Hofer - Liebl - Specialists


"Common disease" haemorrhoids: Symptoms and causes

Talk to us about the taboo subject

Is it the haemorrhoids?

Most patients who consult a proctologist because of complaints in the rectum suspect a problem with haemorrhoids.

Much more common are anal thrombosis, called "external" hemorrhoids by laymen, and anal fissure (anal fissure) in case of bleeding and pain. Find out now about the symptoms of hemorrhoidal disease and find out what treatment is recommended in your case....

Learn more about the causes in the following: What is the significance of pressing during bowel movements, chronic constipation, sedentary work, taking laxatives and anal sex?

Schema haemorrhoids | Proctology Practice Munich
Schematic of the anal canal with haemorrhoid in an anatomical position and of normal size (left half of the image), with significant enlargement and prolapse (right half of the image). © Dr Bernhard Hofer

What are haemorrhoids?

The proctologist understands this to mean (also: haemorrhoids) swelling bodies arranged in a ring at the level of the sphincter muscle in the rectum (anus), also called "corpus cavernosus recti".

These well perfused vascular cushions take their name from the Greek word for blood flow (haíma = blood; rhoos = to flow).

What an apt term: the blood supply to the rectum and anus is provided by four arteries whose terminal branches fill the spongy blood vessels (sinusoids) inside the haemorrhoids.

When the sphincter muscle is tensed, the haemorrhoidal plexus fills up, resulting in an air- and fluid-tight seal of the anal canal. When the muscle relaxes, the corpus cavernosum recti empties. Unhindered passage of stool is guaranteed. 

Haemorrhoids are therefore a functional tissue and only become a problem if they become permanently enlarged or prolapse outwards due to a weakness in the connective tissue.

Haemorrhoids develop during puberty and are anchored in the muscular intestinal wall with collagen fibres and muscle fibres.

The presence of haemorrhoids is therefore the normal state and not a disease.

How to tell if you have haemorrhoids

The 5 most common symptoms


Why does itching occur? Haemorrhoids are located in the transition zone from the mucous membrane of the rectum to the normally dry, outer skin. As the name suggests - mucous membrane produces mucus. Enlarged haemorrhoids can block the sphincter muscle like "the foot in the door", allowing the passage of mucus and moisture onto the skin. The result is skin irritation (irritant anal eczema). When the slightly damaged skin loses its barrier function, it becomes more susceptible to intestinal bacteria and digestive enzymes in the stool. The process takes on a life of its own.

In some skin diseases (psoriasis, neurodermatitis), isolated infestation of the pre-damaged skin in the area of the anus is also found for this reason.


Blood in the stool is considered an alarm symptom for bowel cancer and therefore often leads to uncertainty. However, the vast majority of all bleedings have benign causes. The type of bleeding gives clues about the probable cause: slight traces of bright red blood on the toilet paper are often signs of eczema or enlarged haemorrhoids. An anal fistula or coccygeal fistula can also cause such traces of blood. Dripping bleeding is typical of anal fissure. Blood admixtures to the stool or clotted blood is suspicious of a source of bleeding in the colon. The proctologist will therefore first perform an endoscopy of the rectum and treat any visible source of bleeding. To be on the safe side, he will usually arrange for a colonoscopy to remove any doubts about the cause of the bleeding.


The reduction or loss of stability of the connective tissue can cause a haemorrhoidal knot to become mobile in relation to the sphincter and the muscles of the bowel wall. The knot can then protrude from the rectum when going to the toilet or spontaneously. If such a prolapse recedes on its own, it is called stage II; if it has to be pushed back, it is called stage III of haemorrhoidal disease. The protrusion of the haemorrhoid leads to disruption of the fine seal (regreasing, laundry soiling) and dampness around the anus. This in turn can cause skin irritation (irritant anal eczema) with itching and soreness.

Stool smearing, moisture

The haemorrhoids are actually a useful part of the so-called continence organ and, in interaction with the sphincter muscle, provide the fine seal. If the haemorrhoids become enlarged or displaced, this fine continence can suffer. Patients then complain of secretion of moisture or stool smearing. This symptom usually has nothing to do with a real weakness of the sphincter muscles. Often, optimising the composition of the stool (building up the intestinal flora, plant-based bulking agents) is enough to restore normal function. Treatment can then be limited to stabilising the connective tissue by sclerotherapy.

