Hemorrhoids

Hemorrhoids are enlarged, symptomatic vascular cushions of the anal canal — a normal anatomic structure that becomes a "disease" only once it is swollen, prolapsed, thrombosed, or bleeding enough to cause symptoms.^[1] They are classified by location relative to the dentate line: internal hemorrhoids arise above the dentate line from the internal hemorrhoidal plexus, are covered by mucosa, carry visceral (not somatic) innervation, and are therefore usually painless unless they prolapse, strangulate, or thrombose; external hemorrhoids arise below the dentate line, are covered by squamous epithelium supplied by the pudendal nerve and sacral plexus, and are the type that typically causes pain, especially when thrombosed; mixed hemorrhoids bridge both plexuses.^[1] Internal hemorrhoids are further graded I-IV by degree of prolapse using the Goligher classification, which — despite real limitations, including that it was developed for surgical settings and does not track symptom severity — remains the standard reference point for matching treatment intensity to disease severity; no equivalent formal grading system exists for external hemorrhoids, which are assessed by symptoms and examination findings instead.^[1] Hemorrhoidal disease is extremely common: an estimated 50-70% of Canadians will develop hemorrhoids at some point in their life, and about half of adults over age 50 report symptoms.^[2] It is also one of the more frequently over-diagnosed anorectal conditions — in one study, only 18% of patients who believed their symptoms were caused by hemorrhoids actually had them on examination, with the remainder driven by other anorectal or colorectal conditions.^[1] That gap is exactly why hemorrhoids belong in self-care: most confirmed, uncomplicated disease responds well to conservative measures and OTC therapy, but the pharmacist's first and most important job is confirming the diagnosis and screening out the minority of presentations — particularly new or unexplained rectal bleeding — that need medical assessment before any self-care plan begins.^[3][4]

Anatomy of internal hemorrhoids (above the dentate line, mucosa-covered, visceral innervation) versus external hemorrhoids (below the dentate line, squamous-covered, somatic innervation). (WikipedianProlific and Mikael Häggström, CC BY-SA 3.0, Wikimedia Commons)

External hemorrhoids present differently: because they carry somatic sensory innervation, they cause pain — most often when a vein within one thromboses, producing a tense, tender, bluish-purple perianal lump that can appear suddenly.^[1] Mixed hemorrhoids, where internal and external plexuses are both involved and bridge the dentate line, combine features of both.^[1]

Symptoms across grades and types include painless bright red bleeding (the classic first symptom of internal disease), pruritus, mucus discharge, fecal seepage or soiling, a palpable lump, and — mainly with prolapse, thrombosis, or a coexisting fissure — pain.^[1] Symptom severity does not track cleanly with Goligher grade, so use the grading system as a guide to selecting treatment intensity, not as a predictor of how bothered a given patient will be by their symptoms.^[1]

• Age — prevalence peaks between 45 and 65 years and is uncommon under age 20.^[1]
• Pregnancy — increased pelvic venous pressure and hormonal changes cause anal cushion congestion; more than 1 in 4 women experience hemorrhoids during pregnancy, and symptoms often resolve after delivery.^[2]
• Chronic constipation and straining during defecation.^[1]
• Chronic diarrhea — increasingly recognized as a contributor alongside constipation, not simply its protective opposite.^[1]
• Low dietary fiber intake, which drives the constipation and straining above.^[2]
• Obesity, including abdominal obesity specifically.^[1]
• Sedentary lifestyle and prolonged sitting or standing; conversely, at least 150 minutes/week of moderate physical activity has been associated with lower hemorrhoid occurrence.^[1]
• Family history of hemorrhoidal disease.^[1]
• Depressive mood — population studies have found a consistent association between depression and hemorrhoid prevalence, for reasons not yet fully understood.^[1]
• Prolonged toilet time, including habits such as reading or using a phone while on the toilet.^[1]

History

• Characterize the bleeding: color (bright red versus dark or tarry), timing relative to defecation, whether it is on the tissue, dripping into the bowl, or mixed into the stool, and duration.
• Ask specifically about pain — severity, whether it is present at rest or only with defecation, and whether a tender lump is present — since pain out of proportion to typical hemorrhoidal symptoms points toward a fissure or abscess rather than hemorrhoids.^[1]
• Ask about prolapse (does anything come out, and does it reduce on its own, need to be pushed back, or stay out), pruritus, mucus discharge, and fecal seepage or soiling.
• Screen bowel habits directly: frequency, straining, and stool consistency — the Bristol Stool Scale is a useful structured tool (types 1-2 suggest constipation, types 3-4 are ideal, types 5-7 suggest diarrhea).^[1]
• Ask about diet (fiber sources), fluid intake, physical activity, occupation (prolonged sitting/standing), and, in women, pregnancy or recent delivery.
• Screen every red flag explicitly rather than waiting for it to be volunteered — patients frequently minimize or feel embarrassed about anorectal symptoms.^[1]

