What are haemorrhoids*

In the rectum, several elements work together to ensure secure closure of the anus. In addition to the pelvic floor muscles, the anal sphincter (sphincter ani) plays the most important role. Slightly higher up in the rectum there is a network of small arteries and veins that provide fine adjustment for complete closure (e.g. in the case of softer stool). This system is known as the haemorrhoidal cushion or haemorrhoidal plexus and refers to a ring-shaped arrangement of haemorrhoids. The term therefore does not originally describe a disease; rather, healthy haemorrhoids fulfil the extremely important function of ensuring secure continence. However, this applies only when they remain in their natural position within the haemorrhoidal cushion – from which they have now prolapsed.

Note: Strictly speaking, pathological changes should therefore not be referred to as haemorrhoids, but as piles (medically correct term: haemorrhoidal disease). For the sake of simplicity, however, we will continue to use the common term below.

Haemorrhoides* cause a distinct foreign-body sensation. They usually develop over a long period of time and do not necessarily cause pain. The most noticeable symptom is often almost constant, intense itching. Bleeding may occur during or after bowel movements and does not necessarily have to be painful. Weeping and stool leakage cause persistent hygienic discomfort and can easily lead to inflammation. When inflamed, haemorrhoides* are almost constantly painful.

Internal and external haemorrhoids*

Internal haemorrhoids*

Piles (haemorrhoidal disease) develop when individual vessels of the haemorrhoidal cushion enlarge and become pathologically pronounced for a variety of reasons. As long as these are moderate enlargements that remain inside the rectum, they are referred to as internal haemorrhoides*. These are often not noticed and cause little or no discomfort. If the causes are not addressed and internal haemorrhoides* continue to swell and enlarge, they may protrude temporarily or persistently.

External haemorrhoids*

If enlargements or protrusions are visible or palpable outside the anus, these are referred to as external haemorrhoides*. These unfamiliar thickenings, swellings, bulges or clearly protruding skin folds may appear partly overnight and can be alarming. As a rule, external haemorrhoides* are noticed during cleaning after bowel movements or due to itching, pain or bleeding.

Classification or severity grades of haemorrhoids*

Haemorrhoids* are classified into the following severity grades:

Grade 1 haemorrhoids*
refer to the internal variant with no or only minor symptoms.

Grade 2 haemorrhoids*
means that they protrude temporarily – usually after a bowel movement – but retract spontaneously or gradually afterwards.

Grade 3 haemorrhoids*
describe the variant that does not retract on its own, but can be manually pushed back into the haemorrhoidal cushion in the rectum with a finger or with suitable dilators (see below). This process is referred to as repositioning.

Grade 4 haemorrhoids*
is the classification for the severity level at which repositioning is no longer possible and they remain permanently outside. Grade 4 haemorrhoids usually require surgical removal.

Other conditions affecting the anal area

In the anal region and around the anus, there are various unpleasant conditions that are often collectively referred to as haemorrhoides* in everyday language. This generalisation is incorrect: not every thickening, fold or bulge at the anus is a haemorrhoid, and treatment approaches therefore differ accordingly.

Below, we provide an overview of different conditions in the area of the anus and rectum to help you distinguish them reliably: anal skin tags, anal fissures and thrombosed haemorrhoids. In rare cases, changes in this region may indicate anal carcinoma, which requires urgent medical treatment.
Symptoms and typical appearances of the individual conditions are described here.
At the outset, an image of external haemorrhoids* for comparison:

It is important to understand that there is no single ‘typical’ appearance of haemorrhoids*. They can look very different depending on their severity, location and current condition. While early stages are often hardly visible externally, advanced haemorrhoides* protrude clearly. These differences are illustrated in the graphical overview of severity grades shown above. The image shown here depicts prolapsed haemorrhoids* (grade 3) and serves as a comparative example for other anal conditions.

