A pain in the butt: everything you’ve ever wanted to know about hemorrhoids

About two weeks after I graduated medical school, when I wasn’t even an official intern yet, I got my first consult.  It came from a friend of my mom’s, who called on the phone, and asked what to do about a painful hemorrhoid. (It’s like she knew I wanted to be GI before I did!)  My recommendation was essentially equivalent to “Try washing your ass.” And now, after 3 years of residency, 3 years of fellowship, and 6 years of practice, I realize… my advice was pretty much right on!

So, yeah, let’s discuss hemorrhoids.  Doctor, I have a “pain in the butt” (even funnier the thousandth time I hear that joke, har har, please don’t make it, I’ve heard it before)  is actually a pretty common presenting complaint in my office, and a lot of the time, people are pretty mortified to discuss their anuses with me, but let me assure you, if you’ve discussed one, you’ve discussed them all, and very few things about your anus will surprise me.  There are a few, but they’re very few.  Please don’t be afraid to bring it up.

What are hemorrhoids?

Yes, this is your anus in cross section

They are clusters of dilated veins in the rectum and anus that can get engorged and full of blood.

What causes hemorrhoids?

They’re caused by a few different things, but the common denominator is gravity and blood pooling.  Standing for long periods of time, for example, puts you at risk for them.  If you’re a guy who goes into the bathroom and spends an hour on the throne with the iPad (formerly a newspaper), you’re basically screwed, and you’re going to have hemorrhoids.  Pregnancy also causes them, in addition to many of the other ways in leaves you busted… but I’m not bitter.  Constipation and straining is a big factor as well.  Basically, anything that will increase pressure above the venous chains located in the rectal area and cause blood to pool there.  Sometimes, none of these risk factors are present, and the unfortunate person still develops hemorrhoids.  Ain’t that just how it goes.

How do I know if I have hemorrhoids?

Well, you can sometimes see them.  Grab a compact and sit on the toilet.  Go ahead.  Do it.  If you have external hemorrhoids, you’ll see bluish clusters or little spheres down there, or perhaps, you’ll see skin tags, little extra fleshy appendages, which is what’s left over after you’ve had engorged hemorrhoids, and they’ve deflated.  And that’s what they do: they inflate and deflate and inflate and deflate, and once you’ve got them, you’ve got them and they don’t go away.

Symptoms of hemorrhoids

They can cause you to develop rectal bleeding, get a blood clot inside them and cause severe pain, or just bother you by their sheer existence by itching and irritating.

  • Bleeding – they can get engorged and when you go to the bathroom, you will see bright red blood, and sometimes even clots, in variable amounts.  Sometimes, it’s just a few streaks on the tissue, and sometimes it’s in the water.  Keep one thing in mind: it doesn’t take a lot of blood to make the toilet water super-red and look very scary.  So, you’re most likely not dying even if the the toilet looks like borscht.  But obviously, if there is borscht in your toilet, go see a doctor! Or call a plumber, if it’s actual borscht.
  • Thrombosis – as mentioned, blood clots can form inside these veins from blood sitting around doing nothing, and this is usually extremely painful.  It makes sense, I mean, it’s a space occupying lesion in your anus, and one that causes inflammation to boot.  Ouch.
  • Bothering you by their sheer existence – this is fairly self explanatory.  They itch, they cause excess moisture in the area, they burn sometimes, and generally, they make you think about your butt way more than is usually necessary.

What do I do??


  1. sitz bath
    Sitz bath set up
  2. WASH YOUR ASS – see?? I was right even as a freshly baked MD without any training.  Warm water and mild soap.  A lot of people will tell you to do Sitz baths (basically, a warm water butt soak), but I would actually recommend against it, because–have you ever seen a Sitz bath?   You’re basically sitting there, with your peri-anal area flapping in the breeze, in warm/hot water, and all that gravity and all that nice warm water, is just making the blood flow right into those veins, and making everything worse.  I’d suggest you get one of those squirt bottles like the ones they give you after you have a baby, or even just a cup of warm water, and do a wipe-warm water wash-wipe sandwich.
  3. Avoid excess rubbing or wiping.  In fact, don’t use toilet paper at all, it irritates the already irritated anus, and I think most people realize this, BUT! many will go to baby wipes because they think they’re soothing.  In reality, they contain fragrance and alcohol, and all sorts of chemicals and things that will  bother it more.   Use Witch Hazel.  You can buy medicated pads (Tucks and Preparation H both make them), or, if you want to spend less, get a giant bottle of Witch Hazel at the health food store, and use that with a cotton makeup pad.  It’s an astringent, and will whisk away excess moisture and be soothing to the skin.
  4. Make sure you’re not constipated – fiber and stool softeners are your friends.  Hard stool and straining are your enemies.  Metamucil dissolves into a gritty orange drink, and if you can tolerate it, it’s probably the best, but in the interest of full disclosure, it’s pretty gross; Benefiber is clear and comes in a pillform; if you’re hardcore (or really hard poop), get some Miralax.  A capful in a glass of water daily ought to do it, but you can play with the dose up and down to regulate as needed.  And don’t worry, you can’t get “addicted” to Miralax.  All it does is draw water to soften things up and make them mushy, which is good for everyone.



