Can You Have Painless Hemorrhoids?

Hemorrhoids are classified as internal or external:

• Internal hemorrhoids develop behind the lining of the anus. The most typical symptoms include painless bleeding and protrusion during bowel movements. However, if an internal hemorrhoid is prolapsed, it can be extremely painful and cannot be forced back within the anal canal.
• External hemorrhoids develop close to the anus and are covered by delicate skin. They may not cause severe pain unless a blood clot (thrombosis) occurs, or they swell up significantly. Thrombosed external hemorrhoids are blood clots that develop as external hemorrhoids under the anal skin and can be extremely painful. A painful anal mass may appear overnight and subside during the next 48 hours. You may observe bleeding if the top skin cracks.

Constipation is the main cause of hemorrhoids. Constipation makes it difficult to pass stools and can cause the blood vessels in the anus to become compressed and swollen. Other factors that can raise your risk of developing hemorrhoids include:

• Older age
• Obesity
• Diarrhea
• Sitting for long periods of time
• Lifting heavy objects regularly
• Coughing and sneezing often
• Pregnancy due to:
  • The growing fetus which puts pressure on the abdomen
  • Increase in blood circulation
  • Pregnancy hormones that cause the blood vessels to soften
• Family history of hemorrhoids

If you have hemorrhoids, you may observe bright red blood on your toilet paper or in your toilet when you have a bowel movement. The area around the anus may be itchy, uncomfortable, or painful. Occasionally, a prominent bump may develop around the anus.

In many cases, there are no symptoms at all or only very minor symptoms that subside on their own. For some people, however, hemorrhoids may be more painful.

Based on the degree of prolapse (how much the hemorrhoids protrude outside the anus and whether it is temporary or permanent), internal hemorrhoids are divided into four grades:

• Grade I: May bleed slightly with bowel movements, but usually stay inside the anus and is not particularly painful
• Grade II: Bleed and protrude out of the anus with bowel movements, then retract on their own afterward
• Grade III: Need to be forcefully pushed back inside the anus after a bowel movement; may cause pain if large in size
• Grade IV: Larger masses that protrude permanently and cannot be retracted; may clot (thrombose) and may become excruciatingly painful

Although hemorrhoids can be painful, they rarely result in major complications. In rare cases, hemorrhoids may lead to:

• Anemia
• Blood clots
• Infection
• Anal fistula (a tiny channel forms between the inside of the anus and the skin)
• Fecal incontinence (loss of control over bowel movements)

Hemorrhoids often resolve on their own without medical intervention. Pain and bleeding symptoms may linger for a week or even longer. In the meantime, you can do the following to minimize symptoms:

• Apply topical medications such as hydrocortisone,  witch hazel, or lidocaine to the area
• Take nonsteroidal anti-inflammatory medications (NSAIDs) for pain and inflammation
• Drink more water and increase your fiber intake
• Take laxatives to soften the stools
• Take a warm sitz bath for 10-20 minutes each day
• After a bowel movement, gently pat and clean your bottom with toilet paper infused with lotion, flushable wet wipes, or a washcloth or tissue that is slightly wet (wipes should be disposed of in the garbage; washcloth should be washed separately in hot water to prevent the spread of germs)

For grades, I, II, and III hemorrhoids that have not responded to conservative management, office-based treatment methods are frequently employed. Reducing blood flow to the hemorrhoidal sac is the main objective of these treatments:

Rubber ligation

Rubber band ligation involves wrapping a small elastic band around the base of the hemorrhoids. The band holds the hemorrhoids in place, causing the hemorrhoids to contract and the surrounding tissue to scar as it heals. To completely remove the hemorrhoids, 2-4 procedures must be performed 6-8 weeks apart. 

Mild discomfort or tightness (which is typically eased with a sitz bath), bleeding, and infection are among the rare complications.

Sclerotherapy

Sclerotherapy involves injecting a sclerotic substance into the submucosa of the hemorrhoidal sac, which sets off an inflammatory response and causes fibrotic tissue to develop that interrupts the blood supply to the hemorrhoids. There are many sclerotic agents available, such as quinine, ethanolamine, and hypertonic saline, and 5% phenol in almond or vegetable oil. 

Although rare, the injection can result in sepsis and prostatic abscess. People with a high fever and postoperative discomfort should be closely monitored.

Infrared photocoagulation

With infrared photocoagulation, your physician will produce a tiny burn (using an electric probe, laser beam, or infrared light) to remove tissue and gently seal the ends of the hemorrhoids, causing them to close off and shrink. Prolapsed hemorrhoids respond best to this treatment method.