Anal skin tag

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

Anal fissure

An anal fissure (visible at the top centre of the image) is a longitudinal tear in the sphincter muscle or the anal canal and is therefore (incorrectly) also referred to as an cut in the anus. Although it often appears very fine externally, it can be quite deep and cause severe pain, particularly during bowel movements, cleaning after bowel movements or showering. No tissue protrudes outward and there is no foreign-body sensation, which clearly distinguishes an anal fissure from haemorrhoides*. Further information on anal fissures can be found in our Anal fissure guide.

Thrombosed haemorrhoid* (anal vein thrombosis)

Thrombosed haemorrhoids* (anal vein thrombosis or AVT) are acute events, unlike the other conditions described here. Within a few hours, a clot develops in the form of a bluish-black, tense lump. Another clear indicator is severe, stabbing pain. A thrombosed haemorrhoid* typically occurs as a single lesion.

Anal carcinoma (anal cancer)

An anal carcinoma or anal cancer (the tumour-like tissue change visible in the centre of the image) is a malignant growth in the area of the anal canal or the skin near the anus. It may initially present with non-specific symptoms such as persistent itching, bleeding, weeping or poorly healing skin changes, as well as a sensation of pressure or a foreign body in the anus. In contrast to acute events, symptoms usually develop gradually and increase over weeks or months. Pain may occur, but is often absent in the early stages, which is why changes in the anal area that cannot be explained or do not heal despite treatment should always be medically assessed.

If you are unsure whether you are dealing with haemorrhoides* or an anal carcinoma, a medical consultation should clarify this before you attempt any self-treatment.

Causes and development of haemorrhoids*

The most common causes of haemorrhoides* are:

Chronic constipation

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

Incorrect toilet habits

Rushed toilet visits, frequent, forceful straining during bowel movements, often in an unfavourable sitting position. This is especially common in patients with chronic constipation (obstipation).

Overstrain in the pelvic floor

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

Weak connective tissue

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

Frequent diarrhoea or frequent use of laxatives

...cause excessive stretching of the haemorrhoidal cushion and therefore also create the basis for piles (medically correct term: haemorrhoidal disease).

Pregnancy and childbirth

Women are more likely to develop haemorrhoides* due to their hormonal situation and the natural physical strain during this time. For more details, see Haemorrhoides* after pregnancy or childbirth.

Prevention of haemorrhoides*

To help prevent haemorrhoides* and to support treatment, your diet should be geared towards good, uncomplicated digestion and therefore be high in fibre. Fibre consists largely of indigestible food components, mainly carbohydrates, found primarily in plant-based foods such as fruit, vegetables and grains, and helps counteract digestive problems.

Adequate fluid intake of around 2 to 3 litres per day, with most of it ideally being water, results in a softer stool consistency and makes bowel movements easier.

Correct toilet habits are important. Avoid straining and pressure; instead, it is better to “push” from the abdomen: take a deep breath in and press the air as far down into the abdomen as possible. The right posture supports this: a rounded back and feet flat on the floor. Instead of the upright, “civilised” sitting position, posture should resemble the original posture that is optimal for bowel movements – namely the squat. A footstool helps you adopt this posture.

How are these connected?
The musculus levator ani – or more simply: levator ani – is a key pelvic floor muscle. In everyday life, it keeps the anus and rectum slightly lifted and thereby supports secure closure. Its innermost part, the puborectalis, forms a sling around the rectum. In an upright posture, it bends the rectum slightly and thereby contributes significantly to continence. When this muscle relaxes – especially in a squat or when the upper body is 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 gentle dry pre-cleaning with soft toilet paper, a wet follow-up clean is essential, ideally with water, e.g. using a hand shower, bidet or portable bidet. When out and about, it can exceptionally be done with wet wipes. It is important to ensure they contain as little as possible beyond water and no additives. This could unnecessarily irritate the sensitive mucosa and disrupt its flora. Please note that most wet wipes must not be disposed of in the toilet, but belong in the bin. Finally, the anal area should be dried with toilet paper.
In this way, inflammation is deprived of a breeding ground and the skin’s pH value is not irritated. At the end, a healing ointment or haemorrhoides* ointment can be applied if needed.

