Illustration: Olivier Heiligers
One of the most harrowing experiences of his life, Jeff tells me, began with a bloody toilet bowl 20 years ago. Only after I’ve guaranteed his anonymity — Jeff is not his real name — does he share the whole story: “I was in my early-to-mid-30s, and there was significant bleeding from my butt after a bowel movement.” That had never happened before, and Jeff had no idea why it was happening. Panicked, he raced to the ER. “They told me I had internal hemorrhoids and one had become inflamed,” he says.
In a sense, we all have hemorrhoids. The term refers to both the anal ailment and the anatomy it affects: the cushiony rings of veins that line the anal canal and swell and expand to prevent stool from leaking before we’re ready to release it. “You can also think of them like a gasket in an engine or a rubber ring in a water faucet,” says Dr. Sanghyun Kim, associate professor of surgery at the Icahn School of Medicine and site chief of colon and rectal surgery at Mount Sinai. When hemorrhoids are taxed beyond their limit — from too much pressure — they swell too much, bulging like a kinked hose. That’s when hemorrhoids become varicose veins in your butt (or just outside it). And they are ubiquitous. “I would say we are absolutely seeing an increased incidence in hemorrhoids,” says Dr. Felice Schnoll-Sussman, director of the Jay Monahan Center for Gastrointestinal Health at NewYork-Presbyterian and Weill Cornell Medicine, who explained that since the recommended age for a first colonoscopy was recently changed from 50 to 45, more people are being diagnosed with them than ever.
Research shows that one in three people in America who undergo a colonoscopy are diagnosed with hemorrhoids and that hemorrhoids account for 4 million doctor’s-office and emergency-room visits annually. Doctors expect this number to continue to rise. It’s estimated that at least $1.7 billion is spent on medical hemorrhoid treatments each year, a figure projected to increase another billion dollars by 2034. (In 2017, sales of Preparation H — which can temporarily ease hemorrhoid pain but does not solve the problem — totaled $136 million.)
Given the nightmare health scenarios that bloody stool can portend (colon cancer, inflammatory bowel disease), a diagnosis of hemorrhoids was a relief for Jeff. He vowed to stop reading on the toilet (which he’d done all his life and which he was told may have caused his hemorrhoids) and to eat more fiber and drink more water so as to strain less. A bowel movement should occur swiftly and effortlessly; some experts say it should take no more than two minutes. Back before his Trump-toadying days, Dr. Mehmet Oz famously remarked that poop should hit the bowl “like a diver from Acapulco.”
Typically, this is where a hemorrhoid story ends. If your only symptom is occasional blood or intermittent discomfort, doctors often advise that after getting checked out, you wait for things to improve on their own, which they generally do. This is how things transpired for Lana (also not her real name) after she noticed “some minor itchiness and then a weird lump” along with “blood in my poop.” Her doctor told her, “Oh, you probably have hemorrhoids; if they don’t bother you, don’t worry about it.” She made some lifestyle changes, though she admits that toilet-scrolling remained a treasured pastime (“Because phones are interesting,” she tells me). Meanwhile, Jeff hewed to his doctor’s counsel: “Lots of fiber, lots of hydration. Just doing everything I could,” he says. But hemorrhoids are mercurial menaces — sometimes easily vanquished, sometimes not. Though Lana was lax and Jeff meticulous, her hemorrhoids resolved while his persisted, eventually causing him brutal pain on top of the bloody mess he would ashamedly clean up each time he moved his bowels. On Reddit, many others have shared their private ordeals with their own intractable hemorrhoids. “Is anybody else severely depressed because of these things?” one asked in r/hemorrhoid. Another answered, “It’s all I think about all day.” A woman going by u/misssorebutt called her hemorrhoids “the worst pain imaginable.” The title of her post is “Hemorrhoids are ruining my life.”
Some reasons for this problem are becoming clearer. Many of us are doing our damnedest to let hemorrhoids flourish: We sit too much, eat too poorly, drink too little water, work out too hard, poop too aggressively, bidet too ferociously, and, perhaps most prevalently these days, stick around too long — chronically scrolling on the toilet is as surefire a path to hemorrhoids as one could hope to find.
