What are haemorrhoids

In the rectum, various elements work together to ensure the secure closure of the anus. In addition to the pelvic floor muscles, the anal sphincter (Sphincter Ani) performs the most important function. Slightly deeper in the rectum there is a network of small arteries and veins that guarantee the fine adjustment required for complete closure (e.g. with softer stool). This system is called the haemorrhoidal ring or haemorrhoidal plexus and refers to a circularly arranged collection of haemorrhoids. The term therefore originally does not describe a disease, but rather healthy haemorrhoids fulfil the extremely important function of securely sealing the bowel. However, only in their place within the haemorrhoidal ring — from which they have now protruded.

Note: Strictly speaking, in the case of a pathological change one should not speak of haemorrhoids, but of a haemorrhoidal disease. For the sake of simplicity, however, we will continue to use the common term below.

Haemorrhoids cause a distinct sensation of a foreign body. They usually develop over a longer period of time and do not necessarily have to be painful. The most noticeable symptom is almost permanent, intense itching. Bleeding may occur during or after bowel movements, which does not necessarily have to be painful. Moistness and stool smearing cause a constant hygienic discomfort and can easily lead to inflammation. When inflamed, haemorrhoids are almost permanently painful.

Internal and external haemorrhoids

Internal haemorrhoids

A haemorrhoidal disease develops when individual vessels of the haemorrhoidal ring enlarge for a wide variety of reasons and develop pathologically. As long as these are moderate enlargements that remain inside the rectum, they are referred to as internal haemorrhoids. These often go unnoticed and cause no or only minor symptoms. If the causes are not eliminated and internal haemorrhoids continue to swell and enlarge, they may protrude temporarily or permanently to the outside.

External haemorrhoids

If the enlargements or protrusions can be seen or felt on the outside of the anus, they are referred to as external haemorrhoids. These unusual thickenings, swellings, bulges or clearly protruding folds of skin sometimes appear overnight and can be alarming. As a rule, external haemorrhoids are noticed during cleaning after a bowel movement or through itching, pain or bleeding.

Classification or severity levels of haemorrhoids

The classification of haemorrhoids is divided into the following severity levels:

Haemorrhoids grade 1
refer to the internal variant with no or only minor symptoms.

Haemorrhoids grade 2
means that they temporarily – usually after a bowel movement – protrude from the anal canal but retract spontaneously or gradually afterwards.

Haemorrhoids grade 3
describe the variant that does not retract into the anal canal on its own but can be pushed back into the haemorrhoidal ring in the rectum manually with a finger or with suitable dilators (see below). This process is referred to as reposition.

Haemorrhoids grade 4
is the classification for the severity level in which reposition is no longer possible and they remain permanently outside. Grade 4 haemorrhoids can usually only be removed surgically.

Other conditions in the anal area

In the anal region and around the anus there are various unpleasant conditions that are often generally referred to in everyday language as haemorrhoids. However, this equation is not correct: not every thickening, fold or bulge on the anus is a haemorrhoid, and accordingly the treatment approaches also differ.

Below we give you an overview of the different conditions in the area of the anus and rectum in order to distinguish them clearly from one another: anal skin tags, anal fissures and anal thromboses. In rare cases, changes in this region of the body may indicate anal cancer, which requires urgent medical treatment.
The symptoms and typical appearances of the individual conditions are described here.
To begin with, a comparison image of external haemorrhoids:

It is important to understand that: There is no “typical image” of haemorrhoids; they can look very different depending on their severity, location and current condition. While early stages are often hardly visible externally, advanced haemorrhoids protrude clearly outward. These differences are illustrated in the graphic representation of the severity levels (above). The image shown here depicts prolapsed haemorrhoids (grade 3) and serves as a comparison example for other anal conditions.

Anal skin tag

An anal skin tag is a relatively harmless condition, namely a thickened fold of skin in or around the anus. Skin tags can occur singly or in multiples. They are usually skin-coloured to dark, feel soft and look like small pouches or flaps of skin. Normally they cause no pain or discomfort, but since they can make cleaning the anus more difficult, they may occasionally lead to itching and in more severe cases to inflammation.