* NOTE: Throughout this guide we use the medically correct term “haemorrhoids” instead of the commonly used term “piles”.

Home remedies for haemorrhoides*

If you want to treat haemorrhoides* without medication containing chemical active ingredients, the following home remedies and naturopathic approaches are available:

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

For severely swollen or inflamed haemorrhoides*, the following can help:

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

The measures listed above are both important support for effective treatment of existing haemorrhoides* and good prevention against developing them.

However, in addition to suppositories, ointments and medication, there are also ideal mechanical tools:

Tools for the natural treatment of haemorrhoides*

We would like to introduce you to two tools that you can use individually or in combination to treat your haemorrhoides* effectively on your own:
“Theros® FMS dilators” and “Viball® therapy balls”.

Both products are certified medical devices with proven effectiveness. Their safety of use is confirmed by the European CE marking.

In addition to their use for haemorrhoides*, they also help many people with a range of other issues in the body’s centre, such as pelvic floor dysfunction, prostate or potency issues, vaginismus, injuries or post-operative effects and many other concerns in the vaginal or anal area (links to all applications can be found on the respective product pages).
In this guide, we want to focus on how both products are used for haemorrhoides*.

Theros® FMS dilators

Theros® FMS dilators are high-quality, hand-crafted glass dilators made from extremely shatter-resistant borosilicate glass for vaginal or rectal treatment of a wide range of conditions or problems in women, men and people of all genders, such as vaginismus, anal spasm, prostate issues and many more.
The extremely smooth and hygienic material and the 27 different sizes enable exceptionally gentle use, even with inflamed haemorrhoides*. Theros® FMS dilators are certified medical devices; their effectiveness is clinically proven.

Repositioning haemorrhoides* with FMS dilators

Repositioning refers to pushing the pile* back into the haemorrhoidal cushion from which it has prolapsed. This is usually done with a finger. The problem is that the contact surface is very small and the pile* can slip sideways, especially in the case of larger haemorrhoides*. Even if it succeeds, the pressure is often not broad enough, so the repositioning is only partly sustainable. This is why haemorrhoides* often prolapse again some time after repositioning, meaning that repositioning has to be repeated several times over the entire course of treatment.

FMS dilators are ideal for repositioning: thanks to the many sizes, you can adjust them optimally to your body, and they act over a large area.
With Theros® FMS dilators, repositioning is not uncommonly successful the very first time. For repositioning, you should choose the largest dilator possible, because it leaves the haemorrhoides* in the rectum less room to move out of the way.

However, this is virtually impossible with a single dilator.
For the treatment of haemorrhoides*, a set of dilators is required.
Because the following factors play a role in selecting the appropriate size(s):

• Your individual physique, your physical characteristics,
• the current grade and state of your symptoms,
• your current mental state or mood: if you are tense, this also affects the anal region and you will need smaller sizes.

Further reasons for a dilator set:

• You can increase the size step by step by using successive dilator sizes one after another. This increases the effectiveness of repositioning, and improving flexibility in the anal region is the best prevention against haemorrhoides* recurring.
• As a man, you can also use FMS dilators to massage your prostate and thereby increase potency.

We offer various dilator sets at a special price, or you can put together your individual set with up to 20% discount. And we give you tips on determining your individual right sizes.

Use for repositioning:
You start with a dilator size that you can insert without difficulty, and insert it using high-quality medical lubricant. By slowly moving the head of the dilator back and forth a few times at the narrowest point, you relax the sphincter so that after a while you can insert the next size. Increase sizes according to your individual possibilities. This increases the efficiency of repositioning because your rectum is more filled, so the pile* is pushed back into the haemorrhoidal cushion. Leave the last / largest dilator in place for around 10 minutes.
Note: Ideally, repositioning should be done with a dilator from approx. 32 mm. If you are familiar with rectal insertion or the grade of your symptoms allows it, you can also use considerably larger dilators.

Ideally, repositioning should be done with a dilator from approx. 32 mm. If you are familiar with rectal insertion or the grade of your symptoms allows it, you can also use considerably larger dilators.