Feeling of pressure

The sensitive receptors of the rectum cannot always distinguish whether the bowel is full or whether it is just enlarged haemorrhoids causing a feeling of pressure or foreign bodies in the anal area. Patients then often repeatedly go to the toilet and try to empty themselves by pressing harder. Understandably, this is counterproductive in this situation, as the increase in pressure causes the haemorrhoids to swell further and be pushed downwards, so that the discomfort even increases. This symptom can often be treated very effectively with simple remedies.


How advanced are the complaints?

Hemorrhoidal disease: Four stadiums

The generally accepted classification of severity refers to the size, the external protrusion (prolapse) and the need to then push the haemorrhoids back by hand. Depending on how full they are with blood, haemorrhoids are not always the same size; there is no standard for size. A prolapse does not always necessarily occur, the degree of subjective impairment differs from patient to patient.

  • Stage I: Magnification, no incident. Bright red bleeding, feeling of pressure
  • Stage II: Prolapse during pressing, spontaneous degeneration, irritation of the skin around the anus (irritative anal eczema), itching
  • Stage III: Incident, pushing back possible, smearing stools
  • Stage IV: Prolapse, pushing back no longer possible, pain, weak stool position (incontinence)

Why do haemorrhoids occur?

Haemorrhoids: Causes

  • Are haemorrhoids hereditary? There seems to be a certain family history of haemorrhoids. This probably has to do with a congenital weakness of the connective tissue.
  • Chronic constipation and a low-fibre diet: Emptying the rectum is an active process in which the hollow muscular organ of the rectum contracts and the sphincter muscle relaxes at the same time. If even one of these processes does not work or does not work synchronously, there is an increase in pressure. Dietary fibres loosen up the stool and lead to sufficient stool volume so that the rectum has to make less effort.
  • Pregnancies: Many women suffer from constipation during pregnancy. The baby and the amniotic sac put pressure on the intestines, and especially towards the end of pregnancy it is often difficult to get enough exercise. Towards term, the connective tissue loosens up and the body's water content increases. All these changes favour swelling conditions.
  • Whether being overweight is a risk factor in itself has not been proven. If you are very overweight, you have to assume that you have dietary deficiencies and that the motility that stimulates the intestines also decreases.
  • Is haemorrhoidal disease a symptom of old age? We have the impression that it is not. In our waiting room you will find patients of all ages.
  • Does a lack of hygiene play a role? No, most of our haemorrhoid patients are extremely well groomed. When they have symptoms, they tend to overdo it with washing, which can also damage the skin again.
  • Are laxatives harmful? No, the laxatives commonly used today, macrogol, sodium picosulphate and bisacodyl, are well tolerated. The herbal Senna preparations that were frequently used in the past have fallen into disrepute somewhat, but the only thing that has been proven is the dark colouring of the mucous membrane after many years of use (melanosis coli).
  • And what about anal sex? Anal sex is more common than a Twitter account in the United States: About a third of women and men in an American study have had anal sex, including 11% of teenagers (15-19 years). However, studies on possible health consequences - apart from infections - are scarce. In any case, one can imagine that the mechanical stretching of the elastic fibres and the so-called "longitudinal muscle", which anchor the haemorrhoids to the pad, can be overstressed during anal sex and thus promote prolapse. We often see increased mobility of the mucosa on the pad ("internal mucosal prolapse"), less enlarged haemorrhoidal nodes in our patients who report anal sex.

And finally, the evidence to read again

Diagnosis of haemorrhoids: Bibliography

  1. Habel, M. A., Leichliter, J. S., Dittus, P. J., Spicknall, I. H., & Aral, S. O.. (2018). Heterosexual anal and oral sex in adolescents and adults in the United States, 2011-2015. Sexually transmitted diseases, 45(12), 775-782.
  2. Loder, P. B., Kamm, M. A., Nicholls, R. J., & Phillips, R. K.. (1994). Haemorrhoids: pathology, pathophysiology and aetiology. The British journal of surgery, 81(7), 946-954.
  3. Maierhofer, C. N., Lancaster, K. E., & Turner, A. N. (2018). Anal Sex Is More Common Than Having a Twitter Account in the United States. Sexually transmitted diseases, 45(12), 783-785.
  4. Stelzner, F. (1964). The corpus cavernosum recti. Diseases of the Colon & Rectum, 7(5), 398-399-398