Anal fissure

An anal fissure (in the upper centre of the image) is a longitudinal tear in the sphincter muscle or in the anal canal; for this reason it is (incorrectly) also referred to as an anal tear. Although it often appears very small externally, it can extend quite deeply and cause severe pain, especially during bowel movements, when cleaning after bowel movements or when showering. However, no tissue protrudes outward and there is no sensation of a foreign body, which clearly distinguishes an anal fissure from haemorrhoids. Further information about anal fissures can be found in our Anal fissure guide.

Anal venous thrombosis

Anal thromboses, also known as anal venous thromboses, are acute events in contrast to the other pathologies: within a few hours a clot develops in the form of a bluish-black, tense nodule. Another clear sign is severe, stabbing pain. An anal thrombosis or anal venous thrombosis usually occurs only singly.

Anal cancer

An anal cancer (the tumour-like tissue change in the centre of the image) is a malignant growth in the area of the anal canal or the skin near the anus. Initially this may manifest itself in a non-specific way, for example through persistent itching, bleeding, weeping or poorly healing skin changes, as well as a feeling of pressure or a foreign body in the anus. In contrast to acute events, the symptoms usually develop gradually and increase over weeks or months. Pain may occur but is often absent, especially in the early stages. For this reason, changes in the anal area that cannot be explained or that do not heal despite treatment should always be medically examined.

If you are unsure whether you have haemorrhoidal disease or anal cancer, a visit to a doctor should clarify this before you begin self-treatment.

Causes and development of haemorrhoids

The most common causes of the development of haemorrhoids are:

Chronic constipation

It often results from a combination of a low-fibre diet, low fluid intake and lack of exercise, promoted by sedentary work.

Incorrect behaviour during bowel movements

Rushed visits to the toilet, frequent, strong straining during bowel movements, especially in an unfavourable sitting position. Patients with chronic constipation (obstipation) are particularly prone to this.

Excessive strain on the pelvic floor

Incorrect lifting of heavy loads, excess weight and/or a weak pelvic floor also promote the development of haemorrhoids.

Weak connective tissue

Possibly hereditary weakness of the connective tissue, which can also appear in other areas of the body in the form of varicose veins, is another cause.

Frequent diarrhoea or frequent use of laxatives

...cause excessive expansion of the haemorrhoidal cushion and thus also create the basis for haemorrhoidal disease.

Pregnancy and childbirth

Due to their hormonal situation and the natural strain during this time, women are more prone to developing haemorrhoids. For more details, see Haemorrhoids after pregnancy or childbirth.

Prevention of haemorrhoids

To prevent haemorrhoids and also to support treatment, your diet should be high in fibre with regard to good and therefore trouble-free digestion. Fibre is largely indigestible food components, mainly carbohydrates, which are found primarily in plant-based foods such as fruit, vegetables and cereals and counteract digestive problems.

Adequate fluid intake of about 2 to 3 litres per day, with water making up the main portion, ensures a smooth stool consistency and makes bowel movements easier.

Correct behaviour during bowel movements is important. Avoid straining and pressure; instead, it is better to “push” from the abdomen: To do this, take a deep breath and press the air as far down into the abdomen as possible. The correct posture helps with this: a rounded back and feet flat on the floor. Instead of the upright, “civilised” sitting position, the posture should correspond as closely as possible to the original posture that is optimal for bowel movements, namely the squat. A footstool helps you to adopt this posture.

How is this connected?
The musculus levator ani - or more simply: levator ani - is a central muscle of the pelvic floor. It keeps the anus and rectum slightly lifted in everyday life and thus supports secure closure. Its innermost part, the puborectalis, forms a sling around the rectum. In an upright posture it slightly bends the rectum and thus makes a significant contribution to continence. When this muscle relaxes – especially in a squat or with the upper body leaning forward – the rectum straightens. This makes bowel movements much easier and reduces unnecessary straining.

Here you can see an illustration of the different positions and their effect on the puborectalis sling:

Anal hygiene after going to the toilet should be thorough: After dry pre-cleaning with gentle toilet paper, moist follow-up cleaning should definitely be carried out, ideally with water, e.g. by means of a hand shower, bidet or portable bidet. When out and about, wet wipes may also exceptionally be used. It is important to make sure that they contain as much water as possible and no additives. This could unnecessarily irritate the sensitive mucous membrane and disturb its flora. It should also be noted that most wet wipes must not be disposed of in the toilet, but belong in the rubbish bin. Finally, the anal area should be dried with toilet paper.
This removes the breeding ground for inflammation and the skin’s pH value is not irritated. At the end, a healing ointment or haemorrhoid ointment can be applied if needed.

