Hemorrhoids risk factors
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Ahmed Younes M.B.B.CH [3]
Overview
Hemorrhoidal disease (HD) is the symptomatic enlargement and distal displacement of the anal cushions. Current models attribute it mainly to age- and strain-related degeneration of the supporting connective tissue and anchoring (Treitz) muscle, with vascular engorgement as a secondary feature. This replaces the older varicose-vein (venous stasis) model.[1][2] The most consistent risk factors are increasing age, constipation with straining or hard stools, and the late-pregnancy and peripartum period. Prior HD is a strong predictor of HD during pregnancy. Higher adiposity has genetic support for a causal role, even though observational data are inconsistent.[3][4]. In cirrhosis with portal hypertension, HD is more prevalent but must be distinguished from rectal varices, which are a separate entity.[5]
Risk Factors
Summary of Risk Factors
- Increasing age
- Constipation, straining, hard stools, incomplete evacuation
- Pregnancy (third trimester and postpartum)
- Parity / gravidity
- Prior hemorrhoidal disease
- Adiposity (BMI, waist circumference, body-fat %)
- Smoking,
- hypertension
- Chronic venous disease
- Portal hypertension
Constipation and Defecatory Behavior
- Constipation, straining, hard stools, and incomplete evacuation are the best-supported modifiable factors, although effect sizes are modest.[6]
- Prolonged toilet sitting is also implicated. The proposed mechanism is that raised intra-abdominal pressure and shear forces during straining are transmitted to the anal cushions.[1]
- In care-seeking patients, constipation was among the variables most strongly associated with HD severity.[7]
- Causality is weaker than traditionally taught. HD and constipation have different epidemiologic profiles, and some studies implicate diarrhea rather than constipation.[2][8]
Pregnancy, Parity, and Delivery
- HD is common in late pregnancy and the postpartum period. Reported frequency varies widely between studies, from 51% symptomatic in one survey cohort to as high as ≈80% in some reports.[9][10]
- Contributing mechanisms include:
- Delivery-related and peripartum predictors identified in a prospective cohort include:[12]
- Prior perianal disease (hemorrhoids or anal fissure)
- Constipation during pregnancy
- Second-stage straining for more than 20 minutes
- Birth weight greater than 3800 g
- In a randomized trial, dietary and behavioral counseling reduced postpartum HD (ITT RR 0.38; 95% CI 0.24–0.59).[13]
- Gravidity alone was not associated with HD on controlled screening data. This underscores heterogeneity between populations.[6]
Adiposity
- Observational data are inconsistent, including a null association in a large U.S. screening colonoscopy cohort.[6]
- Two-sample Mendelian randomization supports a causal effect on HD of higher BMI, body-fat percentage, waist circumference, and waist-to-hip ratio. The findings were robust to adjustment for physical activity, and testing showed no evidence of reverse causation.[4]
- The effect appears to be modified by sex and parity. BMI and waist circumference were positively associated with HD in parous women.[3]
Cirrhosis and Portal Hypertension
- HD is more prevalent in cirrhosis with portal hypertension (≈59%) than in cirrhosis without it (≈19%).[14]
- Rectal varices are a distinct entity. They are portosystemic collaterals rather than degenerated anal cushions, and hemorrhoids occur independently of them.[15][5]
- Distinguishing features:
- Hemorrhoids: soft cushions at or near the dentate line, contiguous with the anal columns.
- Rectal varices: tortuous, bluish, compressible submucosal veins, typically more than 4 cm above the anal verge and not contiguous with the anal columns. They are often accompanied by esophageal varices or ascites.[5][16]
- Misclassifying rectal varices as hemorrhoids can lead to inappropriate banding or excision and potentially massive bleeding. In patients with portal hypertension and hematochezia, perform anorectal evaluation, with or without endoscopic ultrasound, before any intervention.[5][16]
Factors With Weak or Controversial Evidence
- Diarrhea vs constipation: which bowel disturbance drives HD remains disputed.[2][8]
- Physical inactivity: sedentary behavior was paradoxically associated with lower HD risk in screening data, and the reason is unresolved.[6]
- Diet: only grain fiber showed a protective signal in screening data. A "high-fat" component is not supported as a risk factor.[6]
- Male sex: associated with HD severity in care-seeking populations.[7] In population screening, however, prevalence was higher in women.[3]
- Methodologic caveat: most data are cross-sectional. Colonoscopy-based ascertainment, including congestion related to bowel preparation, may overdiagnose or overstage HD.[3][17]
Clinical Implications
- Most actionable lever: target straining and stool consistency with adequate dietary fiber and fluids, and limit time spent sitting on the toilet.[1][14]
- Pregnancy: address constipation early. Bulking agents and osmotic laxatives are considered safe in pregnancy.[11][10]
- Counseling: avoid presenting obesity, gravidity, or inactivity as definitive causes, because the evidence is mixed.[6][4]
- Rectal bleeding in pregnancy or cirrhosis: examine the patient rather than attributing bleeding to hemorrhoids by default. In pregnancy, exclude anal fissure. In cirrhosis, exclude rectal varices.[10][5]
References
- ↑ 1.0 1.1 1.2 Wald A, Bharucha AE, Limketkai B, Malcolm A, Remes-Troche JM, Whitehead WE, Zutshi M (2021). "ACG Clinical Guidelines: Management of Benign Anorectal Disorders". Am J Gastroenterol. 116 (10): 1987–2008. doi:10.14309/ajg.0000000000001507. PMID 34618700 Check
|pmid=value (help). - ↑ 2.0 2.1 2.2 Bharucha AE, et al. An evidence-based practical review on common benign anorectal disorders. Gastroenterology. 2026.