We use suppositories, creams, and foams shrink these mofos down.  Over the counter Preparation H comes in a cream (steroid), and a suppository (phenylephrine); I would recommend using both.  The doctor might give you prescription stuff, like Anusol, Proctosol, Proctofoam – most topicals contain some sort of topical steroid, like hydrocortisone, and a vasoconstrictor, like phenylephrine, to decrease inflammation and make them smaller.  I understand that it’s skeevy to think about sticking something up your butt, but a suppository or a rectal cream applicator are tiny, much smaller than an average stool.  Smearing a cream on the outside is going to do nothing for the internal hemorrhoids.  So, just do it.  Unless you want to be aware of your butt for much longer than necessary.  It’ll feel funny for about 10 seconds, and then the suppositories melt down into a goo that works to make it all better.  Lidocaine jelly, if it’s painful, will numb the area up.

(NB: if you’re a dude, and you’re in my office and you’re acting all weird because I’m telling you about a rectal therapy, and you have issues with that b/c it’s not manly, know that internally, I’m rolling my eyes and telling you to grow up.  Just saying.)


Butt surgery.  Say that a few times.  Eek, right?

The problem with hemorrhoids, as I said before is that once you’ve got them, you’ve got them, and they tend to deflate inflate deflate inflate, so usually, if you have a problem, it’s a recurrent problem.  Most people prefer to prevent and treat them medically, even if repeated courses are needed intermittently because the alternative is, well, butt surgery, and it’s painful and awful.  However, sometimes, the episodes are just too frequent, or the hemorrhoids don’t respond, and an invasive procedure is preferred.

First – let me say, if you have a large hard painful lump, which could be a thrombosed hemorrhoid, it can be incised, but only if you show up to see a surgeon within 72 hours of onset of problem.  PCP’s often send patients to me (GI) with a painful hemorrhoid, and I can’t do anything but give you the aforementioned unguents, and there is a delay getting to surgeon that will prevent you from getting this baby cut open and emptied out.  So, ask your PCP to go straight to a surgeon.  After 72 hours, the pain and suffering of incising it is worse than the pain and suffering you’ve already felt.

Ok, so, if they don’t respond to medical therapy, I might refer to a surgeon, or a GI might want to do endoscopic therapy.  Neither option is all that great, because they’re uncomfortable, and there is no guarantee that the little suckers won’t come back, but we an do it anyway if necessary.  Endoscopic surgery usually refers to  banding, when we deploy a tiny rubber band around the hemorrhoid and it basically chokes the vein off, and is done for internal hemorrhoids.   Surgical stripping involves a surgeon going in and literally strips the venous chain that is supplying the hemorrhoid, and will require days off work and some recovery.

So that’s all I need you to know about this topic!

And remember: EVERYONE has hemorrhoids.  Really.  To one degree or another.  So, if they’re bothering you, and nothing is helping, come on in.  It’s not embarrassing, I promise.

And for extra credit, count how many times I said the word “hemorrhoids” in this post.

A pain in the butt (2)


6 thoughts on “A pain in the butt: everything you’ve ever wanted to know about hemorrhoids

  1. Wow! More information than I ever would need to know πŸ˜› Being the ”mature” person I am I laughed greatly at this πŸ˜› As much as this is an awkward and embarrassing subject, there is someone out there who would benefit reading this.


  2. I appreciate your style and candid approach. I have never had more anxiety than when I was having my hemorrhoid examined. I wanted to crawl into a hole and cry. You normalize the issue which really helps put it into perspective. Still awkward but manageable.


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