The anal canal connects to the rectum at the top and ends at the anus. At the junction between the lower end of the rectum and the anal canal lies an irregular line known as the dentate line (or dentate margin). Hemorrhoids are swellings that occur on either side of the dentate line, caused by varicose veins in the upper and lower venous layers of the rectum. They are one of the most common conditions, with incidence rates increasing with age, and can affect both men and women. There is a saying: “Nine out of ten people have hemorrhoids, and nine out of ten hemorrhoids go untreated,” which illustrates that this is a highly prevalent condition. Since there are no obvious symptoms in the early stages, many people neglect to seek treatment.
I. Etiology and Pathogenesis
Traditional Chinese Medicine (TCM) holds that hemorrhoids have many causes, primarily involving the following factors:
(1) A constitutional excess of yang heat, or excessive consumption of rich, sweet, and spicy foods, leading to the internal generation of damp-heat. This damp-heat accumulates in the large intestine, descends to the anus, and causes stagnation of qi and blood, resulting in this condition.
(2) Prolonged sitting or standing, carrying heavy loads over long distances, or chronic constipation can disrupt the balance of qi and blood in the anal region and obstruct the meridians, leading to this condition.
(3) Prolonged diarrhea or dysentery, pregnancy, childbirth, abdominal masses, or local lesions in the anus and rectum can impair the smooth flow of qi and blood or cause damp-heat and turbid qi to accumulate in the anal region, thereby causing this condition.
Modern medicine holds that the rectum and anal canal are located in the lower part of the body; prolonged sitting or standing impedes venous return in this region. The absence of venous valves in the rectal veins, combined with the thin walls and superficial location of the superior and inferior rectal veins, all contribute to the formation of hemorrhoids. Direct factors leading to hemorrhoids include: ① habitual constipation; ② chronic inflammation of the lower rectum and anal canal; ③ increased intra-abdominal pressure; ④ prolonged standing or sitting; ⑤ malnutrition resulting from old age, frailty, or chronic illness; ⑥ prolonged alcohol consumption and excessive intake of spicy or irritating foods, leading to local anal congestion, etc.
II. Classification and Pathology of Hemorrhoids
Hemorrhoids are classified into three categories based on their location:
Internal hemorrhoids: These are clusters of varicose veins in the upper rectal venous plexus, located above the dentate line and covered by rectal mucosa. They commonly occur in three areas: the left side, the anterior right, and the posterior right.
External hemorrhoids: These are clusters of varicose veins in the lower rectal venous plexus, located below the dentate line and covered by the skin of the anal canal. Simple external hemorrhoids occur around the anus and often protrude outside the anus due to thrombosis within the veins.
Mixed hemorrhoids: These consist of clusters of varicose veins from both the upper and lower rectal venous systems that interconnect and influence one another. Consequently, the hemorrhoidal masses (hemorrhoidal nodules) are located both above and below the dentate line and are covered by both rectal mucosa and anal canal skin, resulting in mixed hemorrhoids.
In the early stages, internal hemorrhoids are more common. As venous varicosities progressively worsen, different clinical manifestations emerge. Therefore, internal hemorrhoids are further classified into three stages:
Stage I is characterized by blood in the stool—bright red in color and varying in amount—with the hemorrhoidal mass not protruding outside the anus; it is visible only during an anoscopy;
Stage II is characterized by the prolapse of hemorrhoidal tissue outside the anus during defecation, which retracts spontaneously afterward.
Stage III is characterized by the prolapse of hemorrhoidal tissue outside the anus during defecation; the tissue does not retract spontaneously and must be manually pushed back into place.
By the time internal hemorrhoids progress to Stage II, they have often already developed into mixed hemorrhoids. If they continue to worsen, they may further progress to “ring-shaped hemorrhoids,” in which the hemorrhoidal tissue prolapses completely outside the anus.
III. Clinical Manifestations of Hemorrhoids
Bleeding During Bowel Movements: The most common symptom of internal and mixed hemorrhoids is bleeding during bowel movements. This bleeding is typically painless, bright red in color, occurs during defecation, and stops on its own afterward. Bleeding is often intermittent; constipation, hard stools, increased bowel movements, alcohol consumption, and eating irritating foods are common triggers for hemorrhoidal bleeding.
Prolapse of Hemorrhoidal Nodes: When internal or mixed hemorrhoids progress to stages II or III, they may prolapse outside the anus. The prolapsed hemorrhoidal nodes gradually increase in size, evolving from being able to retract spontaneously to requiring manual repositioning into the anus. Over time, the contractile strength of the anal sphincter gradually weakens, resulting in the hemorrhoids prolapsing even with slight increases in abdominal pressure, such as when the patient walks or coughs.
Pain: Simple hemorrhoids are generally painless. However, when internal or mixed hemorrhoids prolapse and become incarcerated, leading to edema, infection, or necrosis, the patient experiences severe localized pain. Localized pain is a characteristic of thrombosed external hemorrhoids.
