Hemorrhoids: Symptoms, Grades and What Really Helps

At a glance

What is it? A vascular cushion in the anal canal that everyone has. Only when it enlarges and causes symptoms is it a problem.
Key symptom Bright red blood on the toilet paper, plus itching, burning or weeping. Pain is rather unusual.
Most common cause Heavy straining when passing stool, often with constipation and a low-fibre diet.
Four grades From grade I (internal only) to grade IV (permanently outside). The grade guides the treatment.
Important Always have blood in the stool checked at least once to rule out other causes.
ICD-10 K64.0 to K64.3 (grade I to IV)

Contents

  1. What are hemorrhoids?
  2. Symptoms
  3. Causes and risk factors
  4. The four grades
  5. Diagnosis: how is it determined?
  6. Treatment by stage
  7. Creams and suppositories: which ingredient for what?
  8. What you can do yourself
  9. When to see a doctor

What are hemorrhoids?

Hemorrhoids are a perfectly normal vascular cushion in the anal canal that everyone has. They help to seal the anus finely. Only when this cushion enlarges and causes symptoms does it become a problem. In everyday language, though, that is usually what people mean by hemorrhoids.

The condition is very common and in the vast majority of cases harmless, even if it is unpleasant and sometimes worrying. Worth knowing: only what causes symptoms is treated. Enlarged hemorrhoids without symptoms do not need treatment.

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Symptoms

Which symptoms appear depends on the size of the hemorrhoids. Typical ones are:

  • bright red blood, usually on the toilet paper or on the stool. More on this: Blood in stool.
  • itching, burning or weeping around the anus.
  • a feeling of pressure or of something being there.
  • with larger hemorrhoids, a lump that comes out when passing stool.

Hemorrhoids themselves usually do not hurt, because they sit above the pain-sensitive zone. Severe, sudden pain with a hard lump points more to an anal vein thrombosis or a small tear (anal fissure) and should be checked by a doctor.

Always have blood in the stool checked Hemorrhoids are the most common cause of bright red blood, but not the only one. So have any bleeding checked by a doctor at least once to rule out other causes. This is especially important from around the age of 50, with dark blood, with changes in bowel habits or with a family history.

Causes and risk factors

The main trigger is usually heavy straining when passing stool, often as a result of constipation. Contributing factors are:

  • chronic constipation and hard straining. More on this: Constipation.
  • a low-fibre diet and drinking too little.
  • prolonged sitting, including sitting on the toilet for a long time.
  • excess weight and lack of exercise.
  • pregnancy and childbirth.
  • a family tendency and increasing age.

The four grades

Hemorrhoids are divided into four grades according to severity. The grade helps determine which treatment makes sense. The transitions between grades are gradual.

Grade What happens
Grade I enlarged, but internal only. Not visible or palpable from outside. Often painless bleeding.
Grade II come out on straining and retract on their own afterwards.
Grade III come out on straining and have to be pushed back with a finger.
Grade IV stay permanently outside and can no longer be pushed back.

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Diagnosis: how is it determined?

The diagnosis is usually straightforward. The doctor looks at the area, examines it by touch and uses a short proctoscope (a small scope of the anal canal) to look directly at the hemorrhoids.

Telling it apart from other causes is important. With blood in the stool, from around the age of 50 or with risk factors, a colonoscopy can be useful to reliably rule out more serious causes.

Treatment by stage

Treatment depends on the grade. The basics, that is good stool regulation, belong to every stage, though. As a rule: grades I and II are the domain of gentle procedures, while grades III and IV more often need surgery.

Grade Typical treatment
Grade I basic therapy (stool regulation). For persistent bleeding, sclerotherapy.
Grade II sclerotherapy or rubber band ligation (tying off with a small rubber band).
Grade III usually rubber band ligation, often surgery.
Grade IV as a rule surgery (for example a hemorrhoidectomy).

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Sclerotherapy and rubber band ligation are small outpatient procedures with little effort. Surgery is mainly an option for grades III and IV. Which procedure fits also depends on other conditions, medication and the medical history.

Creams and suppositories: which ingredient for what?

