Enlarged Hemorrhoids and Hemorrhoidal Disorders: Information & Doctors

Hemorrhoids are completely normal anatomical structures in the human body. A doctor diagnoses hemorrhoidal disease when patients experience symptoms in the area of the anus and rectum or the anal mucosa. These symptoms usually do not cause pain, but they can cause discomfort such as itching. 

About 4 out of every 100 adults report symptoms of hemorrhoidal disease; a family history of enlarged hemorrhoids increases the risk of developing them.

Problems in the anal region are still considered a taboo subject. As a result, very few patients seek early treatment from a proctologist for conditions affecting the rectum. 

According to estimates, about 50% of the population in Germany over the age of 50 suffers from hemorrhoids. In principle, no age group is immune to hemorrhoids. The number of unreported cases is very high, and it appears that slightly more men than women are affected. 

Treatments such as suppositories or anal tampons can provide short-term relief; however, in cases of advanced hemorrhoids, proctologists recommend surgical treatment, in which the hemorrhoids are tied off.

Doctors classify hemorrhoids into 4 stages:

First-degree hemorrhoids

The dilated blood vessels are still very small. Doctors usually discover them incidentally during a colonoscopy. Pain does not occur at this stage, but bleeding may occur.

Second-degree hemorrhoids

The hemorrhoidal nodules are already somewhat enlarged and protrude outward during bowel movements due to abdominal pressure. However, they spontaneously retract back into the rectum after a bowel movement. In addition to bleeding, burning and itching may also occur at this stage.

Third-degree hemorrhoids

Here, the hemorrhoids protrude outward when straining or even spontaneously, but do not retract on their own. You must push the hemorrhoids back into place with your finger. In addition to burning and itching, there may be increased pain and fluid discharge. A mild form of fecal incontinence, known as “fecal smearing,” may also occur.

Grade 4 Hemorrhoids

When hemorrhoids protrude but can no longer be pushed back, doctors refer to them as fourth-degree hemorrhoids. This often occurs as an acute event, which can be accompanied by severe pain. Insufficient blood supply and thrombosis (blood clots) further increase the burden on those affected.

The exact causes of hemorrhoids are unknown. Genetic factors appear to play an important role. Dietary factors can also contribute to symptomatic hemorrhoids.

When constipated, patients usually have to strain harder to have a bowel movement. This causes the hemorrhoidal vessels to fill with blood, which can lead to their enlargement. The mucous membrane can also tear due to the increased pressure during straining and protrude outward at the opening of the rectum.

The doctor often makes the diagnosis based on the patient’s description during the medical history interview. The doctor’s initial suspicion can be confirmed by examining the anal region. If necessary, a rectoscopy is performed.

This examination of the rectal area makes it possible to determine the stage of the hemorrhoids and to identify the cause of blood in the stool. When hemorrhoids are suspected, doctors always rule out colorectal cancer and polyps, which are precursors to colorectal cancer.

Treatment is primarily based on the nature of the symptoms. In most cases, however, medication combined with lifestyle changes is sufficient. Surgery is always the last resort for treating hemorrhoids.

The stated goal of treatment is to ensure that stools are sufficiently soft. They should be passed without significant effort, i.e., without straining. To achieve this, the patient should adopt a high-fiber diet and also ensure adequate fluid intake and physical activity.

Taking bulk-forming agents such as psyllium husks can also lead to softer stools and thus reduce discomfort.

Creams, ointments, and suppositories are often used to treat hemorrhoids. While the ingredients they contain (e.g., local anesthetics or cortisone) can reduce the sensation and thus alleviate symptoms, they do not provide a cure.

If these conservative treatment approaches are unsuccessful, interventional methods are available. Rubber band ligation and sclerotherapy are particularly common. With these procedures, doctors reduce the blood supply to the hemorrhoids.

In ligation, doctors place a rubber band around the adjacent mucous membrane, causing that tissue to die off. In sclerotherapy, they inject a liquid that has the same effect as the rubber band. Long-term success with these methods, however, is rather rare.

The best results are achieved through surgical treatments.

In these procedures, doctors remove:

• the enlarged hemorrhoids themselves (known as hemorrhoidectomy) or
• the mucous membrane above the hemorrhoids (known as stapled mucosectomy)

The long-term success rate with these methods is 85–95%.