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Hemorrhoids (Piles) are blood vessels located in the smooth muscles of the walls of the rectum and anus. They are a normal part of the anatomy and are located at the junction where small arteries merge into veins. Smooth muscles and connective tissue cushion them. They are classified by where they are located in relationship to the pectinate line. The pectinate line is the dividing point between the upper 2/3 and lower 1/3 of the anus. This is an important anatomic distinction because of the type of cells that line hemorrhoid, and the nerves that provide sensation.

What are the internal and external hemorrhoids?

Internal hemorrhoids are located above the pectinate line. And are covered with cells that are the same as those that line the rest of the intestines. External hemorrhoids arise below the line and are covered with cells that resemble skin.

What are the symptoms of hemorrhoids?

Hemorrhoids become an issue only when they begin to swell, causing itching, pain, and or bleeding.

Rectal Bleeding Symptoms and Causes

Recognize blood in the stool
Blood in the stool can be bright red, maroon in color, black, and tarry, or occult (not visible to the naked eye). Examples of causes of blood in the stool are:
     • Hemorrhoids
     • Cancer
     • Anal fissures
     • Crohn’s disease
     • Ulcerative colitis
     • Anal cancer
Blood in the stool should be evaluated by a health care professional.

What do external and internal hemorrhoids look like?

Healthy hemorrhoidal tissue cannot be seen since they must first swell and become inflamed or develop a clot to cause symptoms. One can see swollen external hemorrhoids or internal prolapsed hemorrhoids exposed outside the anus, but internal hemorrhoids cannot be seen because they remain inside the anus. A thrombosed hemorrhoid will appear as a lump at the anal verge, protruding from the anus, and will be dark bluish because of the blood clot contained inside the swollen blood vessel. Non-thrombosed hemorrhoids will appear as a rubbery lump. Often more than one swollen hemorrhoid appears at the same time.

What causes hemorrhoids?

While the presence of hemorrhoids is a reflection of the normal anatomy, most people and care professionals refer to hemorrhoids as an abnormal finding because they only present when they swell and cause problems.
Hemorrhoid swelling occurs when there is an increase in the pressure in the small vessels that make up hemorrhoids, causing them to swell and engorge with blood. This causes them to increase in size leading to symptoms. A variety of factors may cause increased pressure:
     • Low-fiber diet and smaller caliber stool cause a person to strain when having a bowel movement, increasing the blood vessels’ pressure.
     • Pregnancy is associated with hemorrhoid swelling and is likely due to increased pressure of the enlarged uterus on the rectum and anus. Also, hormonal changes with pregnancy may weaken the muscles that support the rectum and anus.
     • Prolonged sitting on the toilet may increase pressure within the hemorrhoid blood vessels.
     • Obesity
     • Diarrhea, both acute and chronic
     • Colon cancer
     • Previous rectal surgery
     • Spinal cord injury and lack of erect posture

What are the symptoms and signs of hemorrhoids?

Hemorrhoids are the most common cause of rectal and anal complaints. The most common complaint symptoms are:
     • painless bleeding from the anal area,
     • anal itching,
     • pain in the anal area,
     • swelling and feeling a lump at the anus are all associated with inflamed hemorrhoids.

It is important to remember that rectal bleeding or blood in the stool is never normal and, while it may come from a relatively benign cause like hemorrhoids, more serious causes can be life-threatening. These include bleeding from ulcers, diverticulitis, inflammatory bowel disease, and tumors. If rectal bleeding occurs, it is essential to contact your health care professional or seek emergency medical care. This is especially important if the person is taking blood-thinning medications.
When internal hemorrhoid becomes inflamed, it can cause swelling. This, in itself, does not cause pain because there are no pain fibers attached to the veins above the pectinate line. Passing a hard stool can scrape off the thinned lining of hemorrhoids, causing painless bleeding. However, swollen hemorrhoids can also cause spasm of the muscles that surround the rectum and anus, causing pain, especially if they protrude or prolapse through the anus. A lump can be felt at the anal verge. Internal hemorrhoids can also thrombose (clot), leading to severe pain.

Inflamed hemorrhoids can leak mucus, causing inflammation of the skin surrounding the anus, causing burning and itching, known as pruritis ani. However, other causes of itching include yeast and other skin infections and parasites like pinworms. Most importantly, just as blood in the stool should not be ignored because it might be a sign of colon cancer, anal itching or bleeding should not be presumed to be due to hemorrhoids because it can be a sign of anal cancer tumor.

External hemorrhoids behave differently since they are covered by “regular skin” and have pain fibers associated with them. A thrombosed external hemorrhoid occurs when an underlying vein within hemorrhoid clots off, causing intense pain from the rapid stretching of the skin covering hemorrhoids. A hard, painful lump can be felt at the anus. External hemorrhoids can also result in excess skin tags that can be felt at the anal verge and can cause difficulties with cleaning after a bowel movement, leading to secondary skin infections.


By reading this website, you acknowledge that you are responsible for your own health decisions. The information throughout this medical website is not intended to be taken as medical advice. The information provided is intended for general information regarding gastroenterology conditions and services.

If you are interested in finding out more, avoid worrisome self-diagnosis, please contact a Doral Health & Wellness specialist for a personal consultation. No information on this site should be used to diagnose, treat, prevent, or cure any disease or condition.