Examination

Visual inspection of the perianal area, with straining if tolerated, identifies external hemorrhoids, prolapse, skin tags, fissures, and fistula openings. A digital rectal exam and, where available, anoscopy allow direct visualization and grading of internal hemorrhoids, and are recommended for every new suspected-hemorrhoid presentation before treatment begins — specifically to confirm the diagnosis rather than assume it.^[4]

Differential diagnosis

Diagnostic uncertainty matters in practice: in one study, only 18% of patients who believed they had hemorrhoids actually did on examination, with the rest attributable to one of the conditions above.^[1] When the presentation is atypical, when pain is disproportionate, or when bleeding is new and unconfirmed by prior anoscopy, confirm the diagnosis before treating rather than defaulting to a hemorrhoid self-care plan.^[1][4]

• Relieve bleeding, pain, pruritus, and the discomfort of prolapse or swelling.
• Normalize bowel habits — softer, more regular stool passed without straining — to reduce both current symptoms and the drivers of recurrence.^[3]
• Prevent progression to a higher Goligher grade or to acute complications such as thrombosis or strangulation.
• Use topical corticosteroids, anesthetics, and vasoconstrictors only for the shortest effective course, since all 3 classes carry real harms with prolonged or repeated use.^[4][1]
• Correctly identify the minority of patients whose presentation needs anoscopy, colonoscopy, or specialist referral rather than a self-care trial — this is a bigger determinant of good outcomes than the choice of OTC product.^[1]

• Increase dietary fiber gradually toward a total intake of roughly 25-30 g/day (age- and sex-specific targets: about 25 g/day for women and 38 g/day for men under 50, and about 21 g/day for women and 30 g/day for men over 50), pairing the increase with about 2 L of fluid daily to limit bloating.^[1]
• Use a commercial fiber supplement (e.g., psyllium) when dietary sources alone are not enough to reach target intake.^[1]
• Avoid straining and limit time spent on the toilet; do not bring a phone, book, or other reading material into the bathroom, since it encourages prolonged sitting.^[1]
• Respond promptly to the urge to defecate rather than deferring it.
• Take a sitz bath — warm water covering the hips and buttocks — for about 15-20 minutes after bowel movements and as needed for comfort.^[1][2]
• Maintain regular moderate-intensity physical activity (at least 150 minutes/week) and avoid prolonged sitting or standing.^[1]
• Maintain a healthy body weight; obesity, including abdominal obesity specifically, is an independent risk factor.^[1]
• Practice gentle anal hygiene — pat rather than wipe vigorously, and consider unscented, alcohol-free moist wipes instead of dry toilet tissue during a flare.^[1]
• Treat the underlying driver directly — constipation or diarrhea — rather than only treating the hemorrhoidal symptoms it is causing.^[1]

Pregnancy

Hemorrhoids are very common in pregnancy — over 1 in 4 pregnant women are affected, driven by increased pelvic venous pressure, hormonal changes, and later straining — and symptoms often improve after delivery.^[2]

Breastfeeding

Topical products with minimal systemic absorption (astringents, protectants, anesthetics, and short-course topical corticosteroids) are reasonable choices. Data on oral phlebotonics in lactation are limited; apply the same prescriber-judgment approach as in pregnancy if oral therapy is being considered.

Pediatrics

True hemorrhoidal disease is rare in children. A perianal mass, bleeding, or pain in a child should not be assumed to be a hemorrhoid — the pediatric differential (constipation-related fissures, rectal prolapse, juvenile polyps, and other causes) differs from the adult differential, and these presentations warrant medical assessment rather than a self-care trial.

