Hemorrhoid (piles) treatment: stages, methods and recovery

Everyone has vascular cushions in the anal canal: they help keep the anus tightly closed. Long-lasting constipation and straining enlarge these cushions and weaken the tissue that holds them in place, and the cushions turn into nodes. In everyday speech these are called “piles,” and sometimes “hemorrhoid nodes.”

A cushion that has turned into a node does not go back to its former size on its own. Even if the symptoms settle for a while, the condition keeps progressing as long as the cause remains. That is why treatment has two goals: to shrink or remove the nodes, and at the same time to eliminate the constipation and straining that produced them. We explain in detail how hemorrhoids develop, their types and what they look like in the article What are hemorrhoids and how do they develop.

Hemorrhoids most often show up as bright red blood on the paper or in the toilet bowl after a bowel movement, a node that comes out during a bowel movement, and itching, burning and dampness around the anus. As the nodes grow, discomfort when sitting and a feeling that the bowel has not emptied completely are added. Blood from internal nodes is often painless, but when it goes on for months it can lead to anemia. We describe the symptoms in detail and when to see a doctor in a separate article.

These symptoms are not specific to hemorrhoids. A cutting pain that lasts for hours during and after a bowel movement is more often a sign of an anal fissure, and polyps and bowel cancer can also cause bleeding. So when you see blood, do not diagnose yourself. We explain the differences in the article 6 causes of blood on toilet paper.

The main causes of hemorrhoids are constipation and straining on the toilet. Sitting on the toilet with a phone for a long time, a sedentary job, heavy lifting, pregnancy and childbirth, excess weight and a family tendency also raise the risk. That is why hemorrhoid treatment goes together with treating constipation: if the cause remains, new nodes can form even after surgery.

Treatment for internal, external and thrombosed nodes

Internal nodes are located inside the anal canal and are divided into four stages. For them, treatment is chosen mainly according to the stage (see the table below).

External nodes are located at the edge of the anus. A small external node that causes no discomfort is usually just monitored, without surgery. Large external nodes that interfere with hygiene are often removed surgically.

With a thrombosed node (a node with a blood clot inside that swells suddenly and hurts a lot), timing is decisive. If you come in during the first days, removing the clot with a small procedure can quickly ease the pain, while in later days medication is often chosen. Internal nodes that come out and do not go back in can also become thrombosed.

Treatment by stage

The method is decided not by the stage alone, but by the size of the nodes, whether there is an external part, your symptoms and your general health together.

During pregnancy and after childbirth

Pregnancy and childbirth are times when hemorrhoids often flare up. Treatment at this point is mainly conservative: fiber, water, toilet habits and only those remedies prescribed by a doctor that are safe in pregnancy and breastfeeding. Planned surgery is usually left until after childbirth, with urgent cases being the exception. After childbirth, symptoms often ease within a few weeks. If they do not go away, come in for an examination.

If an anal fissure or a rectocele is found along with hemorrhoids, they can be treated in the same session. We explain why hemorrhoids develop in pregnancy in What are hemorrhoids, and other problems after childbirth in the article intimate problems after childbirth.

Treatment in men

Most of our male patients come after waiting for years, when the nodes have already grown. Heavy physical work, weight training and long hours behind the wheel often make the symptoms flare. That is why, after treatment, it is important to return to these activities gradually and with your doctor's permission. Treatment methods are the same for men and women.

In the following situations, do not wait. Seek care right away:

• bleeding does not stop, comes with clots or turns the toilet bowl red;
• dizziness, weakness or a racing heart along with bleeding;
• the stool is black and tar-like;
• a suddenly hard, bluish, very painful lump has appeared at the edge of the anus;
• a node that has come out does not go back, and it swells and darkens;
• fever along with pain and swelling in the anus: this may be a sign of paraproctitis.

The first visit with a hemorrhoid doctor starts with a conversation: we ask about your symptoms, your toilet habits and the medications you take. For the examination you usually lie on your left side with your knees drawn toward your abdomen. Your body stays covered, and only the area being examined is uncovered.

First the area around the anus is inspected, then a finger (digital rectal) examination and anoscopy are done: a small lubricated tube is used to look inside the anal canal. The examination takes a few minutes, and most patients feel mild discomfort rather than pain. No special preparation is usually needed.

