Hemorrhoids

What is Hemorrhoids?

Hemorrhoids are swollen vascular cushions in the anal canal that cause symptoms such as bleeding, itching, pain and prolapse. Everyone has these cushions, which are normal tissue made of connective tissue, smooth muscle and blood vessels. The word hemorrhoids, or piles, refers to the state in which they cause symptoms.^[1] They are one of the most common reasons for outpatient gastroenterology visits in the United States.^[2]

Common symptoms

The classic symptom is bright red blood with a bowel movement, because hemorrhoidal tissue has many connections between arteries and veins.^[1] Other symptoms include itching or irritation, anal discomfort, mucus discharge, swelling and prolapse.^[2]

Internal hemorrhoids are inside the anal canal and are graded from I to IV by how far they prolapse and whether they go back in on their own. External hemorrhoids sit under the skin around the anus. A clot inside an external hemorrhoid (thrombosed hemorrhoid) can cause sudden, severe pain and a hard lump.^[1]

Causes and risk factors

Straining, chronic constipation or diarrhea, long periods of sitting on the toilet, obesity, pregnancy, a low-fiber diet and aging are commonly listed causes. Persistently raised pressure in the veins of the anal area is thought to contribute.^[3] The exact cause is not well established, and the link between constipation, low fiber and hemorrhoids has been assumed more than proven.^[2]

How it is diagnosed and treated conventionally

Diagnosis starts with the history, a look at the anal area and a digital rectal exam, sometimes with anoscopy. Accuracy even among surgeons is only about 70 percent, which is one reason a proper evaluation matters.^[4]

Treatment is chosen by symptom severity and anatomy, after addressing modifiable risk factors.^[5] Fiber has the best-studied supportive role. A meta-analysis of 7 trials with 378 patients found fiber reduced persisting symptoms and bleeding.^[6] Office procedures such as rubber band ligation and infrared coagulation are widely used, and surgery effectively removes hemorrhoids but can be painful.^[2]

Why Hemorrhoids calls for a whole-person approach

Hemorrhoids are rarely just a local problem. Bowel habits, diet, venous pressure and recovery after procedures all play a part, and the cause of symptoms is not always clear.^[2]

Care that also looks at digestion, daily routine and comfort is therefore a reasonable addition to the medical treatment of the anal area.

Bowel habits and fiber

Hard stools and straining are the factors most often blamed for hemorrhoid symptoms. In trials of symptomatic hemorrhoids, fiber supplements improved symptoms and bleeding, with moderate-quality studies overall.^[6] Bowel regularity is therefore an obvious target for diet and lifestyle advice.

Venous pressure and tissue support

Hemorrhoids are often described as developing when pressure in the anal veins stays high.^[3] This is one reason plant-derived venous tonic medicines have been tested for hemorrhoids.

Pain and recovery after procedures

Pain is the main problem after hemorrhoid surgery. A review of 157 trials found that pain reduction relies on a combination of anesthetic methods, surgical technique, topical medicines and postoperative measures, including laxatives and flavonoids.^[7]

What remains uncertain

Research on hemorrhoids is thin. One review points out that symptoms commonly attributed to hemorrhoids were reported equally by people with and without them, and that medical therapies apart from fiber have hardly been formally studied.^[2] This is a reminder that new symptoms need medical assessment rather than self-diagnosis.

Acupuncture for Hemorrhoids

What the research shows

The research on acupuncture is limited, and the studies we found are about pain after hemorrhoid surgery, not hemorrhoid symptoms in general. We found no trials of acupuncture for untreated hemorrhoids.

A systematic review of 4 trials with 275 patients found that electroacupuncture lowered pain after hemorrhoidectomy at some time points, especially during the first bowel movement. Studies of manual acupuncture against pain medicines gave inconsistent results, study quality varied, and the authors judged the evidence not conclusive.^[8] In a single-center trial of 72 patients, electroacupuncture after surgery gave lower pain scores than sham acupuncture at several time points.^[9]

How acupuncture may work

For postoperative pain, acupuncture is thought to act on how the nervous system processes pain. We did not find a hemorrhoid-specific mechanism study to cite, so this is a general proposal and not a settled explanation.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the body, usually left in place for about 20 to 40 minutes. Care is given as a course of several visits with reassessment. The trial above applied electroacupuncture for 30 minutes right after surgery.^[9]

In prospective studies, about 9 in 100 patients had a minor reaction such as soreness, bleeding or bruising at a needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker, which matters for electroacupuncture.

