What Are Internal Hemorrhoids (Piles)?

Hemorrhoids (also called piles) are swollen blood vessels around the anus. There are two types of hemorrhoids: external, which appear outside the anus, and internal, which appear just inside the anus in the lower rectum. Both types of hemorrhoids are primarily caused by extreme or prolonged pressure on the rectum walls, although there can also be other contributing factors. 

Hemorrhoids affect all genders equally. They are more common in white people and people of higher socioeconomic status. They are not common in people under age 20, become more common as people age, then become less common after age 65. About half of people over the age of 50 have had one or more hemorrhoids.

Internal hemorrhoids can cause symptoms such as bleeding, itching, and pain in the anal area. While external hemorrhoids generally go away on their own, symptomatic internal hemorrhoids likely need further treatment. Doctors diagnose this type of hemorrhoid by looking or feeling inside the rectum for lumps.

Once diagnosed, hemorrhoids often can be treated with at-home measures or simple non-surgical procedures. However, more extreme cases may require surgery.

Symptoms

Internal hemorrhoids usually are not visible from the outside, and they often do not cause noticeable symptoms. In fact, only about 5% of people with hemorrhoids experience symptoms. These symptoms tend to build slowly over time, and they may come and go.

One common sign of internal hemorrhoids is finding blood in the toilet or on toilet paper after a bowel movement. This blood is typically bright red. Sometimes, internal hemorrhoids can become prolapsed, or so swollen that they protrude from the anus. A prolapsed internal hemorrhoid can cause symptoms ranging from minor discomfort to intense pain.

Along with bleeding and prolapse, other internal hemorrhoid symptoms may include:

• Itching around the anus
• Irritation around the anus
• Mucus in your stool
• Trouble or discomfort cleaning your anus after a bowel movement
• Feeling that stool is blocked at the anus
  

What Causes Internal Hemorrhoids?

In general, internal hemorrhoids are caused by factors that increase the pressure on the veins inside your rectum or factors that weaken the tissue around those veins. All of these factors can cause the veins to dilate.

Factors that may cause increased pressure on the veins inside the rectum include:

• Chronic constipation that leads to frequent straining on the toilet
• Chronic diarrhea
• Eating a low-fiber diet
• Lifting heavy objects frequently

Factors that may weaken the tissue around the veins inside the rectum include pregnancy and the natural aging process, among others.

Diagnosis

A medical professional, usually a gastroenterologist or a colorectal surgeon, can diagnose internal hemorrhoids. Your healthcare provider will use several methods to make a diagnosis. 

First, they will ask about your symptoms, your medical history, and your family’s medical history. Then, they will visually inspect your anus to see whether you have external hemorrhoids, prolapsed internal hemorrhoids (internal hemorrhoids that are protruding through your anus), or both.

To learn more, they may also perform:

• A digital exam, which involves feeling inside your lower rectum with a gloved finger to assess your muscle tone and check for bleeding or lumps.
• An anoscopy, in which the they use a hollow tube with an attached light (anoscope) to look at the tissue that lines your rectum.
• A rigid proctosigmoidoscopy, in which they use a metal tube (proctoscope) to look at the lining of your rectum and lower colon.

If bleeding is one of your symptoms, they will need to rule out other, more serious causes of the bleeding first. They may want to perform a colonoscopy to do so. A colonoscopy is a procedure in which a scope is used to inspect your entire colon while you are under general anesthesia.

Stages of Internal Hemorrhoids

Internal hemorrhoids are assigned a grade according to the severity of the prolapse. These grades are:

• Grade 1: No prolapse
• Grade 2: Some prolapse, but the hemorrhoid retracts into the rectum on its own
• Grade 3: Some prolapse, but you are able to push the hemorrhoid back inside your rectum
• Grade 4: Constant prolapse that is often painful

Treatments for Internal Hemorrhoids

Treatment for internal hemorrhoids varies depending on their severity and symptoms. Hemorrhoids that are not symptomatic generally do not require treatment. However, there are several treatment options that can relieve the pain or discomfort of symptomatic hemorrhoids.