Itching: Due to the prolapse of hemorrhoids and relaxation of the anal sphincter, mucus flows out of the anus and irritates the surrounding skin, causing itching and even eczema, which can be extremely uncomfortable for the patient.
IV. Differentiating Hemorrhoids from Other Anal Diseases
Such as anal fissures, rectal cancer, rectal prolapse, and rectal polyps.
V. Treatment of Hemorrhoids
Traditional Chinese Medicine (TCM) Differential Diagnosis and Treatment
(1) Internal Medication
① Early Stage (Stage I): The patient’s hemorrhoidal nodules are small and purplish-red in color, with a soft texture. The nodules do not prolapse outside the anus during bowel movements. Bleeding occurs during defecation, with the bleeding being most pronounced toward the end of the bowel movement, appearing in drops or a spray. The blood is bright red, and the volume is generally small. The patient experiences no discomfort, and the bleeding stops on its own after standing up following the bowel movement. The treatment principle should be to clear heat and moisten dryness, as well as cool the blood and stop bleeding; Liangxue Dihuang Decoction may be used.
② Intermediate Stage (Stage 2): The hemorrhoids are larger and dark purple in color. They prolapse outside the anus during defecation but retract spontaneously afterward. Bleeding is generally more profuse and bright red in color. The treatment principle should be to clear heat and eliminate toxins, cool the blood, and dispel wind; Huai Jiao Wan with appropriate modifications may be used.
③ Late Stage (Stage 3): The hemorrhoids prolapse outside the anus during defecation; they are dark gray in color, hard in texture, thickened, and rough. There is minimal bleeding. and the hemorrhoids cannot be reduced spontaneously. In severe cases, they may even prolapse during coughing or walking, requiring manual reduction or a supine position to be repositioned. If not promptly reduced, edema or incarceration may occur, causing persistent distending pain or severe pain, or accompanied by difficulty urinating. The treatment principle should be to clear and drain damp-heat and promote blood circulation to resolve stasis; the Si Shun Qing Liang Decoction, with appropriate modifications, may be used for treatment.
④ Thrombosed External Hemorrhoids: Crescent-shaped, purplish-blue, spherical swellings appear on both sides of the anus, accompanied by severe pain that worsens during bowel movements and is markedly tender to the touch. The treatment principle is to clear heat, cool the blood, and relieve pain; the Liangxue Dihuang Decoction, with appropriate modifications, may be used.
(2) External Fumigation and Washing: This is a traditional method in Traditional Chinese Medicine for treating hemorrhoids. It involves decocting medicinal herbs to prepare a decoction; the procedure requires fumigation followed by washing, performed 2–3 times daily for half an hour each time. Decoctions such as Wu Beizi Decoction or Kushen Decoction can be used for fumigation and washing.
(3) Other treatment options include topical application of Chinese herbal medicines, hemorrhoid cauterization, and surgical intervention.
Modern Medical Treatment: Modern medicine holds that most hemorrhoids remain in a quiescent, asymptomatic state and do not require specific treatment; instead, patients should focus on dietary adjustments, maintaining regular bowel movements, and preventing complications. Active treatment is only necessary when hemorrhoids are complicated by bleeding, thrombosis, prolapsed hemorrhoidal nodules causing symptoms, or incarceration.
(1) Stage I: Improving diet and ensuring regular bowel movements are the primary measures. Concurrently, inserting suppositories containing anti-inflammatory and analgesic medications into the anus is effective for thrombosed external hemorrhoids; warm water sitz baths may also be used.
(2) Injection therapy: Used for Stage II and Stage III hemorrhoids accompanied by bleeding. A 5% glycerol carbonate solution is injected into the hemorrhoidal mass and around the small submucosal blood vessels supplying it to induce a sterile inflammatory reaction. This leads to the occlusion of small blood vessels and fibrous proliferation, sclerosis, and atrophy within the hemorrhoidal mass, thereby achieving a cure.
(3) Cryotherapy: Used for smaller, bleeding hemorrhoids. The method involves applying liquid nitrogen (–196°C) to the hemorrhoid via a specialized probe, causing the tissue to freeze, necrotize, and slough off, followed by wound healing.
(4) Surgical Therapy: Although surgery is effective for most hemorrhoids, non-surgical treatments also yield good results; therefore, surgery is generally not required for the majority of cases and is reserved only for patients with extremely severe conditions. Surgical methods include the following: ① ligation; ② hemorrhoidectomy; ③ circular hemorrhoidectomy; and other techniques.
VI. Prevention of Hemorrhoids
Given the high incidence of hemorrhoids, prevention is of utmost importance. In daily life, increase your intake of fiber-rich foods to maintain regular bowel movements; correct poor bowel habits—ideally, aim for one bowel movement per day; promptly treat conditions that cause increased intra-abdominal pressure; quit smoking and drinking; avoid or limit consumption of irritating foods; if your job or occupation involves prolonged sitting, take regular breaks to promote blood circulation and prevent congestion in the superior and inferior rectal venous plexuses; engage in regular physical exercise; and if you suffer from constipation, take some traditional Chinese medicine to promote regular bowel movements.