Internal Hemorrhoids: Symptoms, Causes and Treatment

Medical review: Dr. Clarisse Bezerra
Family Doctor
November 2021

Internal hemorrhoids are enlarged veins inside the rectum that are not visible in the external anus. Common symptoms include bright red blood in the stool or on toilet paper with wiping, and anal itching and discomfort which make using the restroom difficult.  

Internal hemorrhoids can be classified by a grading system, according to the symptoms presented. The grade of hemorrhoids identified will guide the recommended treatment. Regardless of the grade, it's important to consider increasing intake of food rich in fiber, which will help relieve symptoms and decrease pain and discomfort when passing stool.

Main symptoms

Although internal hemorrhoids are not visible, signs and symptoms that happen are specific and predictable. The most common symptom is bright red blood in the stool. Other signs and symptoms that may indicate internal hemorrhoids include:  

  • Anal itching
  • Mucus discharge from the anus
  • Difficulty and pain with bowel movements
  • Anal discomfort
  • Anal tenesmus, which is the urgent need or feeling that you need to poop even though your bowels are empty
  • Feeling that you haven't completely emptied your bowels after pooping

In addition, you may also feel a small bulge in the anus during pooping which may or may not retract on its own. The bulge is an enlarged vein that protrudes from the rectum, otherwise known as an internal hemorrhoid. Depending on how this bulge presents, it can be classified as a grade 1, 2, 3 or 4 hemorrhoid. 

Main causes

The emergence of internal hemorrhoids is related to the person's lifestyle, such as a diet with little fiber intake, frequent use of laxatives, sitting on the toilet for a long time, smoking and sedentarism. An unhealthy diet can negatively affect your ability to poop, as unhealthy food can dry-up the stool and make it harder to pass, which then causes hemorrhoids.  

Internal hemorrhoids can also occur due to anal infections or chronic diarrhea. Pregnancy is also a common cause of internal hemorrhoids, due to pregnancy-related weight gain and also due to the pressure the baby exerts on the pelvic region.

How to confirm a diagnosis

The diagnosis for internal hemorrhoids must be done by a gastroenterologist via a rectal examination. The doctor will assess the anal region for any abnormalities that may suggest internal hemorrhoids. To complete the exam, the doctor will position the patient as needed (lying belly up or down) and inspect the anus. The doctor may ask the patient to stimulate straining, so that the presence of hemorrhoids or anal fissures can be visualized.

In addition to the rectal exam, the doctor may also assess the patient's history and ask questions about their diet and activity level. (Oftentimes, an unhealthy diet and sedentary lifestyle can contribute to the development of internal hemorrhoids).

Grading system

Internal hemorrhoids can be classified, or graded, based on the extent of the presenting symptoms. The grade of hemorrhoid will guide the treatment indicated.

  • Grade 1 internal hemorrhoid: there is anal bleeding present, but the veins do not bulge out from the rectum
  • Grade 2 internal hemorrhoid: the veins protrude during bowel movements, but retract to their original position on their own. Anal bleeding will also occur.
  • Grade 3 internal hemorrhoid: there is anal bleeding present, and protruded veins will only retract if they are manually pushed back to place
  • Grade 4 internal hemorrhoid: there is heavy anal bleeding and the vein remains protruded (ie. the vein doesn't go back to the original position even when pushed)

The gastroenterologist will assess the characteristics of the hemorrhoid and determine the severity, or grade, which will direct the treatment required.

It's important to see your doctor if you have any signs or symptoms that indicate internal hemorrhoids, as only a doctor can confirm a diagnosis. The process of a diagnosis will start with the collection of subjective information like symptoms, patterns of bowel movements, diet habits, history of laxative use, and a history of surgical procedures and GI diseases. After this, assessment of the anus is completed, where the doctor will inspect for any anal abnormalities.

Treatment

Treatment for internal hemorrhoids should be directed by a gastroenterologist and is indicated according to the severity, or grade, of the hemorrhoid. The doctor may recommend diet changes (e.g. increase fibre intake), sitz baths, analgesics or anti-inflammatories (e.g. naproxen), and topical hemorrhoid ointments (e.g. Preparation H or Proctosedyl). Other treatment options that may be considered (again, depending on the severity) include sclerotherapy, cauterization, cryotherapy and rubber band ligation.

In more serious cases, in which the hemorrhoid gets lodged in the anus, a blood clot can form within the vein, causing a thrombosed hemorrhoid. Surgery is typically recommended for repair.

Diet changes are recommended for all types of hemorrhoids. Adequate fiber intake helps with bowel movements by making the stool softer, which prevents too much straining.

Learn about all the treatment options available for the management of internal hemorrhoids below:

1. Medication 

Medication may be recommended for the treatment of internal hemorrhoids, especially in cases in which the hemorrhoid is very painful or bleeding heavily. Analgesics (like paracetamol) and anti-inflammatories (like ibuprofen) can be used to relieve the pain and reduce inflammation.

