Health ConditionsHemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. Confusion often arises because the term "hemorrhoid" has been used to refer to both normal anatomic structures and pathologic structures; in the clinical context, "hemorrhoids" refers to the pathologic presentation of hemorrhoidal venous cushions.
Hemorrhoids are one of the most common reasons that patients seek consultation from a colon and rectal surgeon, and this disease is reported to affect around 10 million Americans per year with a prevalence of 4.4%. In the United States, hemorrhoids are the third most common outpatient gastrointestinal diagnosis, with nearly 4 million office and emergency department visits annually.
Hemorrhoids are highly vascular submucosal cushions that generally lie along the anal canal in three columns — the left lateral, right anterior, and right posterior positions. Hemorrhoids are naturally occurring vascular tissues within the submucosa in the anal canal, and comprise loose connective tissue, smooth muscle, and blood vessels with many arteriovenous connections — which is why hemorrhoidal bleeding is typically bright red. Hemorrhoids are thought to aid in stool continence by providing bulk to the anal canal.
Hemorrhoids are classified by their anatomic origin within the anal canal and by their position relative to the dentate line; thus, they are categorized into internal and external hemorrhoids. External hemorrhoids develop from ectoderm and are covered by squamous epithelium, whereas internal hemorrhoids are derived from embryonic endoderm and lined with the columnar epithelium of anal mucosa. External hemorrhoids are innervated by cutaneous nerves that supply the perianal area, including the pudendal nerve and the sacral plexus. Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain.
The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. Symptoms commonly attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge.
Hemorrhoids are classified into four grades: Grade I hemorrhoids bulge into the anal canal and do not prolapse. Grade II hemorrhoids prolapse during defecation and reduce spontaneously, while Grade III require manual reduction, and Grade IV are permanently prolapsed and cannot be reduced manually. Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology, and symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding.
Hemorrhoidal disease is principally a condition of the anorectal vascular and connective tissue systems, but several interacting body systems are implicated in its development and expression:
The exact pathophysiology of hemorrhoids remains poorly understood and is believed to be multifactorial. Aetiology and pathophysiology of hemorrhoidal disease are still controversial, but multifactorial.
Hemorrhoids correlate with pathologic conditions that result in increased intra-abdominal pressure — including patients with chronic obstructive pulmonary disease (COPD), those who chronically strain from an enlarged prostate or urethral stricture, patients with a space-occupying intraabdominal lesion, patients with ascites, and during pregnancy. These conditions lead to symptomatic hemorrhoids by causing a decrease in the venous return from the hemorrhoidal veins, which leads to a pathologic increase in the size of the vascular cushions.
Other contributing factors include situations that increase intraabdominal pressure such as pregnancy, constipation, or prolonged straining, as well as weakening of supporting tissue as a result of aging or genetics. It is thought that clinical disease develops as a result of dilation and distension of the veins along with weakening of the supporting connective tissue.
Factors commonly assumed to increase the risk of developing hemorrhoids include inadequate dietary fiber, constipation, diarrhea, chronic straining during defecation, pregnancy, and a sedentary lifestyle, but these have actually not been well investigated.
Peery et al. found that fiber intake was associated with a reduced risk of hemorrhoidal disease. Surprisingly, the association between high fiber intake and reduced risk of hemorrhoidal disease was held even after adjustment for constipation.
Multivariate analysis from a case-control study revealed that daily fiber intake below 12 g (OR 7.08; 95% CI 1.24–40.30; p=0.027) and daily water intake below 2 L (OR 8.68; 95% CI 3.07–24.51; p<0.001) significantly increased the risk of internal hemorrhoidal disease. Internal hemorrhoidal disease was more frequently observed in patients with a low-fiber diet and a reduced water intake.
Chronic constipation, straining, prolonged toilet sitting, low fiber intake, inadequate hydration, obesity, smoking, and certain dietary patterns contribute to hemorrhoidal disease. While constipation and straining are traditionally linked to hemorrhoids, recent research has challenged this assumption, suggesting that diarrhea may also play a role, as the relaxation of connective tissue can be provoked by chronic or intermittent loose stools.
