diagnosis. Polyps and cancers of the colon and rectum also bleed, and the blood alone can't tell them apart. In primary care studies, about 2.4% of people over 40 who saw a doctor for rectal bleeding turned out to have colorectal cancer; pooled across studies of people over 50, about 8.1%. The share is not high, but this is exactly why doctors check the bowel when someone has rectal bleeding.
Painless rectal bleeding at any age deserves a doctor's visit soon. In these situations, even more so, don't treat it as just piles:
New rectal bleeding after 50.Bleeding that doesn't look like typical hemorrhoid bleeding, such as dark blood or blood mixed into the stool.A change in bowel habits (thinner stools, a different frequency, a constant feeling of not having finished).Weight loss, or a finding of anemia or a positive fecal occult blood test.
Whether and when to have a colonoscopy is for a doctor to decide based on your age and symptoms (see constipation).
But that is only typical, not a diagnosis. Polyps and cancers of the colon and rectum also bleed, and the blood alone can't tell them apart. In primary care studies, about 2.4% of people over 40 who saw a doctor for rectal bleeding turned out to have colorectal cancer; pooled across studies of people over 50, about 8.1%. The share is not high, but this is exactly why doctors check the bowel when someone has rectal bleeding.
Painless rectal bleeding at any age deserves a doctor's visit soon. In these situations, even more so, don't treat it as just piles:
New rectal bleeding after 50.Bleeding that doesn't look like typical hemorrhoid bleeding, such as dark blood or blood mixed into the stool.A change in bowel habits (thinner stools, a different frequency, a constant feeling of not having finished).Weight loss, or a finding of anemia or a positive fecal occult blood test.
Whether and when to have a colonoscopy is for a doctor to decide based on your age and symptoms (see constipation).
Numbers · Reading the cancer odds behind bleeding
These figures are positive predictive values: among people who see a primary care doctor with a given symptom, the share who turn out to have a given disease. They are not your personal risk; they tell a doctor whether a symptom is worth investigating.A case-control study in Exeter, UK (349 people over 40 with colorectal cancer, 1,744 controls): the positive predictive value was 2.4% for rectal bleeding, 7.1% for a positive fecal occult blood test, 2.3% for hemoglobin below 10 g/dL, 1.2% for weight loss and only 0.42% for constipation.A systematic review pooling 13 studies found positive predictive values for rectal bleeding of 2.2% to 16% in people over 50, about 8.1% combined; bleeding together with weight loss or a change in bowel habits made cancer somewhat more likely still. The authors conclude that rectal bleeding or anemia in primary care is worth investigating whether or not other symptoms are present.
Read the other way, it also holds: the great majority of rectal bleeding is not cancer. But whether it is is answered by testing, not by the color of the blood. Another review puts it bluntly: a positive fecal occult blood test or anemia should not be put down to hemorrhoids until the bowel has been properly examined.
Chapter 4
Less bleeding, fewer flare-ups
The first step in treating hemorrhoids is making stools soft and easy to pass, so they stop pushing the cushions down.
Fiber has the best evidence: pooling 7 randomized trials, people given fiber had a 47% lower risk of symptoms persisting and a 50% lower risk of bleeding. Its effect on prolapse, pain and itching was not shown, and it can take up to 6 weeks to work, so don't give up after a few days.
Other things you can do day to day:
Drink plenty, which together with fiber keeps stools soft.Cut down on alcohol and caffeinated drinks, which can lead to constipation.A warm bath eases itching and pain; an ice pack wrapped in a towel also eases discomfort for a while.Keep the area clean and dry, and pat rather than rub when you dry.For pain, paracetamol is fine; painkillers containing codeine make constipation worse, so avoid them; don't take ibuprofen while the piles are bleeding.
Pharmacies sell creams that ease pain, itching and swelling. A class of oral drugs called phlebotonics (mostly flavonoids extracted from plants) reduced bleeding and improved overall symptoms in trials, though the studies have methodological limits; whether they suit you is for a doctor to decide. If several weeks of home care haven't helped, or the piles keep coming back, see a doctor; common office treatments include rubber band ligation.
Fiber has the best evidence: pooling 7 randomized trials, people given fiber had a 47% lower risk of symptoms persisting and a 50% lower risk of bleeding. Its effect on prolapse, pain and itching was not shown, and it can take up to 6 weeks to work, so don't give up after a few days.