At-Home Treatments

Most internal hemorrhoids, including prolapsed ones, can be resolved with lifestyle changes you make at home. Depending on your healthcare provider's recommendations, these changes may include:

• Eating more fiber-rich foods or taking a fiber supplement
• Taking an over-the-counter stool softener
• Increasing your intake of water and other liquids
• Trying not to strain on the toilet or sit too long on the toilet
• Taking over-the-counter pain relievers
• Applying over-the-counter ointments or hemorrhoid creams
• Using anal suppositories
• Taking warm, shallow baths (sitz baths) frequently

In-Office Procedures

If the methods listed above have not successfully managed your symptoms, ask your healthcare provider about non-surgical options. The following are non-surgical procedures that can be performed in their office:

• Rubber band ligation: This procedure is commonly used for prolapsed internal hemorrhoids. A small rubber band is placed around the base of the hemorrhoid to cut off its blood supply. Eventually, the hemorrhoid falls off.
• Sclerotherapy: A chemical solution is injected into the hemorrhoid, which creates scar tissue that cuts off the blood supply to the hemorrhoid. This may cause it to shrink and eventually disappear.
• Infrared coagulation: In this procedure, a special device is used to apply heat to the hemorrhoid. The heat creates scar tissue, which cuts off the blood supply and may cause the hemorrhoid to shrink.
• Electrocoagulation: This procedure has the same effect as infrared coagulation, but an electric current is used instead of heat to create the scar tissue.

Hemorrhoidectomy

In severe cases, a hemorrhoidectomy may be necessary. This is a surgical procedure in which a surgeon removes the hemorrhoid, usually with a scalpel or electrosurgical device. There are several techniques the surgeon may use to perform a hemorrhoidectomy, but they all share the same goal of removing a severe hemorrhoid.

Grade 3 or 4 internal hemorrhoids that are causing extreme pain or bleeding may require a hemorrhoidectomy. Hemorrhoids that have not resolved with at-home treatments or non-surgical procedures also may qualify for this treatment.

Prevention

Methods of preventing internal hemorrhoids are highly similar to methods of treating them at home. The following lifestyle changes may help to both prevent new and treat existing hemorrhoids:

• Eat foods that are high in fiber and/or take a fiber supplement: The federal Dietary Guidelines for Americans, 2020–2025, recommends getting 14 grams of fiber per 1,000 calories you take in. Foods that are high in fiber include fruits and vegetables, beans, and whole grains.
• Drink more water and other liquids. These can include fruit juices and clear soups if your healthcare provider recommends them. 
• Try not to strain or sit for too long on the toilet.
• Take an over-the-counter stool softener if you are having trouble passing hard stool.
• Avoid lifting heavy objects on a regular basis.

Related Complications

Complications of internal hemorrhoids are rare. However, if left untreated, some internal hemorrhoids may lead to:

• Severe prolapse and/or pain: Weakened tissue and ongoing strain can lead to the gradual prolapse of the rectum, where the rectal tissue protrudes through the anus.
• Extreme blood loss: Prolonged and consistent loss of blood can lead to iron deficiency anemia, which is characterized by low iron levels in your blood.
• Thrombosis: This term refers to a blood clot forming in the vein affected by the hemorrhoid. Thrombosis is more common with external hemorrhoids but can occur with internal hemorrhoids. A thrombosed hemorrhoid is painful and needs treatment from a medical professional.
• Strangulation: This occurs when the muscles of the anus cut off the blood flow to a prolapsed hemorrhoid. Strangulated hemorrhoids are extremely painful, and they can lead to ulcers or tissue decay. They require immediate medical attention.

A Quick Review

Hemorrhoids are a common health issue that many people will experience, especially as they age. Internal hemorrhoids may not be visible and may cause no symptoms. If they do cause symptoms, simple lifestyle changes such as eating more fiber may help treat them as well as prevent new ones from appearing. Non-surgical and surgical treatment options are available for more severe cases.

If you experience persistent symptoms like bleeding, pain, or itching near your anus, consult a healthcare provider for proper diagnosis and treatment. These symptoms may be a sign of something other than hemorrhoids, such as inflammatory bowel disease or cancer.