Older adults

Age over 65 alone warrants additional scrutiny and a lower threshold for referral, since the prevalence of colorectal cancer and other serious anorectal pathology rises with age and can present with the same symptoms as hemorrhoids.^[1] Comorbidities and polypharmacy — anticoagulant or antiplatelet therapy especially — further lower the threshold to investigate new or changing bleeding rather than attribute it to hemorrhoids by default.^[1]

Immunosuppression and anticoagulation

Both change the risk-benefit calculation: immunosuppressed patients need closer monitoring for infection (including one a topical corticosteroid could mask), and patients on anticoagulant or antiplatelet therapy need a lower threshold for investigating bleeding, since it can be harder to distinguish clinically significant bleeding from expected minor hemorrhoidal bleeding in this group.^[1]

Set a specific follow-up point rather than leaving it open-ended — reassess at about 7 days, matching the duration most OTC hemorrhoid product labeling supports before advising the patient to stop self-care and seek medical attention if symptoms persist, worsen, or bleeding continues.^[3][1]

1. Confirm the diagnosis is actually hemorrhoids — reconsider anal fissure, abscess, fistula, pruritus ani, or a more serious anorectal or colorectal condition, and arrange anoscopy or referral if this was never confirmed on examination.^[1]
2. Confirm adherence to conservative measures specifically — actual daily fiber and fluid intake, not just intention to increase them, since this is the intervention most likely to be under-dosed.^[1]
3. Confirm topical therapy was used correctly and for an adequate duration, and that a corticosteroid-containing product was not used too briefly (or too long) to still be expected to help.
4. Re-screen every red flag — new or changing symptoms since the first assessment can shift a patient from appropriate self-care into needing referral.^[1]
5. If diagnosis, adherence, and duration are all confirmed adequate but symptoms persist, add or escalate — an oral phlebotonic if not already tried, or referral for an office-based procedure (rubber band ligation preferred) for grade I-III disease.^[3][1]
6. Persistent grade III-IV disease, external or mixed disease with prolapse, or failure of office-based procedures warrants surgical referral.^[3]

• Treating any rectal bleeding as automatically hemorrhoidal without an exam or a red-flag screen — only about 18% of patients who self-attribute symptoms to hemorrhoids actually have them on assessment.^[1]
• Continuing a topical corticosteroid-containing product well beyond its labeled duration because symptoms are "better but not gone."^[4]
• Recommending a suppository for external hemorrhoids — suppositories are formulated to melt inside the rectum and are not an effective delivery method for external disease; use a cream or ointment applied externally instead.^[1]
• Treating severe anal pain as hemorrhoidal without considering a fissure or abscess, which are more likely causes of pain that severe.^[1]
• Not asking about anticoagulant or antiplatelet therapy before reassuring a patient that their bleeding is minor.^[1]
• Leaving the underlying constipation or diarrhea untreated while only managing the hemorrhoidal symptoms it is causing.
• Increasing fiber too quickly, or without adequate fluid, producing bloating and gas that undermines adherence to the single most effective conservative measure.^[1]
• Recommending an oral phlebotonic, or any other therapy, without setting a follow-up point — an open-ended self-care trial delays recognizing treatment failure.
• Assuming pregnancy explains new bleeding without at least considering the same differential used in a non-pregnant patient.

How to use this table: Doses are adult doses unless a separate line is given, and require patient-specific confirmation, including renal/hepatic adjustment. Select any drug name to open its complete Pharmasist Drug Database page.

Bulk-forming fiber supplements

The single most evidence-supported intervention for hemorrhoidal bleeding and recurrence; a first-line measure for every grade, not just mild disease.

Stool softeners and short-term laxative adjuncts

Used when straining persists despite adequate fiber, or when straining specifically must be avoided (e.g., after a procedure).

Topical astringents

Cause protein coagulation on the skin surface to reduce itching and irritation; limited controlled trial evidence specific to hemorrhoids but a long safety record.

Topical protectants

Create a physical barrier over the affected area to reduce further irritation and promote healing; effectiveness data specific to hemorrhoids are limited but these agents are considered safe.

Topical anesthetics

Provide temporary pain and pruritus relief; do not treat the underlying disease.

Topical corticosteroids

Reduce inflammation, pruritus, and swelling; the class most in need of an explicit duration limit.

Topical vasoconstrictors

Temporarily shrink swollen hemorrhoidal tissue.

Oral venotonics / phlebotonics

Plant-based bioflavonoids that improve venous tone, capillary permeability, and lymphatic drainage; newly acknowledged (with a weak recommendation) in the 2024 ASCRS guideline.

Prescription options for refractory anorectal pain (off-label, adjunct)

Reserved for prescriber-directed use when conservative and standard topical/oral therapy have not controlled pain — not routine first choices for uncomplicated hemorrhoids.