A 2021 survey revealed that 73 percent of people bring their phone with them into the bathroom; among respondents ages 18 to 29, that number climbed to 93 percent. While it’s possible that these people are just lugging their phones along for safekeeping, it seems unlikely given a more recent small survey, which found that of the survey subjects who reported having hemorrhoids, 93 percent admitted to using their phones while on the toilet at least once a week. The correlation between increasingly ubiquitous toilet-based phone usage and hemorrhoid prevalence seems clear.
It’s a widening public-health problem — and for many, the treatments are arguably just as bad as the affliction itself.
Jeff had to reach a point of sheer misery before being referred for surgery. His hemorrhoids began to protrude, and he could no longer push them back. Jeff saw a specialist who attempted a rubber-band ligation, or RBL. For decades, this has been the most common — and, in many gastroenterology practices, the only — nonsurgical treatment for hemorrhoids. It’s a five-minute procedure in which a rubber band is placed at the base of a hemorrhoid, cutting off its blood supply to shrink it. Patients are often told that the procedure isn’t that painful since the rubber band is placed at a part of the hemorrhoid without any pain sensors. In practice, however, many patients report otherwise. (“I am in agony,” says a post-RBL redditor. “Nothing is helping.”) Says Jeff, “He tried to band a couple of them to see how that would go, with the idea that possibly the rest could be banded as well. But the biggest one was too sensitive — I could feel it being pulled at, and it was painful. So the doctor said it wasn’t a good idea, and surgery was recommended.”
Hemorrhoidectomies — in which hemorrhoids are excised, or, in a stapled hemorrhoidopexy, stapled to choke their blood supply — are effective 95 percent of the time. But they have long suffered from a serious PR problem: It’s common knowledge that recovery is painful and long, lasting weeks. “I’ve been doing old-fashioned hemorrhoidectomies for 25 years,” says Kim. “And there is not too much we can do to make the pain better. It does hurt, no matter what we do, because it’s a very sensitive area.”
For Jeff, recovery from surgery was far worse than he could have anticipated. It started out okay, he says, “because they give you a nerve block so you don’t feel much after.” But all good painkillers must come to an end, and once Jeff’s did, the full picture of what his anus had undergone became clear. “It’s incredibly agonizing to shit through an open wound,” he says.
To help with the pain, Jeff was given oxycodone, an opiate — a common side effect of which is constipation. This is how the task of defecating became downright life-threatening for him. When he finally had a bowel movement, his bleeding became profuse. Jeff’s wife ran out to buy adult diapers so the pair could go to the ER. It turned out that Jeff had delayed post-hemorrhoidectomy bleeding, which affects as many as 10 percent of patients and is more common in men. After a night in the hospital and a quick patch-up of his wound, he underwent blood tests over several months to monitor the severe anemia he suffered thanks to the blood loss. During this period, he was weak, easily fatigued. The surgery was in February; it took until June for Jeff to return to his normal level of activity.
This lackluster state of affairs — a pervasive problem with solutions that range from irritating to horrific — has been the reality for hemorrhoid sufferers for decades. But fresh avenues for treatment are emerging with some promising to be game-changing.
A newer procedure that Kim favors is transanal hemorrhoidal dearterialization, in which a device is inserted into the anus to locate the artery feeding blood to your hemorrhoids, before another device is inserted to tie that artery off with sutures. “I’ve compared traditional hemorrhoidectomy to THD, and the return-to-work rate was 20 days for hemorrhoidectomy and only three with THD,” Kim says. But because THD can leave deflated skin dangling from the anus, causing cleanliness issues and irritation, Kim has added what he calls an “anal lift.” He uses a barbed tie popularly deployed in face-lifts in Korea, his mother country, called V-Loc sutures. “The sutures have tiny hooks on them with a one-way spike so that when the hook goes in, it won’t come out,” he says. “I can use that to decrease the prolapsed skin.” However, Kim explains, the procedure is sometimes denied by insurance companies for being either too experimental or more expensive than RBL.
That’s a recurring theme I encountered while researching procedures beyond RBL and traditional hemorrhoidectomy: They exist, and they are well proven, but because they are neither familiar nor cheap, they present more challenges in terms of coverage. I spoke with Dr. David Mauro, a vascular surgeon in Chapel Hill, North Carolina, who often performs a low-recovery hemorrhoid procedure known as hemorrhoid artery embolization. The procedure involves snaking a catheter through a tiny hole in the groin or wrist down to the artery feeding the hemorrhoid, then delivering typically a combination of tiny metal coils and particles into the blood vessel to block the hemorrhoid’s supply of blood. “There’s a significant subset of patients that recur after banding,” says Mauro, “or banding fails or is intolerable. And that’s where I think hemorrhoidal embolization has a role.” However, a failed banding is often a painful hurdle to clear.