Other things you can do day to day:
Drink plenty, which together with fiber keeps stools soft.Cut down on alcohol and caffeinated drinks, which can lead to constipation.A warm bath eases itching and pain; an ice pack wrapped in a towel also eases discomfort for a while.Keep the area clean and dry, and pat rather than rub when you dry.For pain, paracetamol is fine; painkillers containing codeine make constipation worse, so avoid them; don't take ibuprofen while the piles are bleeding.
Pharmacies sell creams that ease pain, itching and swelling. A class of oral drugs called phlebotonics (mostly flavonoids extracted from plants) reduced bleeding and improved overall symptoms in trials, though the studies have methodological limits; whether they suit you is for a doctor to decide. If several weeks of home care haven't helped, or the piles keep coming back, see a doctor; common office treatments include rubber band ligation.
Evidence · Fiber and phlebotonics, by the numbers
Fiber: a systematic review of 7 randomized trials in 378 people with symptomatic hemorrhoids compared fiber with no fiber. The fiber group's risk of symptoms persisting was 0.53 times that of controls, and of bleeding 0.50 times; results at 6 weeks and 3 months agreed. The pooled for prolapse, pain and itching were wide and included no effect, so fiber can't be said to help those. Because fiber is safe and cheap, it is the foundation of hemorrhoid treatment and continues after banding or surgery.Phlebotonics: a Cochrane systematic review pooled 20 trials and 2,344 people. Compared with control, they reduced bleeding ( 0.12) and discharge and leakage, and clearly improved overall symptoms; the improvement in pain was not statistically significant. Safety concerns were few, but the studies had methodological limits, and the authors call for more rigorous trials.
Both only manage symptoms. Doctors say the same: treatment does not always stop hemorrhoids coming back, and bowel habits are the long-term half of the job.
Chapter 5
When to see a doctor
Most hemorrhoids improve with home care, but don't wait in these situations:
Go to the emergency department now (don't drive yourself; get someone to take you or call an ambulance):
Bleeding that won't stop.A lot of blood, or large blood clots.Severe pain.
See a doctor soon:
A very high temperature, or feeling hot, cold, shivery and generally unwell.Pus leaking from the piles.Painless bleeding from the bottom, especially over 50, with dark blood, a change in bowel habits, weight loss or anemia.
Book an appointment:
No improvement, or getting worse, after home treatment.Piles that keep coming back.A change around your anus that isn't normal for you.
This list is not a diagnosis. It tells you when to stop handling things yourself and have a doctor look in person.
Go to the emergency department now (don't drive yourself; get someone to take you or call an ambulance):
Bleeding that won't stop.A lot of blood, or large blood clots.Severe pain.
See a doctor soon:
A very high temperature, or feeling hot, cold, shivery and generally unwell.Pus leaking from the piles.Painless bleeding from the bottom, especially over 50, with dark blood, a change in bowel habits, weight loss or anemia.
Book an appointment:
No improvement, or getting worse, after home treatment.Piles that keep coming back.A change around your anus that isn't normal for you.
This list is not a diagnosis. It tells you when to stop handling things yourself and have a doctor look in person.
References · 7
- Lohsiriwat, V. (2012). Hemorrhoids: from basic pathophysiology to clinical management. World Journal of Gastroenterology, 18(17), 2009-2017. Hemorrhoids are the symptomatic enlargement and distal displacement of the normal anal cushions; the sliding anal canal lining theory: they develop when the supporting tissues of the cushions disintegrate; three major cushions (right anterior, right posterior, left lateral); pathology includes venous dilatation, thrombosis, degeneration of collagen and fibroelastic tissue; constipation and prolonged straining claimed as causes; varices are a distinct entity. Internal hemorrhoids arise above the dentate line (mucosa-covered), external below it (squamous epithelium); Goligher grades I bleed without prolapse, II prolapse on straining and reduce spontaneously, III need manual replacement, IV stay out. Most common symptom: painless bright red bleeding with bowel movement dripping into the toilet; positive faecal occult blood or anaemia should not be attributed to hemorrhoids until the colon is adequately evaluated, especially with atypical bleeding or risk factors for colorectal neoplasia. US prevalence 4.4% (1990), peak at 45-65. Fiber reduced persisting symptoms and bleeding by about 50% but not prolapse, pain or itching, and may take up to 6 weeks; lifestyle: more fiber and fluids, regular exercise, anal hygiene, no straining or reading on the toilet, avoid drugs causing constipation or diarrhoea; rubber band ligation preferred among non-operative approaches (full text PMC3342598; PMID 22563187). 10.3748/wjg.v18.i17.2009
