Crash Course in Hemorrhoids

There are three (and a half) different types of hemorrhoids:

• External hemorrhoids occur under the skin around the anus.

• Symptoms include:

• Itching and irritation in the anal area.

• Pain or discomfort.

• Swelling around the anus.

• Bleeding.

• Internal hemorrhoids occur inside the rectum. They are typically not visible and rarely cause discomfort unless aggravated.

• Symptoms include:

• Painless bleeding during bowel movements (e.g., bright red blood on toilet paper or in the toilet bowl)

•  Prolapsed hemorrhoids are a type of internal hemorrhoid, where internal hemorrhoids push through the anal opening, leading to pain and irritation.

• Thrombosed hemorrhoids occur if blood pools in an external hemorrhoid and forms a clot (thrombosis).

• Symptoms include:

• Severe pain.

• Swelling and inflammation, a hard lump near the anus.

• Technically, a hemorrhoid is not always a pathology or disease/condition - it is a type of vascular cushion in your rectum/anus area made of arterioles and veins, which is why they bleed such huge amounts, and the arteriolar part is why hemorrhoidal bleeding is typically bright red. Everyone is born with hemorrhoids, hemorrhoidal disease has to be precipitated by something like the triggers described below.

• There are four different “grades” of hemorrhoids” - where yours falls makes a big differences in your symptoms, and what your limitations MAY be.

  Grade 1 hemorrhoids

• These are small, and not visible or palpable.

• Unlikely to cause discomfort, but they may cause bleeding when you pass a bowel movement.

  Grade 2 hemorrhoids

• Enlarged hemorrhoids that may come out of the anus while passing stool but will recede inside on their own. 

• Symptoms can include pain, itching and bleeding.

  Grade 3 hemorrhoids

• Enlarged hemorrhoids that come out while passing stool but cannot withdraw back inside on their own.

• However, they can be physically pushed back inside.

• These are also symptomatic, and may be associated with bleeding, pain, discomfort, itching, and irritation in the rectal area.

  Grade 4 hemorrhoids

• These are associated with enlarged hemorrhoids are always outside the anus and cannot be positioned back inside.

• The bulging vessels will stay outside the anal canal, even if you manually reposition them

• Symptoms are likely to be severe.

What causes hemorrhoids?

• They are often caused by increased pressure in the rectum and anus (such as from straining during bowel movements, prolonged sitting for long periods of time, especially on the toilet.

• Having chronic diarrhea or constipation, obesity, pregnancy, regularly lifting heavy items, internal sphincter dysfunction, faulty bowel function due to overuse of laxatives or enemas, and a low fiber diet can also contribute to hemorrhoid formation.

• Anal sex/bottoming DOES NOT immediately cause hemorrhoids according to multiple sources.

• According to the American Society of Colon and Rectal Surgeons, anal sex/bottoming is not listed as an explicit cause of hemorrhoids.

• The exact cause of hemorrhoids is unknown - a lot of pressure is put on human rectal veins due to our upright posture, which can potentially cause bulging of these blood vessels, leading to their formation.

  Preventive Measures

• Avoiding activities that strain these areas.

• Avoiding prolonged sitting or straining during bowel movements (if because of your IBD you are constipated, sitting on the toilet straining for too long can be a factor, or the opposite - too much diarrhea, causing extended toilet trips).

• If you deal with constipation, you may find benefit from the squatty potty, which relaxes the puborectalis muscle so you don’t strain and you poo better. (not sponsored or endorsed by squatty potty).

  • Keep bathroom trips short and limit toilet use to 1 to 2 minutes at a time (as much as you can, I know with IBD and IBS this may be difficult) and avoid straining whenever possible.

  • Eat more fiber and drink more water. Get 25 to 30 grams of fiber daily, either from fiber-rich foods (such as whole grains, fruits, vegetables, and beans) - if possible and feasible with your IBD/IBS according to any dietary restrictions it may create for you, or supplements (such as Metamucil or Benefiber). This helps make stools easier to pass, reducing the need to strain.

