Haemorrhoids and other anal symptoms: sorting them out instead of enduring them

You are sitting on the toilet and you see blood on the paper. Not much. A streak, bright red.

Your head does two things in that second. It says: those will be haemorrhoids. And it says: what if they are not. Then comes the third thought, and that one is the most expensive. It says: I am certainly not going to a doctor with this.

Many people know this pattern. Buy an ointment, wait, it gets better, it comes back. At some point a state of affairs has settled in that nobody talks about, even though it shapes sitting, sport and sometimes closeness too.

This text is not a treatment manual, it is an aid to sorting things out. Because with anal symptoms the medical work lies before the treatment: in naming cleanly what is actually there.

Every person has haemorrhoids. Not everyone has a disease.

Let us start with the misunderstanding that underlies all the others. Haemorrhoids are not a disease you catch. They are an organ you have had since birth.

In the uppermost part of the anal canal sits a ring shaped vascular cushion, the corpus cavernosum recti. Not a venous plexus in the sense of varicose veins, but an arteriovenous cushion, a tissue that can fill with blood and empty again.

Picture a soft sealing collar. The sphincter provides the coarse closure, the cushion the fine one. Without it you would not reliably know whether air, liquid or solid stool is waiting down there. The German S3 guideline writes that these cushions play an important role for fine continence. That is why no established procedure aims to remove this cushion completely. Surgery too takes away only the prolapsed parts and leaves the fine seal standing as far as possible.

When does this turn into a disease? When three things come together: the vascular channels widen, the cushion slides downwards, and the supporting connective tissue loses its hold. This three part account comes from a review by Varut Lohsiriwat. It explains why purely vascular agents reach a limit: when the anchoring rope gives way, making the balloon smaller helps little.

For Germany the S3 guideline gives an order of magnitude: about 4 percent seek medical help for this, which is around 3.3 million treatment cases per year, of which about 1.5 percent are operated on. In the same chapter it writes that good valid studies on epidemiology are not available. An estimate, not a measurement.

Inside and outside are two different stories

One anatomical border makes the topic understandable in the first place: the dentate line. Above it lies mucosa that reports pressure and stretch but no sharp pain. That is where the haemorrhoidal cushion sits. Below it the anoderm begins, a very sensitive skin. There you feel an injury immediately and precisely.

Blood at the anus, and why it is never assigned without a look

How often have you heard that bright red blood is harmless and dark blood is dangerous? I have deliberately left that rule of thumb out. The data base is a single observational study, and a sentence about blood colour would make bright blood look like an all clear.

The list of possible bleeding sources is short enough to remember and long enough to forbid guessing: haemorrhoids, anal fissure, anal fistula and abscess, inflammatory bowel disease, polyps, colorectal carcinoma, diverticular bleeding, rectal prolapse and solitary rectal ulcer.

Two of them I only touch on. In Crohn's disease and ulcerative colitis bleeding belongs to the picture, more in the article on inflammatory bowel disease. Diverticula usually bleed suddenly and painlessly, see diverticula and diverticulitis.

How reliable is the attribution actually?

Now an uncomfortable study. I show it because it delivers an argument for the examination and not against anybody.

A fair limitation and a constructive flip side belong with this. The limitation: these were photographs, not examinations. With history, palpation and a proctoscope the accuracy rate looks better.

The flip side comes from Thessaloniki: 36 randomised medical students. Those who had attended a coloproctology clinic recognised 80.6 percent of the findings correctly, the comparison group 43.1 percent. Spanos CP et al. BMC Surg. 2014;14:95. PMID: 25410432 · DOI: 10.1186/1471-2482-14-95 [RCT, n=36]. The poor recognition rate is not a law of nature, it is a question of practice.

The sentence that applies especially to young people

But I am still young. That sentence costs the most time.

This work is retrospective and allows no risk estimate, it describes a pattern. It matches what the German S3 guideline writes about endoscopic investigation from the age of 40.

What a proper basic examination is

So that you know what you are getting into: the basic diagnostic work consists of conversation, inspection, digital rectal examination and proctoscopy, supplemented by rectoscopy when there is bleeding. That takes a few minutes. These examinations belong in a general practice, a coloproctology practice, a surgical practice or a gastroenterology practice. I describe them here so that you know what to expect, not as an offer. And I am not writing this text to frighten you: the large majority of what is found here is benign. In a worldwide survey of 1005 surgeons, 92.9 percent named the history, 91.2 percent the inspection and 91.1 percent the digital rectal examination. Standard, not exception.

