Within the walls of the anal canal there are three main cushion-like areas containing a combination of small, irregularly-shaped blood vessels, connective tissue, and smooth muscle. Smaller, similar areas are interspersed in between and around the internal anal opening.1 During bowel movements and when we cough, sneeze, or strain, these areas engorge with blood. In the case of bowel movements, the swelling protects the underlying anal tissue, and during coughing, sneezing, and straining the fullness created by the engorged cushions helps prevent stool leakage. Typically, the swelling resolves quickly following these actions. The top surface areas also contain nerve endings, which help us sense the difference between liquid, solid, and gas in the anal area.2

When the cushions stay swollen, sometimes pushing out of location, they’re known as hemorrhoids. When the rectal tissue bulges outside of the anus, it’s known as a prolapse.3 You will find that most sources refer to these enlarged masses of rectal tissue simply as hemorrhoids, and we will also do this throughout this article. Hemorrhoids may have a number of predisposing causes, but, in most cases, increased pressure in the abdomen plays a key role. Some of the most common underlying factors for developing hemorrhoids include constipation and straining during bowel movements, repeated lifting of heavy objects, frequent diarrhea, prolonged sitting or standing, obesity, and pregnancy. Nearly 5% of the population have hemorrhoids at any given time,4 and by the time you are fifty years of age, there is a 50% chance you will have experienced them at least once. Your chances increase if you have a family history of hemorrhoids, and 38% of women in the third trimester of pregnancy will have them.5

There are two types, external and internal, which can occur separately or in combination. You could have a single hemorrhoid, or have several at the same time. The main symptom of internal hemorrhoids is bright red blood during or after a bowel movement, but they are not usually associated with pain unless they develop a blood clot (thrombose). External hemorrhoids are more nerve-rich and more likely to cause pain and itching; they usually appear as a hard purple bulge outside of the anus. Many people do not seek medical help unless symptoms are severe, because of embarrassment and stigma around anal problems. It is very important that you receive a correct diagnosis from a medical professional, as rectal bleeding and pain can also be symptoms of other, more serious, gastrointestinal conditions.

Hemorrhoids usually resolve within a few days on their own, and you may find that you can manage the symptoms through at-home methods. Ensuring a balanced diet that is high in fibre and includes adequate amounts of fluid; taking sitz baths, in which you sit in a warm, shallow bath containing salt; and over-the-counter topical treatments might help relieve symptoms. Sometimes, however, hemorrhoids persist, become very large, or cause extreme pain, requiring medical treatment. Depending on your particular situation, a physician will choose from a number of treatments, including traditional surgery, rubber band ligation, coagulation therapy, sclerotherapy, cryosurgery, or stapling. In this article, we will review these procedures and look at how physicians perform them, how they work, possible side effects, and potential complications.


NSAID Risk: It is normal to experience some pain and discomfort following a medical procedure for hemorrhoids. A sitz bath or mild pain medication such as acetaminophen can provide some relief. However, do not use aspirin, ibuprofen, or any other non-steroidal anti-inflammatory drugs (NSAIDs) for 4-5 days before or after treatment, as these drugs increase your risk of bleeding.


Traditional Surgery

This procedure involves the surgical removal of the hemorrhoid using a scalpel, laser, or cautery pencil (which uses electricity). Your physician will usually choose this older methodology treatment only after other, less invasive treatments have failed. It is rare for a hemorrhoid removed by traditional surgery to return, but you may need to stay in the hospital for a few days after surgery, mostly due to pain. In addition, healing time is considerably longer than for other treatments, taking about 5-6 weeks.6


Rubber Band Ligation

Rubber band ligation is the most common procedure to treat internal hemorrhoids and it is very effective. After inserting a device called a syringe ligator into your anus, the physician will gently draw the hemorrhoid into the device, twisting it slightly and then locking it in place above the sensitive dentate line, before quickly securing a rubber band around the hemorrhoid’s base to complete the process. This procedure, like several others we will discuss, works by cutting off the blood supply to the hemorrhoid, causing the tissue to die and fall off in about a week. It is normal to experience slight bleeding when this occurs. Fibrous tissue forms during healing, fixing the remaining hemorrhoidal cushion in place, which helps to prevent future hemorrhoids in that area.4,7

If you experience pain or discomfort after the procedure, your physician can adjust the band slightly with a gloved finger or inject the area with pain medicine.8 Aside from traditional surgery, which comes with additional risks and side effects, rubber band ligation is the most effective removal method for medium-sized internal hemorrhoids. However, it is not appropriate for very small or very large hemorrhoids.