Home remedies for haemorrhoids

If you want to treat haemorrhoids without medication containing chemical active ingredients, the following home remedies and naturopathic treatment methods are available:

• Suppositories with Stibium metallicum and extract from horse chestnut bark
• Ointments containing hamamelis (witch hazel)
• Ointments and pastes containing zinc or panthenol

The following can help with severely swollen or inflamed haemorrhoids:

• Cool sitz baths with sea salt or oak bark
• Quark compresses
• Nasal spray, because it reduces swelling

The measures mentioned above are at the same time an important support for effective treatment of existing haemorrhoids as well as good prevention against their development.

In addition to suppositories, ointments and medication, there are also ideal mechanical aids:

Alternative aids for the treatment of haemorrhoids

Here we would like to introduce two aids with which you can efficiently treat your haemorrhoids yourself, either individually or in combination:
“Theros® FMS dilators” and “Viball® therapy balls”.

Both products are certified medical devices. This means their effectiveness has been clinically proven and their safety of use is confirmed by the CE marking.

In addition to use for haemorrhoids, they are effective for many other problems in the centre of the body such as pelvic floor weakness, prostate or potency problems, vaginismus, injuries or consequences of surgery and many other problems in the vaginal or anal area (links to all applications can be found with the respective product).
In this guide we will focus on the use of both products for haemorrhoids.

Theros® FMS dilators

Theros® FMS dilators are high-quality, handmade glass dilators made from extremely shatter-resistant borosilicate glass for vaginal or rectal treatment of a wide variety of conditions in women, men and people of all genders such as vaginismus, anal spasm, prostate problems and many others.
The extremely smooth and hygienic material and the 27 different sizes allow exceptionally gentle application, even in the case of inflamed haemorrhoids. Theros® FMS dilators are certified medical devices, meaning their effectiveness has been clinically proven.

Repositioning haemorrhoids with FMS dilators

Repositioning or reposition means pushing the haemorrhoid back into the haemorrhoidal ring from which it has protruded. This is normally done with a finger. The problem is that the contact area is very small and the haemorrhoid can escape sideways, especially in the case of larger haemorrhoids. Even if this succeeds, the pressure is often not distributed broadly enough and the reposition is therefore only partially sustainable. For this reason haemorrhoids often protrude again after repositioning, so that they must be repositioned several times during the entire course of treatment.

FMS dilators are ideal for repositioning: thanks to the many sizes they can be optimally adapted to your body and they work over a large surface area.
With Theros® FMS dilators, repositioning is often successful even on the first attempt. For repositioning you should choose a dilator that is as large as possible, because it leaves the haemorrhoids less space to move away within the rectum.

However, this is virtually impossible with a single dilator.
A set of dilators is required for the treatment of haemorrhoids.
The following factors play a role in selecting the appropriate size(s):

• Your individual physique and physical characteristics
• The current degree and condition of your symptoms
• Your psychological state at the moment: if you are tense, this also affects the anal region and smaller sizes will be required

Further reasons for a dilator set:

• You can gradually increase the size by using consecutive dilator sizes one after another. This increases the effectiveness of repositioning and the increased flexibility of the anal region is the best prevention against the recurrence of haemorrhoids.
• As a man you can also use FMS dilators to massage your prostate and thereby improve potency.

We offer various dilator sets at a special price, or you can assemble your individual set with up to 20% discount. Under “How do I determine the right size?” we give tips on determining the correct sizes.

Application for repositioning:
You begin with a dilator in a size that you can insert comfortably and insert it with the help of high-quality medical lubricant. By moving the head of the dilator slowly back and forth several times at the narrowest point, the sphincter muscle relaxes so that after a short time the next size can be inserted. Increase the sizes according to your individual possibilities. This increases the effectiveness of repositioning because the rectum becomes more filled and the haemorrhoid is pushed back into the haemorrhoidal ring. The last / largest dilator should remain in place for about 10 minutes.
Note: Repositioning should ideally be carried out with a dilator from approx. 32 mm. If you are familiar with rectal insertion or the degree of your symptoms allows it, considerably larger dilators can also be used.

Repositioning should ideally be carried out with a dilator from approx. 32 mm. If you are familiar with rectal insertion or the degree of your symptoms allows it, considerably larger dilators can also be used.