A large cross-sectional analysis supports the common wisdom that a low-fiber diet, straining with defecation, and constipation are associated with an increased risk of hemorrhoids.
Body weight has often been correlated to an increased risk for hemorrhoidal disease, but data from clinical studies about the association of high BMI (>25) and hemorrhoidal disease are controversial. This is because hemorrhoidal disease in the obese is not directly and exclusively associated with one's weight, but with intra-abdominal pressure, venous congestion, and chronic inflammation.
Constipation, a low fiber diet, a high Body Mass Index, pregnancy, and a sedentary lifestyle are often assumed to increase the risk of hemorrhoidal disease. However, evidence regarding these factors is controversial.
Fiber-rich diets, adequate fluids, and moderate physical activity improve bowel function and reduce mechanical stress. Behavioral factors, including toilet posture and avoidance of prolonged sitting, also play a role.
In a multivariate logistic regression, smartphone use on the toilet was associated with a 46% increased risk of hemorrhoids (p=0.044) after adjusting for age, sex, BMI, exercise activity, straining, and fiber intake. The most common activity performed while on the toilet was reading "news" (54.3%), followed by "social media" (44.4%). The study suggests that prolonged engagement with smartphones while using the toilet may be associated with an increased prevalence of hemorrhoids.
In a small controlled dietary survey study, overall calorie intake as well as protein, carbohydrate, and fiber intake were similar in hemorrhoid patients and controls. Dietary intake in the hemorrhoid group was higher for fat, alcohol, pepper, and pimento. Subjects in the hemorrhoid group drank less water, smoked more, and were more often constipated. These findings provide arguments suggesting that dietary imbalance or smoking could be involved in the development of hemorrhoids.
Many dietary factors including low fiber diet, spicy foods, and alcohol intake have been implicated, but reported data are inconsistent.
Emerging evidence suggests gut microbiota may influence hemorrhoidal disease development. Furthermore, recent studies have demonstrated a causal relationship between constipation, dysbiosis, and intestinal peristalsis. Cao et al. suggest that gut dysbiosis could inhibit intestinal motility and contribute to the development and persistence of constipation.
Many potential risk factors are associated with the development of hemorrhoids, including aging, obesity, prolonged straining during defecation, lower socioeconomic status, sedentary lifestyle, and depressive mood. Genetic predisposition has also been noted, with hemorrhoidal disease observed to run in some families.
The use of high-fiber foods to ease bowel function and relieve anorectal complaints has roots in traditional dietary medicine across multiple cultures, including traditional Indian medicine (Ayurveda), which emphasized plant-based, roughage-containing diets as fundamental to gastrointestinal health.
Seven randomised trials enrolling a total of 378 participants to fiber or a non-fiber control were identified. Meta-analyses using random-effects models showed that laxatives in the form of fiber had a beneficial effect in the treatment of symptomatic hemorrhoids. The risk of not improving hemorrhoids and having persisting symptoms decreased by 53% in the fiber group (risk reduction 0.47, 95% CI 0.32 to 0.68). These results are compatible with large treatment effects regarding prolapse, pain, and itching, although pooled analyses showed a tendency toward no effect for these parameters. The effect on bleeding showed a significant difference in favour of fiber (RR 0.50, 95% CI 0.28 to 0.89).
Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids, though the studies were of moderate quality.
Evidence strength: Moderate to strong. Consistent direction of benefit across multiple RCTs and a systematic meta-analysis, though the total study populations have been relatively small and study quality is moderate.
Numerous extracts of plants — including horse-chestnut seed extracts, aescin, rutin, troxerutin, diosmin, and hesperidin — have a long tradition in herbal medicine for their venotonic and anti-oedematous properties. Diosmin is a naturally occurring flavonoid glycoside that can be isolated from various plant sources, and it can also be obtained after conversion of hesperidin extracted from citrus rinds. Rutin and quercetin have been used in European herbal traditions to support capillary integrity.