- ↑ 3.0 3.1 3.2 3.3 Hong YS, Jung KU, Rampal S, Zhao D, Guallar E, Ryu S, Chang Y, Kim HO, Kim H, Chun HK, Sohn CI, Shin H, Cho J (2022). "Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults". Sci Rep. 12 (1): 129. doi:10.1038/s41598-021-03838-z. PMID 34996957 Check
|pmid=value (help). - ↑ 4.0 4.1 4.2 Huang J, Gui Y, Qin H, Xie Y (2023). "Causal association between adiposity and hemorrhoids: a Mendelian randomization study". Front Med (Lausanne). 10: 1229925. doi:10.3389/fmed.2023.1229925. PMID 37869154 Check
|pmid=value (help). - ↑ 5.0 5.1 5.2 5.3 5.4 Majid Z, Yaseen T, Tasneem AA, Luck NH (2024). "Rectal varices vs hemorrhoids—diagnosis and management". World J Hepatol. 16 (11): 1216–1218. doi:10.4254/wjh.v16.i11.1216. PMID 39606165 Check
|pmid=value (help). - ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Peery AF, Sandler RS, Galanko JA, Bresalier RS, Figueiredo JC, Ahnen DJ, Barry EL, Baron JA (2015). "Risk factors for hemorrhoids on screening colonoscopy". PLoS One. 10 (9): e0139100. doi:10.1371/journal.pone.0139100. PMID 26406337.
- ↑ 7.0 7.1 Godeberge P, Sheikh P, Zagriadskiĭ E, Lohsiriwat V, Jalife Montaño A, Košorok P, De Schepper H (2020). "Hemorrhoidal disease and chronic venous insufficiency: Concomitance or coincidence; results of the CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research)". J Gastroenterol Hepatol. 35 (4): 577–585. doi:10.1111/jgh.14857. PMID 31512275.
- ↑ 8.0 8.1 Johansen JF, Sonnenberg A (1994). "Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents". Am J Gastroenterol. 89 (11): 1981–1986. PMID 7942722.
- ↑ D'Alfonso A, De Carolis F, Serva A, Valiyeva S, Guido M, Pietroletti R (2024). "Haemorrhoidal disease in pregnancy: results from a self-assessment questionnaire administered by means of a social network". BMC Gastroenterol. 24 (1): 150. doi:10.1186/s12876-024-03228-5. PMID 38698334 Check
|pmid=value (help). - ↑ 10.0 10.1 10.2 10.3 Rao SSC, Qureshi WA, Yan Y, Johnson DA (2022). "Constipation, Hemorrhoids, and Anorectal Disorders in Pregnancy". Am J Gastroenterol. 117 (10S): 16–25. PMID 36194029 Check
|pmid=value (help). - ↑ 11.0 11.1 Kothari S, Afshar Y, Friedman LS, Ahn J (2024). "AGA Clinical Practice Update on Pregnancy-Related Gastrointestinal and Liver Disease: Expert Review". Gastroenterology. PMID 39140906 Check
|pmid=value (help). - ↑ Poskus T, Buzinskienė D, Drasutiene G, Samalavicius NE, Barkus A, Barisauskiene A, Tutkuviene J, Sakalauskaite I, Drasutis J, Jasulaitis A, Jakaitiene A (2014). "Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study". BJOG. 121 (13): 1666–1671. doi:10.1111/1471-0528.12838. PMID 24810254.
- ↑ Poskus T, Sabonyte-Balsaitiene Z, Jakubauskiene L, Jakubauskas M, Stundiene I, Barkauskaite G, Smigelskaite M, Jasiunas E, Ramasauskaite D, Strupas K, Drasutiene G (2022). "Preventing hemorrhoids during pregnancy: a multicenter, randomized clinical trial". BMC Pregnancy Childbirth. 22 (1): 374. doi:10.1186/s12884-022-04688-x. PMID 35490229 Check
|pmid=value (help). - ↑ 14.0 14.1 Ashburn JH (2025). "Hemorrhoidal Disease: A Review". JAMA. doi:10.1001/jama.2025.13083.
- ↑ Bharucha AE, Cima RR. Anorectal diseases. In: Yamada's Textbook of Gastroenterology. 7th ed. Wiley-Blackwell; 2022.
- ↑ 16.0 16.1 Tranah TH, Nayagam JS, Gregory S, Hughes S, Patch D, Tripathi D, Shawcross DL, Joshi D (2023). "Diagnosis and management of ectopic varices in portal hypertension". Lancet Gastroenterol Hepatol. 8 (11): 1046–1056. doi:10.1016/S2468-1253(23)00209-1. PMID 37683687 Check
|pmid=value (help). - ↑ Lohsiriwat V, Sheikh P, Bandolon R, Ren DL, Roslani AC, Schaible K, Freitag A, Martin M, Yaltirik P, Godeberge P (2023). "Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review". Adv Ther. 40 (1): 117–132. doi:10.1007/s12325-022-02351-7. PMID 36331754 Check
|pmid=value (help).