- NHS. (2026). Piles (haemorrhoids). Symptoms: bright red blood after a poo, itchy anus, feeling of incomplete emptying, mucus, lumps, pain. Do: drink plenty and eat fibre to keep poo soft, warm bath for itching and pain, ice pack wrapped in a towel, keep the bottom clean and dry, cut down alcohol and caffeine to avoid constipation, paracetamol for pain. Don't: ignore the urge to poo, push too hard, take codeine painkillers (constipating), take ibuprofen if piles are bleeding, spend longer than needed on the toilet. See a GP if worsening or no improvement with home treatment, recurring piles, or a change around the anus; urgent GP or NHS 111 with very high temperature or feeling hot, cold, shivery and unwell, painless bleeding from the bottom, or pus; go to A&E or call 999 with non-stop bleeding, a lot of blood or large clots, or severe pain. Things that make piles more likely: constipation, pushing too hard, heavy lifting, pregnancy, getting older, being overweight. Hospital treatments include rubber band ligation, sclerotherapy, infrared coagulation and surgery; treatment does not always prevent piles coming back. www.nhs.uk/conditions/piles-haemorrhoids
- Astin, M., Griffin, T., Neal, R. D., Rose, P., & Hamilton, W. (2011). The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. British Journal of General Practice, 61(586), e231-e243. 23 studies; positive predictive value of rectal bleeding 2.2-16% across 13 papers, pooled 8.1% in people aged 50 or more; anaemia pooled 9.7%; rectal bleeding with weight loss or change in bowel habit raised the likelihood further (PLR 1.9 and 1.8); investigation of rectal bleeding or anaemia in primary care is warranted irrespective of other symptoms (abstract, PMID 21619747). 10.3399/bjgp11X572427
- Ramprasad, C., Wu, C., Chang, J., Rangan, V., Iturrino, J., Ballou, S., Singh, P., Lembo, A., Nee, J., & Pasricha, T. (2025). Smartphone use on the toilet and the risk of hemorrhoids. PLOS ONE, 20(9), e0329983. Cross-sectional study of 125 adults having screening colonoscopy in Boston; 43% had hemorrhoids on colonoscopy; 66% used smartphones on the toilet; 37.3% of users spent over five minutes per visit vs 7.1% of non-users; smartphone use associated with 46% higher risk of hemorrhoids after adjusting for age, sex, BMI, exercise, straining and fiber (abstract, PMID 40901789). 10.1371/journal.pone.0329983
- Hamilton, W., Round, A., Sharp, D., & Peters, T. J. (2005). Clinical features of colorectal cancer before diagnosis: a population-based case-control study. British Journal of Cancer, 93(4), 399-405. 349 colorectal cancers aged 40 or more and 1,744 matched controls in Exeter general practices, 2 years of records. Positive predictive values: rectal bleeding 2.4%, weight loss 1.2%, abdominal pain 1.1%, diarrhoea 0.94%, constipation 0.42%, haemoglobin under 10 g/dl 2.3%, positive faecal occult blood 7.1%, abnormal rectal examination 4.0% (abstract, PMID 16106247). 10.1038/sj.bjc.6602714
- Alonso-Coello, P., Mills, E., Heels-Ansdell, D., Lopez-Yarto, M., Zhou, Q., Johanson, J. F., & Guyatt, G. (2006). Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. American Journal of Gastroenterology, 101(1), 181-188. Seven RCTs, 378 patients: fiber reduced the risk of not improving or persisting symptoms by 47% (RR 0.53) and of bleeding by 50% (RR 0.50), consistent at 6 weeks and 3 months; for prolapse, pain and itching the confidence intervals were wide and compatible with no effect (abstract, PMID 16405552). 10.1111/j.1572-0241.2005.00359.x
- Perera, N., Liolitsa, D., Iype, S., Croxford, A., Yassin, M., Lang, P., Ukaegbu, O., & van Issum, C. (2012). Phlebotonics for haemorrhoids. Cochrane Database of Systematic Reviews, 8, CD004322. Phlebotonics (plant flavonoids and synthetic compounds such as calcium dobesilate) improve venous tone and capillary stability; 20 trials, 2,344 participants: benefit over control for bleeding (OR 0.12), discharge and leakage, and overall symptom improvement; pain not significantly improved; few safety concerns but methodological limitations, more robust trials needed (abstract, PMID 22895941). 10.1002/14651858.CD004322.pub3