Micronized purified flavonoid fraction (MPFF) is a flavonoid-based venoactive preparation for oral use, composed of 90% micronized diosmin and 10% other active flavonoids (hesperidin, diosmetin, linarin, and isorhoifolin), all of which contribute to its pharmacological effects. It has a variety of significant anti-inflammatory, antioxidant, and venoprotective actions, which form the basis of its beneficial clinical effects in hemorrhoidal disease.
Diosmin has been shown to have capillarotropic, venotropic, and vasotonic properties, and to act as a powerful inhibitor of prostaglandins and thromboxane A2, interfering with the activation of leukocytes and of the inflammatory cascade, causing a strong decrease in capillary permeability. Hesperidin alone and together with other flavonoids reduces permeability and increases capillary resistance. This role has been attributed to its inhibition of the hyaluronidase enzyme. Hesperidin's anti-inflammatory activity is linked to inhibition of prostaglandins, thromboxane, and the scavenger action of free radicals. Quercetin exerts a protective effect on blood vessels thanks to a reduction in capillary permeability and an increase in the resistance of the vessel walls.
The strongest clinical evidence comes from two major systematic reviews:
Previous non-systematic reviews have found evidence for the efficacy of MPFF not only in reducing pain, bleeding, anal discharge, and prolapse in acute hemorrhoidal disease but also in preventing relapse and reducing the duration and severity of acute attacks in chronic hemorrhoidal disease.
A prospective study evaluated a flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) to reduce bleeding from Grade I–III hemorrhoidal disease, and concluded that the use of this flavonoids mixture is a safe and effective means of managing bleeding from hemorrhoidal disease, with minimal adverse events reported.
Evidence strength: Moderate to strong. The evidence suggests that there is a potential benefit in using phlebotonics in treating hemorrhoidal disease as well as a benefit in alleviating post-hemorrhoidectomy symptoms. However, most trials are of short duration and some have methodological limitations including lack of blinding and small sample sizes.
Horse chestnut has been employed in European folk medicine for centuries as a remedy for venous conditions including varicose veins and hemorrhoids. Horse chestnut seed extract is rich in aescin, a saponin with venotonic and anti-inflammatory properties that promote vascular tone and diminish venous congestion, leading to reduced swelling and discomfort in patients with venous insufficiency and hemorrhoids.
Horse chestnut seed extract is rich in aescin, a saponin with venotonic and anti-inflammatory properties that promote vascular tone and diminish venous congestion. Modern pharmacological evaluations have demonstrated that horse chestnut extract containing aescin exhibits clinical efficacy comparable to synthetic flavonoid therapies in improving venous tone and reducing perianal edema.
The majority of clinical research on horse chestnut has been conducted in the context of chronic venous insufficiency (CVI) rather than hemorrhoids specifically. There are some 20 clinical trials on horse chestnut and CVI, all of which demonstrated a positive effect. In these studies, the herb's adverse effects were mild and infrequent, and it was found to be as effective as rutoside, another common treatment for CVI.
Evidence strength: Preliminary to moderate for hemorrhoids specifically; the bulk of the clinical trial evidence is derived from CVI studies, with extrapolation to hemorrhoidal disease. The mechanistic rationale is clear, but targeted large RCTs in hemorrhoid populations are limited.
Witch hazel has been used topically in North American Indigenous traditions and adopted into European herbal medicine as an astringent agent. It has long been applied as a topical remedy for hemorrhoids, minor bleeding, and perianal irritation, typically as a distilled water or leaf extract applied directly to the affected area.
Witch hazel (Hamamelis virginiana) contains astringent tannins that constrict blood vessels, reduce local inflammation, and alleviate minor bleeding and irritation. Witch hazel, with its high tannin content, acts as a natural astringent that helps reduce bleeding and irritation by stabilizing the capillary walls and decreasing vascular permeability.