  • Clean up well after a bowel movement. Wet the area with a peri bottle filled with warm water (you can buy these at the pharmacy like CVS or Walgreens), or if you have a bidet, you can use that.

  • Get regular physical exercise, as this will help promote gastrointestinal motility and reduce constipation.

  • Limit intake of fatty foods and alcohol. These can worsen constipation.

  • Unfortunately, doing all of these things may not 100% prevent hemorrhoids, and due to IBD or IBS, the chances may just be a little higher - but we can be proactive!

  • And of course, we know that not everyone with IBD can do all of the above all of the time, and everyone’s journey is different. Modify to your situation and don’t feel pressured or that you have to do x,y, and z.

  • It is a silly assumption (and perhaps, part of the source of the untrue idea) that being a bottom means you will have a hemorrhoid.

  • Making sure to take the proper measures to prevent hemorrhoids if possible (not straining, fiber rich diet, drinking water, plenty of lube, etc) is important and being cognizant of when to maybe take a pause on bottoming if you feel a hemorrhoid acting up.

  • Now, the real question:

    Can people with hemorrhoids bottom/engage in anal sex/receptive anal intercourse?

  • While anal sex is generally not painful for most individuals (or shouldn’t be), hemorrhoids can make the experience uncomfortable or even painful.

  • For individuals who have mild or occasional hemorrhoids that do not necessarily require medical treatment (the lower grades from above) the regular “guidelines” (or suggestions discussed here) of anal sex apply: Use lube, go slowly at first and listen to your body.

  • Stop any activity that causes pain, discomfort or irritation.

  • Using a position where you are lying on your stomach and have your butt slightly elevated may decrease swelling in the area during anal play/bottoming.

  • Excess friction can be irritating, so you might want to use plugs or other forms of play that doesn’t involve a lot of in-and-out or thrusting action.

  • Go for smooth toys and condoms rather than ones that have ribs, bumps or other kinds of texture.

  • Try a lube that contains aloe vera or other soothing ingredients (use discretion if you have contact dermatitis or any sensitivities to additives though)

  • Sitz baths with shallow warm water several times a day for about 10-20 minutes may also help.

  • You can add Epsom salt or baking soda to the water to reduce inflammation, but don’t soap or bubble bath solution.

  • Over-the-counter remedies. This may include hemorrhoid wipes with Witch Hazel, which help to gently cleanse the area while reducing swelling and pain.

  • These should only be used in moderation as long-term use has side effects.

  • Tylenol is another option, but if your pain is severe and getting worse, you should seek medical care immediately.

  • You can put an Ice pack on the hemorrhoid area, ice for 5 to 10 minutes at a time, but not any longer (you may burn yourself with the ice and not feel it because it is numb). Place a towel between the ice pack and your skin.

  • This is why it is generally advisable to avoid anal sex or bottoming during an active, more severe hemorrhoid episode and wait until the condition has fully healed, but like always, use your best judgement.

  • With more severe hemorrhoids, intercourse (either vaginal or anal) may be painful.

  • So, long story short;

    The answer is “it’s complicated”.

  • If it is not actively bleeding, severe, or an open wound, it may be okay to take things slow (and vice versa if it is not and if you are experiencing uncomfortable symptomatic hemorrhoids, anal sex or bottoming would probably exacerbate that discomfort. it's probably best to hold off on anal sex/bottoming until the hemorrhoids heal and the symptoms are gone. 

    TL;DR: If it’s bleeding a lot, an open sore, or very bad, hold off for now. Wait until it calms down. If it’s asymptomatic, go slow and steady, and if it hurts bad or bleeds, pause and recollect.

  • If you do chose to…………..

    Bottoming with Hemorrhoids

    Irritation and Aggravation

  • The friction and pressure from anal penetration can worsen hemorrhoid symptoms such as pain, bleeding, and swelling.

  • In severe cases, anal sex may tear the anal lining, leading to additional injuries or fissures.