Whether a colonoscopy makes sense in addition depends on age, symptoms and history. What awaits you there is described in the article on bowel cancer screening and colonoscopy. Here only this applies: if it has been recommended, this article does not replace it.

The look alikes, and how you tell them apart

This is, in my view, the most frequent gap in patient facing texts on this topic.

Many of them list other causes. How to tell them apart is written down less often. Yet the distinguishing feature is often simple: pain speaks against haemorrhoids. So I am trying it here, with the explicit limitation that a table does not replace an examination. It is meant to help you sort your symptoms.

Anal fissure: the tear that holds itself open

The fissure is the most important look alike, because it needs its own treatment.

A small tear in the anoderm triggers pain. The pain can make the internal sphincter cramp, and that cramping can worsen the blood supply exactly where the tear is supposed to close. A circle that carries itself. This is how we explain today why a fissure becomes chronic. It is a well supported model, not a proven sequence. The trigger is often very hard stool, sometimes the opposite, namely persistent diarrhoea.

The framing belongs with this, and it matters more to me than the percentages. All of these substances are prescription only. In Germany, nitroglycerin ointment is licensed for pain relief in chronic anal fissure, so the healing figures come from studies and sit next to that indication. Botulinum toxin, nifedipine and diltiazem are not licensed for the fissure, their use would be off label, with everything that goes with it: a separate medical explanation, no automatic reimbursement, greater medical responsibility.

And the risk side belongs with it just as much. Nitroglycerin frequently causes headaches and must not be used together with erectile dysfunction drugs of the sildenafil, tadalafil or vardenafil type, because blood pressure can then fall dangerously. After botulinum toxin, fine continence can be reduced temporarily, meaning control over wind. Nifedipine and diltiazem as an ointment can cause headache and skin irritation. I deliberately give no dosages here. That belongs in the hands of the treating practice, which knows your other medication.

The basis nevertheless remains stool consistency, because a tear closes poorly if something hard tears it open again every morning.

Perianal venous thrombosis: the lump that is there overnight

This is the finding that most often sends people into panic and least often brings them in quickly enough. Typical: sudden onset after straining, heavy lifting or long sitting, a taut bluish lump at the anal margin, pain even without a bowel movement.

The work is retrospective, and those with more pain were operated on more often. The time figures are therefore not a causal statement.

One distinction that rarely appears in patient facing texts: a perianal venous thrombosis on the outside is something different from an acute haemorrhoidal thrombosis with strangulated prolapse. For the second, the German S3 guideline calls for a primarily conservative approach in recommendation 46, because removing too much anoderm can bring about a narrowing of the anal canal that is hard to undo.

Anal fistula and perianal abscess: the surgical domain

When the pain throbs, increases over days and fever joins in, this is no longer a haemorrhoidal topic. An abscess is a collection of pus that has to be drained, a fistula is a tract from which discharge keeps coming. Both belong in a timely surgical assessment. Anal fistulas are common in Crohn's disease and sometimes the first sign, more on that under inflammatory bowel disease.

Anal skin tags: the most common misreading of all

Many people tell me they can feel their haemorrhoids. Mostly they are feeling a skin tag: a soft flap of skin at the anal margin, not pushable back inside, does not bleed, does not hurt. A reason to treat arises only when it makes cleaning so difficult that eczema develops. Otherwise it is a cosmetic finding, and procedures in this place have consequences.

Anal eczema and pruritus ani: the itch with many fathers

Itching at the anus, stronger at night than by day, is one of the most tormenting and most belatedly presented symptoms of all.

The circle usually looks like this: something irritates, you scratch, a preparation calms it briefly, the trigger stays. That is why the search for the cause comes before the preparation.

Rectal prolapse: the ring that gets confused with grade 4

If something ring shaped pushes outwards on straining and the folds run in circles around the centre, this is more likely a prolapse of mucosa or bowel wall. With grade 4, by contrast, several separate cushions lie outside with normal skin between them. The difference leads to completely different procedures. How pelvic floor and nervous system interact is touched on in the article on the gut brain axis.

