What are hemorrhoids?
Hemorrhoidal disease is the abnormal dilatation and prolapse of the hemorrhoidal cushions — normal vascular structures of the anal canal that contribute to fine continence. When these venous structures become dilated and prolapse, they cause the typical symptoms.
Hemorrhoids are classified as internal (above the dentate line) and external (below the dentate line). Internal hemorrhoids are graded I–IV according to the degree of prolapse, while external are typically associated with thrombosis or skin tags.
How common is it?
Hemorrhoidal disease is one of the most common conditions in the Western world. It is estimated that approximately 40% of the adult population will at some point have symptoms compatible with hemorrhoids. The actual prevalence is likely higher, as many do not consult a doctor due to embarrassment.
It affects men and women almost equally, with peak incidence between 45 and 65 years. Many patients have already self-treated for years before seeking specialist care.
How does it present?
The main symptoms of hemorrhoidal disease include:
- Bright red rectal bleeding, usually painless, on toilet paper or in the toilet bowl after defecation.
- Prolapse: feeling of swelling at the anus, especially after defecation. Initially reduces spontaneously, later requires digital reduction.
- Discomfort, anal itching or feeling of moisture.
- Local pain (typically when there is thrombosed external hemorrhoid).
- Soiling underwear from mucus discharge.
- Acute severe pain — usually thrombosed external hemorrhoid, requires immediate evaluation.
How is it diagnosed?
Diagnosis is mainly clinical:
- Detailed history of symptoms and bowel habits.
- Clinical examination including inspection, digital rectal examination and proctoscopy.
- Colonoscopy in patients >45 years or with risk factors for colorectal cancer, to exclude other causes of bleeding.
- Sigmoidoscopy in selected cases.
- Investigation for other coexistent perianal pathology (fissure, fistula, abscess).
Which factors increase risk?
There is a hereditary predisposition related to connective tissue weakness, but acquired factors predominate.
- Family history of hemorrhoids.
- Chronic constipation and straining during defecation.
- Diet low in fibre and water.
- Sedentary lifestyle, prolonged sitting (drivers, office workers).
- Pregnancy and childbirth.
- Obesity.
- Aging — loss of connective tissue support.
- Heavy lifting, weightlifting without proper technique.
- Chronic diarrhea.
Modern therapeutic options
The choice of the appropriate technique is individualised for each patient, based on disease stage, severity of symptoms and patient preference. The trend today is towards minimally invasive techniques.
Conservative Treatment (1st line)
For most cases of stages I–II. Includes increased fibre and water intake, mild laxatives, avoidance of straining, sitz baths in warm water, topical creams with steroids or local anesthetic. Effective in 70–80% of cases.
Doppler-Guided Hemorrhoidal Ligation
Modern minimally invasive technique for stages II–III. Doppler-guided ligation of the hemorrhoidal arteries with simultaneous repair of the prolapse (mucopexy). Painless procedure, performed in day clinic. Excellent results with rapid return.
Stapler Hemorrhoidopexy (Longo)
For stages III–IV. Uses a specialised stapler that resects a circular ring of redundant mucosa with simultaneous repair of the prolapse. Significantly less postoperative pain compared to classic hemorrhoidectomy and faster recovery.
Conventional Hemorrhoidectomy
Surgical excision of hemorrhoids (open Milligan-Morgan or closed Ferguson technique). Reserved for stage IV, very large hemorrhoids or after failure of minimally invasive techniques. Postoperative pain is more pronounced.
Frequently asked questions
Is the surgery for hemorrhoids painful?
Modern techniques (HAL-RAR, THD, Longo) are almost painless. Even classic hemorrhoidectomy is now performed with modern protocols (multimodal analgesia, sphincter relaxation) that significantly reduce pain. The era of "hemorrhoid surgery is hellish" is over.
Can hemorrhoids recur?
With minimally invasive techniques, recurrence rate is 10–20% at 5 years. With classic hemorrhoidectomy, recurrence is <5%. Most important for prevention of recurrence is changing bowel habits — adequate fibre, water and avoidance of straining.
Will I be able to control gas and stool after surgery?
Yes. Modern techniques (HAL-RAR, Longo) do not affect continence. With classic hemorrhoidectomy and in selected cases, mild transient changes are possible but resolve within weeks.
Is conservative treatment effective?
In stages I–II, conservative treatment is effective in 70–80% of cases — even patients with very advanced disease can have significant symptom improvement. It should always be tried first, before surgical options.