  • Slow and steady wins the race, start slow and gentle until you know what your body can handle.

  • Use PLENTY of lube to prevent chafing or irritation to the area - the lube will decrease the amount of friction on your anorectal area and decrease the irritating things further.

    Increased Infection Risk

  • Bleeding hemorrhoids can create open wounds (DO NOT POP THE HEMORRHOID!), which can elevate the risk of contracting infections - of all types, not just sexually transmitted, this includes all the bad bacteria in your poop and butt area.

  • There are good bacteria too, but a fair amount of bad ones that can make you sick.

  • These bacteria can enter the body more easily through cuts or open sores - and an open or popped hemorrhoid can facilitate that.

  • Always use condoms and a water- or silicone-based lubricant during anal sex with hemorrhoids or fissures to minimize risks.

  • I mention it a lot but if you have a hemorrhoid, using lube is really important here.

  • If you use a generous amount of lube, this decreases the chance you irritate the inflamed hemorrhoid area.

  • In summary, if you are experiencing severe hemorrhoid symptoms, it is best to avoid anal sex while it is “flaring” or quite sympomatic until the condition has improved, and definitely use a condom if you do.

  • While this may prevent you from connecting with penetration and bottoming if that’s your thing, and may not be ideal, that doesn't mean you'll have to avoid intimacy altogether.

  • You and your partner may need to find other ways to express your intimate connections, some things are explained here, here, here and here- some people explore different positions, topping, etc) Get creative!

  • It’s similar to sometimes in IBD introduces intimacy challenges - you may just have to think outside the box.

  • Once you relieve your discomfort and get better/your symptoms get better with hemorrhoid treatment, you can return to bottoming or whatever you like to do surrounding anal intercourse, following your recovery period and all of your doctors instructions.

    Listen to your body!

  • If you experience pain, irritation, or discomfort during intimacy, stop and wait until symptoms improve.

  • Testing the use of small toys or fingers with ample lubrication can help you gauge your comfort levels.

  • If bothersome symptoms persist beyond 3–5 days, consult a doctor, your gastroenterologist or PCP, or any trusted healthcare professional for professional advice. (ChatGPT is not a medical professional and not your healthcare provider)

  • Avoid strenuous or prolonged sexual activity that could strain the rectal area.

  • Pay attention to changes in your condition. Signs like increasing pain, burning, or bleeding may indicate the need to pause anorectal intimacy (bottoming).

  • Opt for gentle approaches and prioritize positions that minimize pressure on the anus.

    Set Boundaries and discuss the Limitations You May Have With Your Partner(s)

  • Discuss limits with your partner(s) that your symptoms are introducing (i.e, it hurts if you do this or that, need to be gentle, taking breaks, etc) before engaging in sexual activities.

  • Agree on when to stop (e.g., if pain or bleeding begins) and allow time for your body to adjust.

    Hemorrhoid Aftercare After Anal Sex/Bottoming

  • Just because you have a hemorrhoid (most people will develop them in life) doesn’t mean you necessarily have to stop everything -and some people bottom without knowing they have a hemorrhoid, or bottom knowing they have a hemorrhoid and just say c’est la vie! (* not endorsing that, it just has been done, and will be done, so harm reduction is key.)

  • Don’t fret, though - there is something to help with the potential discomfort!

  • Many treatments, such as creams, suppositories, medications, and at-home solutions, are available for hemorrhoidal discomfort after bottoming.

    Creams

  • Prescription creams containing hydrocortisone can help reduce pain, itching, and swelling.

  • Steroid-based creams are for intermittent short-term use, i.e., no longer than a week, due to risks of mucosal thinning (if you are familiar with this in IBD, you will know - they are great in the short term, but over long term use, they will not be fun)

  • Over-the-counter creams like Preparation H combine mineral oil and phenylephrine to relieve hemorrhoidal discomfort.

    Suppositories

  • There are prescription suppositories that contain hydrocortisone are also available and can help.