Over-the-counter creams and suppositories relieve symptoms but do not remove the enlarged hemorrhoids. They work symptomatically. Which ingredient makes sense depends on the symptoms. These groups exist:

Ingredient group Examples What they do Good to know
Local anesthetics lidocaine, cinchocaine, polidocanol, benzocaine numb pain, burning and itching for a short time symptomatic only, can make the skin sensitive with longer use
Astringents witch hazel (hamamelis), zinc oxide, bismuth ease weeping and itching, mildly anti-inflammatory and protect the skin usually well tolerated, also for somewhat longer use
Anti-inflammatory with cortisone hydrocortisone (low dose) calm stronger inflammation, swelling and itching short-term only (as a rule a maximum of one to two weeks), not for long-term use
Soothing and protective substances zinc oxide, panthenol, cod liver oil protect the irritated skin and support healing well tolerated, useful as an add-on

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Cream or suppository? This is not a matter of taste but of location. A suppository dissolves higher up in the rectum and often slips past the area that is actually affected. For symptoms right at the anus, a cream (ideally with an applicator) is usually better. For the anal canal, there are anal tampons, that is suppositories with a gauze insert that hold the ingredient in the right place.
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What you can do yourself

The most important measure with hemorrhoids is a soft, well-formed stool so that you do not have to strain. That takes the pressure off the vascular cushions. This helps:

  • eat plenty of fibre, for example wholegrain products, vegetables, fruit and psyllium husks.
  • drink enough, around one and a half to two litres a day.
  • if needed, a gentle laxative such as macrogol, which makes the stool softer. More on this: Macrogol.
  • do not strain and do not sit on the toilet too long, so no reading or phone.
  • do not suppress the urge to go.
  • clean gently after passing stool, ideally with water, and do not rub hard.
  • exercise regularly.

When to see a doctor

A doctor's visit makes sense in these cases:

  • with any bleeding, at least once to have it checked.
  • with pain, a palpable lump or when hemorrhoids come out.
  • when the symptoms do not improve after about a week of self-help and over-the-counter products.
  • with changes in bowel habits, dark blood or unintended weight loss.

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Frequently asked questions

They are usually harmless, if unpleasant. What matters is having any bleeding checked by a doctor at least once, to reliably rule out other causes.

Often not, since hemorrhoids sit above the pain-sensitive zone. Severe, sudden pain with a hard lump points more to an anal vein thrombosis or a tear (anal fissure).

It depends on the symptoms: local anesthetics for pain and itching, astringents such as witch hazel for weeping, short-term cortisone for strong inflammation. All of them only relieve the symptoms, they do not remove the hemorrhoids.

For symptoms right at the anus, a cream (ideally with an applicator) is usually better, since suppositories dissolve higher up. For the anal canal, there are anal tampons, that is suppositories with a gauze insert that hold the ingredient in the right place.

Mild symptoms often improve with good stool regulation. Clearly enlarged hemorrhoids (higher grades), however, usually do not recede on their own and need treatment.

In the short term, over-the-counter creams or suppositories ease itching and pain. You tackle the cause, though, with a softer stool, that is with fibre, enough fluids, macrogol if needed, and less straining.

Eat plenty of fibre, drink enough, do not strain, do not sit on the toilet too long and exercise regularly. That keeps the stool soft and takes pressure off the vascular cushions.

Mainly with grades III and IV, when good stool regulation and small procedures such as rubber band ligation are not enough. Which surgical method makes sense is decided by the doctor.

Related topics

Blood in stool Constipation Macrogol Diarrhoea Irritable bowel syndrome Anal fissure

Quellen

  1. DGK (Deutsche Gesellschaft für Koloproktologie) in Zusammenarbeit mit DGVS und weiteren Fachgesellschaften: S3-Leitlinie „Hämorrhoidalleiden“ (AWMF 081-007). register.awmf.org/de/leitlinien/detail/081-007
  2. IQWiG / gesundheitsinformation.de: Informationen zu Hämorrhoiden. gesundheitsinformation.de
  3. DGVS (Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten): Patienteninformationen. dgvs.de
  4. American Society of Colon and Rectal Surgeons (ASCRS): Clinical Practice Guidelines for Hemorrhoids. fascrs.org
  5. NHS: Piles (haemorrhoids). nhs.uk
Important note: This article is for general information and does not replace medical advice, diagnosis or treatment. You should always have blood in the stool checked by a doctor. Which treatment is right for you depends on your individual situation and should be discussed with a doctor. Last updated: June 2026.