A new medtech company is hoping to interrupt this pattern of muscling through banding and surgery before getting effective (but somewhat more experimental) treatment. For the past few years, a company called HemWell has sought to popularize what it describes as a “painless” outpatient procedure that has been approved for use by the FDA. Essentially, a low current from an electrode inserted into the anus causes nearby blood vessels to narrow, shrinking hemorrhoids within minutes. I ask Dr. Reed Hogan III, a gastroenterologist at the GI Associates & Endoscopy Center in Madison, Mississippi, who has performed many Hemwellectomies, to tell me more. “While the patient is asleep,” he says, “the electrode is inserted, and its current creates a chemical reaction within the hemorrhoid blood vessel that shuts down the blood flow coming in but still allows blood to flow out. This decreases the size of the hemorrhoid.”
I ask Hogan if the procedure is really as remarkable as it seems: Patients are comfortably sedated, and supposedly the recovery time is nonexistent, while clinical efficacy (more than 90 percent) is apparently more predictable than in RBL (between 70 to 90 percent). “I think this is a paradigm shift for hemorrhoid treatment,” he tells me. “I think it should be offered in every GI clinic across the country because it’s so well tolerated by patients.” Hogan sings HemWell’s praises so profusely that I ask point-blank if he is being paid to spread its gospel. He assures me that he has not received a dime. He now performs Hemwellectomies on 90 percent of his hemorrhoid patients, and his father, also a gastroenterologist in the practice, is a fellow convert. “Normally I hate to use the term painless, but in two years of doing these, I’ve had about five people need an Advil or a Tylenol,” the senior Hogan tells me.
As with other nontraditional therapies, HemWell is theoretically covered by insurance but often only if you’ve exhausted the standard options. And if you don’t happen to live near a physician who’s using the procedure — I found only about a dozen across the country — you may have to stick with RBL.
For most of us, it will not be possible to dodge hemorrhoids forever, not in a culture so uniquely suited to producing them (what with the phones, processed foods, constipating weight-loss pills, and jobs that demand we sit most of the day) and not when many of us have one or more unavoidable risk factors (being a woman, carrying a pregnancy, giving birth, and having a chronic cough).
In fact, pregnancy results in hemorrhoids in 30 to 40 percent of cases — especially during the third trimester, when the added weight of the fetus presses down onto rectal veins. A pregnant person’s blood volume increases by as much as 50 percent, which can enlarge those veins. Hormones released during pregnancy can relax the walls of their blood vessels, making them more susceptible to swelling. Pregnancy also causes constipation. Then there’s the final boss of anorectal straining, vaginal delivery, which leaves many new moms with hemorrhoids postpartum.
Remember Lana with the vanishing hemorrhoids? Her luck ran out when she became pregnant with her first child. “Before pregnancy,” she says, “I’d have a lump I’d barely pay attention to, and it would resolve itself. But during pregnancy, they got worse, and they’ve never gone away. They’re just hanging out” — literally and figuratively — “and they’re probably a permanent fixture, because no way am I having surgery.” Though Lana’s hemorrhoids are a nuisance when it’s time to wipe (“They make the topography more complicated,” she says), they still don’t hurt. For unknown thousands, this is the status quo: a lifelong anatomical annoyance one must learn to live around.
But physicians do hope that when people inevitably develop a hemorrhoid, they’ll seek help. Timely treatment (albeit paid for out of pocket) increases the odds of avoiding surgery.
But maybe even that is too much to hope for. Few parts of the body are more freighted with taboo and disgust than the human anus. It is, after all, where poop comes out, poop being among the ultimate embodiments of the abject — all the stuff, according to critical theory, that’s so horrifying and odious it has the power to disrupt the very social order if not hidden or contained. That’s a lot of pressure on one little ring of muscle.
Schnoll-Sussman says that when it comes to anything this taboo, people just don’t want to go into detail with a doctor. “The fear factor, the ick factor, go up exponentially,” she says before summing it all up nicely: “People just do not like to talk about their anus.”
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