  • Over-the-counter suppositories of 76% cocoa butter and 10% zinc oxide can help temporarily relieve burning, pain, and itching from hemorrhoids aggravated by anal sex. These suppositories can also help provide a comfortable bowel movement.

    Medications

  • Lidocaine and Benzocaine: blocks the signals at the nerve endings of tissue, eliminating pain. There is OTC 20% Benzocaine gel/cream that you can buy that is super effective, but as always, check with you GI doctor/PCP/etc if you use this)

  • Lidocaine commonly sold at pharmacies and grocery stores over the counter is 4% to 5% (Common brands include Salonpas, Equate and Aspercreme)

  • Tiger Balm: We all know and love it, but Tiger Balm contains ingredients like menthol, camphor, and clove oil, which can cause burning, stinging, irritation and contact dermatitis.

  • Because hemorrhoidal tissue is very sensitive,these ingredients are typically too harsh for use on irritated mucous membranes or broken skin.

  • Some people swear by it for hemorrhoids, but I am not that brave - as always, use at your own discretion.

  • When shopping, make sure you look closely at the label - sometimes the products have menthol added or are menthol instead of lidocaine. I have not tried that, but unless you like feeling IcyHot on your anorectal area, don’t do that.

  • Don’t get IcyHot.

  • DON’T use lidocaine gel or cream on your butt exclusively to bottom/for anal sex. See more information on why here and here.

  • This will numb the area and you won’t be able to feel pain, and won’t be able to feel if something is going wrong/you’re getting hurt

  • Bulk-forming laxatives (i.e., fiber) for softer stools can help with bowel movements.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation (not preferred in IBD) and Acetaminophen/Tylenol (preferred in IBD) can help reduce pain.

    Hemorrhoid Surgery

  • See this page for more in depth explanation, but if your hemorrhoids are severe, you may have to have surgery for them.

  • There are a few different kinds of hemorrhoid surgery, but if you bottom or have a partner(s) who enjoys anoreceptive intercourse, it is important to be aware of these things.

  • Stapled hemorrhoidplexy has led to documented reports of penile injury upon bottoming as well as condom rupture if having anal sex too soon after surgery before the staples have absorbed into the mucosa (can take as long as 12 months!)

  • Stapled hemorrhoidplexy is preferred at times because it has much less post-op pain than open hemorrhoidplexy, but there is a circular line of staples left in the anal canal, therefore, there is a risk of penile injury or condom damage during anal intercourse or bottoming, which increases the risk of exposure to sexually transmitted diseases.

  • There is no guideline on how long after stapled hemorrhoidplexy you can safely return to bottoming (for the person topping/penetrating, and the person bottoming/receiving), but staples as visible on X-ray 12 months after the procedure and staples should be sloughed off on anoscopy in 3 months. There is no official guidance, yet, though, so this is something to discuss with your colorectal surgeon or GI doctor!

  • TLDR: Bottoming/ anal sex should be limited during an active hemorrhoid episode, and avoided when symptoms are bad and getting worse, and if bottoming, your partner should use a condom.

  • Bottoming while experiencing active/flaring hemorrhoid symptoms may increase your discomfort.

  • Prioritize your health and consult a doctor if symptoms persist or worsen.

    References

  • Also hyperlinked on the sentence or phrase.

  • https://fascrs.org/patients/diseases-and-conditions/a-z/hemorrhoids

  • https://colorectalsurgery.wustl.edu/patient-care/cope-center/anorectal-disorders/hemorrhoids/

  • https://pmc.ncbi.nlm.nih.gov/articles/PMC3342598/

  • https://hemorrhoidsurgeonmd.com/time-to-debunk-6-hemorrhoid-myths/

  • https://jamanetwork.com/journals/jama/fullarticle/2084893

  • https://pmc.ncbi.nlm.nih.gov/articles/PMC4301293/

  • https://pubmed-ncbi-nlm-nih-gov.ezproxy.lib.ou.edu/17387569/