If there is bleeding, a rectoscopy may be recommended to check the rectum. For patients over 40 who have both constipation and hemorrhoids, we recommend a colonoscopy, so that a more serious cause of bleeding is not missed.

We choose treatment according to the stage, the size of the nodes and your symptoms. The aim is not only to get rid of the nodes but also to fix what caused them.

Conservative treatment

In stages I–II, and during pregnancy, treatment starts without surgery:

• diet that relieves constipation, fiber and enough water;
• correcting toilet habits: not straining and not sitting for long;
• an ointment, suppositories or tablets prescribed by a doctor to reduce bleeding, itching and swelling;
• a warm sitz bath, if your doctor recommends it.

Medication does not make the nodes disappear; it reduces the symptoms. Do not choose suppositories or ointments from the pharmacy on your own or on the advice of acquaintances: the wrong medicine can cover up the symptoms for a while but delay the diagnosis. In the early stage, the right treatment often removes the need for surgery.

Surgical and minimally invasive methods

Surgery is recommended when conservative treatment does not help, and in stages III–IV. We use three main methods, and each has its place.

Laser hemorrhoidoplasty (LHP). A thin laser fiber is inserted into the node through a small puncture, and the laser energy shrinks the node from the inside. The mucous membrane and skin are not cut, and stitches are usually not needed. The operation usually takes 15–20 minutes. Compared with methods that involve cutting, pain is often less and recovery is shorter. It is most suitable in stages II–III, when the nodes are not very large. We do not recommend laser in stage IV, or in stage III when the external part of the nodes is very large: such nodes need to be removed surgically. More: laser treatment of hemorrhoids.

Hemorrhoidectomy with LigaSure. Large nodes are cut out. The LigaSure device seals the blood vessels at the same moment it cuts the tissue, which reduces bleeding and shortens the operation. It is often the main choice for stage IV, large external nodes and thrombosed nodes. Recovery takes longer than with laser, but the risk of recurrence is among the lowest of all the methods.

Longo (stapler) procedure. A special circular device removes a strip of mucous membrane above the nodes and lifts the prolapsed nodes up to their original position. Because the incision is in an area with no pain sensation, pain is usually less than after a cutting operation. It is chosen more often for internal nodes with circular prolapse, usually stage III, and for large external nodes it may not be enough on its own.

If an anal fissure, fistula, polyp or rectocele is present along with hemorrhoids, we often deal with them in the same session under one anesthetic. We call this combined (“bouquet”) surgery, and we explain the approach on the surgical and conservative treatment page.

The type of anesthesia (spinal, general or local numbing) is chosen together with the anesthesiologist according to your health and the extent of the operation. Every operation has risks: bleeding, temporary difficulty passing urine, swelling and, rarely, infection or narrowing of the anal canal. We discuss them with you in detail after the examination.

The exact timeline is given after the examination.

The first bowel movement and pain: what to expect

Fear of the first bowel movement after surgery is the concern we hear most. To make it easier:

• start a diet that keeps the stool soft on the day of surgery, and if needed, the doctor prescribes a stool softener;
• don't put off going when you feel the urge, and don't strain; a small footstool raises your feet and makes going easier;
• take your painkiller at the prescribed times; a warm sitz bath after a bowel movement eases pain and burning.

The first bowel movement may burn a little, but it is a passing sensation and cannot be compared with the problem you have put up with for years. Pain is usually less after laser and the Longo procedure and somewhat greater when the nodes are cut out, and in both cases it is kept under control with medication. If you have fever, heavy bleeding, cannot pass urine or the pain keeps increasing, call right away.

1. Fiber every day. About 500 grams of fruit and vegetables a day, plus whole-grain bread and porridge.
2. Spread your water through the day. Most adults need about 1.5–2 liters of fluid; with heart or kidney disease, your doctor sets the amount.
3. 5 minutes on the toilet. Sit without your phone, don't strain, and raise your knees a little with a footstool.
4. Don't hold it in. The “I'll go when I get home” habit hardens the stool.
5. Keep moving. Get up every hour, walk at least half an hour a day, and don't hold your breath when lifting.

These rules also reduce the risk of recurrence after surgery. More: 5 golden rules against constipation.

One of our patients had lived with hemorrhoids for nearly 30 years and in recent years had to help by hand to pass stool. After the examination, the large nodes were removed surgically. After the operation, the patient spoke of the relief of being free of a problem they had put up with for years. Every patient's situation is individual.