Side effects include feeling as if you need a bowel movement. Some pain is also normal, especially 24-48 hours after the procedure. Rare side effects include severe unresponsive pain, bleeding, inability to pass urine, and infection.9 A physician normally performs only one or two ligations per session, as simultaneous ligations increase the risk of complications.3


Coagulation Therapy

The most common type of coagulation therapy is infrared photocoagulation, in which your physician will use the heat from an intense beam of infrared light to create fibrous tissue on the hemorrhoid, cutting off the blood supply to the enlarged rectal tissue. Your physician might also perform coagulation therapy with a laser or an electrical current. This treatment is for small or medium-sized hemorrhoids. There is a risk of pain during this procedure and symptomatic hemorrhoids may recur. Side effects and complications are about the same as those for rubber band ligation.10



Your physician may choose sclerotherapy to treat internal hemorrhoids that are too small for rubber band ligation. The physician injects a chemical (the sclerosant) into the base of the hemorrhoid, which hardens and prevents blood from feeding the enlarged mucosal tissue, which dies and eventually falls off. The resulting fibrous tissue helps to prevent additional hemorrhoids from forming in the same location. However, hemorrhoids do sometimes return after sclerotherapy, requiring a repeat of treatment. It is normal to experience some pain after this procedure. Rare complications may include an allergic reaction to the sclerosant, severe or persistent pain, infection, or bleeding. This procedure requires a high degree of skill, as injecting the chemical into the wrong area, such as the anal vein or the prostate, can cause other, more serious complications.11



In this procedure, your physician will first use local anaesthesia to numb the area before applying either nitrous oxide or liquid nitrogen with a cryoprobe to freeze internal or external hemorrhoids. The physician may also tie them off (ligate) before freezing them. The hemorrhoids shrink and fall off in 2-3 weeks. There tends to be more pain after this type of treatment, and there are increased risks, such as infection and bleeding. Cryosurgery was once very common, but most physicians now opt for a different treatment due to the many potential complications of this procedure.12



Stapling, also known as procedure for prolapse and hemorrhoids (PPH), is a technique used for large prolapsed hemorrhoids.13 A prolapsed hemorrhoid is an internal one that has pushed down and stretched until it bulges outside of the anus. Under local anaesthesia, your physician will use a number of special tools to push the tissue nearer to its original location along the anal or rectal wall, remove excess tissue, and then secure the cushion to its original location with circular titanium staples. Fibrous tissue forms around the staples during healing, which helps to anchor the hemorrhoidal cushion in place. The staples eventually pass unnoticed with your stool.

Stapling results in a higher chance of hemorrhoid recurrence than with traditional surgery, but comes with a faster, less painful healing time.14 As with other procedures, you may have the sensation of rectal fullness and/or pressure for several days following the procedure. You may also have some bleeding. Potential complications include a temporary inability to pass urine, tearing of the lining of the anal wall (fissuring), trauma to the rectal wall, excessive scar tissue that narrows the anal or rectal wall, and infection.15



After any successful hemorrhoid treatment, it is important to maintain a balanced diet that is high in fibre, and to drink adequate amounts of fluid. If you experience hemorrhoids that persist for an extended period or are very painful, visit your physician to discuss the treatment options that are best for you.


4 Simple Steps to Help Prevent Hemorrhoids16

If you are pregnant or genetically predisposed to developing symptomatic hemorrhoids, they may be impossible to prevent, but the following tips may nonetheless lower your risk of experiencing them:

  • Consume well-balanced meals and snacks, ensuring high-fibre content and adequate fluid intake.
  • Avoid sitting or standing for long periods. Take short walks whenever you can.
  • Do not delay bowel movements when you feel the urge.

Breathe freely and avoid prolonged straining during bowel movements and other activities that could involve straining, such as lifting heavy objects.

Dr. Iain G.M. Cleator, Professor Emeritus of Surgery
First published in the Inside Tract® newsletter issue 183 – 2012
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3. Madoff RD et al. American Gastroenterological Association Technical Review on the Diagnosis and Treatment of Hemorrhoids. Gastroenterology. 2004;126:1463-73.
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16. HealthLinkBC. Hemorrhoids: Prevention. http://www.healthlinkbc.ca/kb/content/major/hw213495.html#hw213687. Accessed 2012-08-15.