Anal carcinoma, condylomata and infections: the rare ones that must not be missing

Two findings belong on this list, even though they are rare. There is a tumour of its own at the anus, the anal carcinoma, and at the beginning it can look like a skin tag, a fissure or a haemorrhoid. And there are anal condylomata, that is genital warts, caused by human papillomaviruses, out of which a precancerous change can develop over years. Both are one more reason why a change at the anus that is no better after two to three weeks belongs to be looked at, rather than treated further.

Anyone with a known HPV infection, anyone who is immunosuppressed, lives with HIV or has a history of cervical dysplasia should take this particularly seriously. The NCCN guideline on anal carcinoma records that this condition is treated across disciplines, in oncology, radiotherapy and surgery. I describe it here not as an offer, but so that you know it exists. A case report in the Qatar Medical Journal describes exactly this mix up and closes with the recommendation that symptoms which look like haemorrhoids, as well as rectal bleeding or a palpable lump, justify a physical examination and a prompt referral to gastroenterology or coloproctology. The authors themselves call the link between the mix up and delayed presentation anecdotal. A case report can show that something occurs, it cannot establish how often. Benson AB et al. J Natl Compr Canc Netw. 2023;21(6):653-677. PMID: 37308125 · DOI: 10.6004/jnccn.2023.0030 [Guideline] · English K et al. Qatar Med J. 2024;2024(1):7. PMID: 38362253 · DOI: 10.5339/qmj.2024.7 [Case report, single case]

A third point belongs alongside: infections transmitted during sex can also cause pain, bleeding, discharge or itching at the anus, for example an inflammation of the rectum caused by gonococci, chlamydia, syphilis or herpes viruses. This is not a question of how someone lives, it is a question of what is actually looked for. Without a history and a swab, something like this is not found.

Grades 1 to 4, and what they really steer

There is a number in the report, and many people read it like a school grade. It is not that. The classification goes back to the surgeon John Goligher and describes only one thing: how far the cushion steps outwards.

The German S3 guideline places two sentences beside this that often get lost in everyday practice. First: the transitions between stages are fluid. Second: symptoms need not correlate with size or prolapse. That explains two familiar experiences. A grade 1 can bleed, weep and shape everyday life. A grade 3 can be almost free of symptoms. The grade describes anatomy, not suffering.

What is the classification for, then? It steers the choice of procedure. In a survey of 1005 surgeons from 103 countries, 91.9 percent used four grades, and for 76.3 percent the grade was the single most important factor. Conservative treatment as first choice: at grade 1 in 92.5 percent, at grade 2 in 72.4, at grade 3 in 47.3 percent. At grade 4, 77.6 percent chose surgery first. Samalavicius NE et al. Colorectal Dis. 2024;26(10):1797-1804. PMID: 39169548 · DOI: 10.1111/codi.17140 [Survey of surgeons, n=1005]

The conservative basis is not a side note. For most grades it is the regular first step.

The treatment paths, from conservative to surgical

Do you know the feeling that everyone recommends something to you and nobody says what it costs? That is why I go through the steps in order, with numbers on benefit, recurrence and price. Orientation from the literature, not prescriptions.

Step 1: stool consistency, the supported basis

The German S3 guideline names Plantago ovata and psyllium in recommendation 7 with grade B. How much fibre makes sense and why it can cause bloating at the start is described in the article fibre myths. Four things belong with this. Start slowly. Always take it with plenty of fluid, because bulking agents can clump in the oesophagus or the bowel without water. Do not use it with a known narrowing in the bowel, with suspected bowel obstruction or with swallowing difficulties, and clarify it medically beforehand if you have an existing bowel condition. And keep a gap of about half an hour to an hour from other medicines, because their absorption can otherwise be reduced. With diabetes, adjusting the medication belongs to the treating practice.

A word on laxatives, because they often come into play here. The Cochrane review is filed under the title of laxatives, but what was mainly evaluated was fibre. There can be good reasons for the short term use of a laxative, for example when hard stool keeps tearing a fresh fissure open. Taken on your own over weeks and months, however, it is not a solution, it covers up the question of why the stool is so hard. Which agent makes sense for how long therefore belongs in a medical conversation and under medical guidance, especially in pregnancy and with existing bowel disease.

Step 2: ointments and suppositories, honestly placed

The German S3 guideline puts it soberly: topical preparations are a symptomatic treatment, they may be used for acute symptoms, but they do not replace a targeted therapy. The European guideline adds that for non steroidal anti inflammatory drugs and cortisone in haemorrhoids, scientific data are missing.