Phlebotonic medications help to regulate blood flow in the location of the hemorrhoid, and may also be prescribed by the gastroenterologist. They help to decrease symptoms such as pain, swelling, anal itching and difficulty passing stool. Some of these medications contain Diosmin, or Hesperidin, which additionally act as vasodilators to help blood flow. These medications should be used as directed by your doctor.

2. Ointments

Even though internal hemorrhoids are located deep inside the rectum, topical ointments can help relieve the discomfort when passing stool and can reduce pain associated with sitting.

Hemorrhoid ointments have anesthetic and anti-inflammatory properties. They can be used 3 to 4 times a day, depending on the severity of the symptoms, and many are available as over-the-counter medications. The most popular brands include Proctosedyl, Preparation H, and Doctor Butler's Hemorrhoid & Fissure Ointment.

3. Surgery

Surgery will usually be indicated in the following situations: when the internal hemorrhoid is deemed as a grade 3, internal hemorrhoids that become external and get stuck in the anus, or when all other treatments are not effective and the person has intolerable pain when passing stool or sitting.

Conventional procedures involve the removal of the hemorrhoid, but newer techniques aim to repair the hemorrhoid instead, by fixing it to the rectum. These newer techniques have a reduced recovery time and decreased post-op pain.

4. Natural treatment

Natural treatment for internal hemorrhoids consists mainly of changes to diet. It is important to ensure adequate fiber intake and adequate hydration, so that stool will be formed and require minimally straining.

Sitz baths with warm water can help to relieve pain and discomfort. They can be done for 15-20 minutes with the addition of medicinal herbs like witch hazel. It's important to avoid using toilet paper (this can further irritate the anal mucosa), and to opt for cleaning the perianal area with water and soap instead. Also, avoid any strong straining with bowel movements.

5. Rubber band ligation

Rubber band ligation is a type of treatment indicated for grades 1, 2 or 3 internal hemorrhoids. It consists of tying off the hemorrhoid at its base with a rubber band, which cuts-off the blood flow to the hemorrhoid. Within 4 to 7 days, the rubber band and the hemorrhoid will fall off.

For the symptoms to be relieved, you may need several rubber band ligation sessions, however, in comparison to a surgical procedure, recovery is a lot faster and the pain is much less.

6. Home remedies

Some medicinal plants can be used as home remedies to relieve pain and discomfort in the anal region. Aloe vera, for example, has anti-inflammatory properties and can reduce inflammation in the anus. It is best used when applied directly on he hemorrhoid in its natural form.

Witch hazel also contains properties that help relieve pain, itching, and bleeding caused by internal (and external) hemorrhoids. You can make your own natural ointment at home by mixing this plant with paraffin and glycerin.

Epsom salts can also help with the treatment of internal hemorrhoids. They can be mixed with water and be used in sitz baths.  

7. Injections and laser coagulation

Sclerotherapy involves the injection of sclerosant solution  (e.g. phenol oil at 5% and polidocanol at 2%) into the hemorrhoid. This procedure is done by the gastroenterologist, and works by promoting clotting of the skin around the hemorrhoid. This type of treatment is not as recommended for men, due to the possible proximity of the prostate and seminal ducts around the injection area.

Laser coagulation, or laser photocoagulation, is used for internal first and second-degree hemorrhoids. It consists of applying concentrated infrared rays to the skin around the hemorrhoid to stop blood blow to it. This results in the hemorrhoid dying and eventually shedding. This treatment usually requires 3 to 5 sessions for full removal of the hemorrhoid.

Improvement or Worsening

An internal hemorrhoid is deemed to be improving when it decreases in size, when pain has reduced (especially when passing stool), and when blood in the stool has reduced or resolved.

An internal hemorrhoid is getting worse when it increases in size, when there is more pain in the anal area, and when bleeding becomes heavier.

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Atualizado por Tua Saude editing team, em November de 2021. Medical review por Dr. Clarisse Bezerra - Family Doctor, em September de 2021.

References

  • SOCIEDADE BRASILEIRA DE COLOPROCTOLOGIA. Hemorróida: Diagnóstico. 2005. Available on: <https://diretrizes.amb.org.br/_BibliotecaAntiga/hemorroida-diagnostico.pdf>. Access in 31 Dec 2019
  • DE PAULA, Pedro Roberto. Doença Hemorroidária. 2016. Available on: <https://cbcsp.org.br/wp-content/uploads/2016/aulas/doencahemorroidaria.pdf>.
Medical review:
Dr. Clarisse Bezerra
Family Doctor
Dr. Bezerra possesses a medical degree and specializes in family medicine. She is licensed to practice under CRM-CE licence #16976.