Ayurvedic medicine for Hemorrhoids

The Ayurvedic view

Ayurveda calls hemorrhoids Arsha and describes them as arising from improper diet, long standing and faulty bowel habits that disturb the doshas, mainly Vata, and the digestive fire.^[11] These are traditional explanations, not biomedical diagnoses.

Therapies that may be used

Care is individualized and traditionally includes:

• Diet and routine advice to keep stools soft and regular, such as warm cooked meals, enough fluids and regular meal times
• Triphala and similar herbal preparations for digestion and bowel regularity, prescribed individually
• Warm sitz baths and soothing herbal topical preparations, which may be a transdermal application
• Kshara Sutra and other procedures, which are surgical or minor surgical methods done by specialist Ayurvedic surgeons, not by us^[11]

Panchakarma is not appropriate during pregnancy, acute illness, frailty, or while rectal bleeding has not been medically assessed.

What the research shows

The research on Ayurveda is very limited, and most of it is small, from India, and not placebo-controlled. A trial of 90 patients compared a marketed polyherbal kit with fiber powder plus lidocaine gel for 14 days. More patients in the kit group reached a symptom score of zero, and side effects were similar, though the kit was a commercial product and the trial was not placebo-controlled.^[12]

Other studies compared Kshara Sutra ligation with hemorrhoidectomy in 61 patients, and Apamarga Kshara, infrared coagulation and an herbal tablet in 30 patients. Both were small and reported mainly favorable results, and the second was open-label with no blinding.^{[11, 13]} Studies without blinding or a placebo group cannot establish that a treatment caused the improvement.

Herbal medicine for Hemorrhoids

Herbs and formulas that have been studied

The best-studied plant-derived products are flavonoids, often a micronized purified flavonoid fraction made from citrus, used as venous tonics.^{[3, 14]} Ayurvedic polyherbal products and Chinese topical ointments are also used. We found no systematic reviews of Chinese herbal formulas for hemorrhoids.

What the research shows

The evidence is limited. A Cochrane review of 20 trials with 2,344 participants found venous tonics (plant extracts such as flavonoids and synthetic compounds) reduced bleeding, itching, discharge and overall symptoms against control, with no clear effect on pain. The authors noted methodological limitations.^[3] A systematic review of 11 trials of one micronized flavonoid product found benefit for bleeding and overall improvement, with a trend toward less pain. That review covered a single branded product.^[14]

Evidence on herbal products beyond these flavonoid medicines is thin, and trials of Ayurvedic herbal products are covered above.^[12]

Safety and herb-drug interactions

Herbs can interact with medicines. Case reports describe bleeding or clotting problems when warfarin was combined with herbs including dan shen, dang gui, ginkgo, ginseng and garlic.^[15] Anyone taking blood thinners needs a practitioner's review first, particularly since hemorrhoids themselves can bleed.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[16] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Ayurveda ties Arsha to a disordered digestion and Vata, which governs downward movement. Researchers study related ideas such as stool consistency, straining, venous tone and local inflammation.^{[3, 6]}

Traditional Chinese medicine often describes hemorrhoids as damp-heat or sinking qi in the lower body. No study we found has shown that these patterns match a specific biological process.

How this care fits with your medical care

Integrative care for hemorrhoids is complementary. Keep your primary physician, gastroenterologist or colorectal surgeon, and do not stop or change prescribed treatment, including recommended procedures. We do not diagnose the cause of rectal bleeding, so any bleeding should be medically evaluated first.

Please bring your diagnosis, any colonoscopy or other test results, a full list of medicines and supplements, and details of any procedures, planned or past.

When to seek urgent medical care

Rectal bleeding can come from conditions other than hemorrhoids, some of them serious.

• Rectal bleeding that is heavy, does not stop, or comes with dizziness or fainting
• Black, tarry or maroon stools
• Bleeding that is new after age 45 or that changes your bowel habits, or comes with unexplained weight loss or anemia
• Severe, sudden anal pain or a hard, very painful lump
• A prolapsed hemorrhoid that will not go back in and turns dark or very painful
• Fever with anal pain or swelling

If any of these occur, call 911 or go to the nearest emergency department.