I deliberately name no preparations and no application schemes. Two things are important nonetheless. An ointment may dampen the irritation, it does not change the enlarged cushion. And steroid containing agents belong in short, medically guided applications, because this skin can react to permanent treatment with thinning and stretch marks.

For oral vascular agents, the phlebotonics, a Cochrane review with 20 studies and 2344 participants is available. It reports favourable effect estimates for itching, bleeding and overall improvement, but no significant difference for pain (p = 0.06), and the authors name considerable methodological limits.

I deliberately do not give the individual effect figures here, for a simple reason: the German S3 guideline gives diosmin and hesperidin only grade 0 and records that they are not licensed as medicines in Germany. What is sold here are food supplements, and for those I neither may nor want to claim an effect against a disease. In pregnancy and while breastfeeding the data are thinner still, so the question belongs under medical and midwifery guidance there anyway.

Step 3: sclerotherapy and rubber band ligation

Both are outpatient procedures, usually without anaesthesia.

Step 4: surgery

In Germany about 1.5 percent of all presumed treatment cases are operated on. The question comes up less often than the tone of some advice pages suggests.

The German S3 guideline quantifies the complications of classic surgery like this: early bleeding 1.7 percent, urinary retention 0.7 percent, late fissures 1 to 2 percent, narrowing of the anal canal 2 to 9 percent, disturbances of continence 5 to 20 percent, recurrence 3 percent. What matters is what hides behind the second figure: it covers fine continence for the most part, meaning uncontrolled passage of wind or weeping, and only a small share of it concerns solid stool. That is unpleasant and belongs in the consent conversation, but it is not the same as the picture the word incontinence creates in your head. On aftercare: gentle showering instead of modern wound dressings (recommendation 44), no routine antibiotic prophylaxis (recommendation 45, grade A). Both are decisions for the treating team, not instructions to you. An antibiotic in this context is neither started nor stopped on your own, it is decided and accompanied medically.

What sits in the causal chain, and how much of it is supported

Here it gets uncomfortable. On the development of the condition, the German S3 guideline writes literally that the changes leading to it are insufficiently supported scientifically, that the secured data are sparse and the material often contradictory. A sentence that rarely appears in patient facing texts. That is why I sort the usual suspects by how well they are supported.

Pregnancy and the postpartum period: a case of its own

Hardly any phase of life brings so many anal symptoms, and hardly any is borne so quietly.

A prospective cohort in Ghent followed 94 pregnant women from week 19 to three months after the birth. 68 percent developed anal symptoms, and the most common single symptom was anal pain. Two independent risk factors remained: constipation with OR 6.3 (2.08 to 19.37) and earlier anal symptoms with OR 3.9. Typical were prolapse in the third trimester and thrombosis directly after the birth. Ferdinande K et al. Colorectal Dis. 2018;20(12):1109-1116. PMID: 29972721 · DOI: 10.1111/codi.14324 [Cohort, n=94]

One priority follows from this: whoever keeps an eye on stool consistency during this time is addressing the strongest known risk factor. The German S3 guideline recommends in recommendation 48 that surgery be avoided during pregnancy. Whatever is used in pregnancy and while breastfeeding belongs under medical and midwifery guidance.

The good news: much of it improves in the weeks after the birth. Whatever is still there after three months should be looked at once.

What everyday life can contribute, as directions

No protocol, no quantities. Four directions, each with its evidence strength beside it.

And what about warm sitz baths? An old clinical tradition. I am not aware of a supported advantage over plain showering, and the German S3 guideline explicitly recommends showering for aftercare (recommendation 44). If they do you good, little speaks against them. As a supported treatment I would not sell them.

Why shame is so expensive

Now the part that is medically the simplest and humanly the hardest.

The figure comes from a survey in one country and is not representative. The direction matches what I hear in my consultations.

What the waiting costs can be said in three points. With a thrombosis it is weeks instead of days. In people under 50 with bleeding that has not been investigated it is a delayed diagnosis. And for everyone else it is months or years with a symptom that can often be classified and then addressed in a targeted way, sometimes after the first appointment.

What I still have to say honestly about the evidence

The professional world is divided on this topic too, and that does not come from me, it comes from within it.

Common questions about haemorrhoids and anal symptoms

Where this topic connects to the rest of the body

Anal symptoms hang on stool consistency, on the nervous system, on nutrition and sometimes on a blood loss that nobody has noticed.