Evidence strength: Weak to preliminary for hemorrhoids specifically. Witch hazel has formal EMA (European Medicines Agency) recognition for topical use as a traditional herbal medicine, but controlled clinical trials specifically in hemorrhoid populations are sparse. The mechanistic basis (tannin-driven astringency) is well established, but high-quality RCT data in hemorrhoid patients is lacking.
Butcher's broom, derived from the rhizome of Ruscus aculeatus, has a long history of use in Mediterranean European herbal medicine to address venous and circulatory complaints. It was traditionally used internally as a tea or decoction to relieve heaviness in the legs and perianal venous congestion.
Butcher's broom (Ruscus aculeatus), through the activation of alpha-adrenergic receptors, enhances vascular resistance and promotes lymphatic drainage, leading to reduced perianal swelling and discomfort in hemorrhoidal patients. A review of Rusci aculeati rhizoma noted its recognized use for symptoms of chronic venous insufficiency and hemorrhoids.
Evidence strength: Preliminary. Butcher's broom has EMA traditional herbal medicine recognition. Mechanistic data are available, but large, high-quality RCTs specifically in hemorrhoid patients are limited.
Centella asiatica has been used for centuries in Ayurvedic and traditional Asian medicine for wound healing, venous insufficiency, and gastrointestinal support. It was applied topically and consumed orally as a leaf preparation to support connective tissue integrity.
Centella asiatica stimulates collagen type-1 synthesis, production, and accumulation of new extracellular matrix. It improves vascular-connective tissue deposition and repair processes, which act on enzymatic hydrolysis of microbes and leucocytes to shield collagen. The triterpene fraction of Centella asiatica has peculiar modulating properties on the development of connective tissue. This activity is carried out through an action on fibroblasts and on two essential amino acids for the metabolism of collagen: alanine and proline. It therefore performs a multi-phase and balanced function on the metabolism of connective tissue, which results in improved re-epithelialization and normalization of the perivascular connective tissue, allowing an improvement in the tone and elasticity of the venous wall.
A comparative randomized clinical trial assessed the effects of Centella asiatica versus flavonoids in hemorrhoidal disease patients, finding beneficial effects in both groups. Several lines of evidence have shown how, in hemorrhoidal disease, phlebotonic flavonoid agents such as quercetin reduce capillary permeability by increasing vascular wall resistance, how rutin and vitamin C have antioxidant properties, and that Centella asiatica has reparative properties towards the connective tissue.
Evidence strength: Preliminary to moderate. Mechanistic data and small RCTs are available, but large definitive trials specifically in hemorrhoid populations are still needed.
Aloe vera gel has been used topically in multiple traditional medicine systems — including ancient Egyptian, Greek, Indian (Ayurvedic), and Chinese medicine — as a soothing, wound-healing, and anti-inflammatory agent applied to inflamed or irritated tissues.
Aloe vera has long been known as an anti-inflammatory agent. A study evaluated the effects of aloe vera aqueous, chloroform, and ethanol extracts on carrageenan-induced paw edema in rat — the chloroform and aqueous extracts could suppress the edema. Anti-inflammatory properties of the aloe vera gel on inflammatory bowel disease have also been experimentally confirmed.
Laboratory studies show that medical formulations uniting aloe vera with horse chestnut exhibit stronger benefits than individual components, treating symptoms better and lowering recurrence probability.
Evidence strength: Weak to preliminary for hemorrhoids specifically. Most supportive data are from in vitro and animal studies, or from studies of related anorectal conditions (e.g., anal fissures). High-quality RCTs directly in hemorrhoid populations are lacking.
Triphala — a formulation composed of three fruits (Terminalia chebula, Terminalia bellerica, and Phyllanthus emblica) — is among the most widely used preparations in Ayurvedic medicine for digestive conditions including hemorrhoids. Traditional preparations such as Triphala Guggulu have been used internally for bowel regulation, detoxification, and wound support.
Ayurvedic medicines like Triphala Guggulu and Pilex contain neem (Azadirachta indica) together with haritaki (Terminalia chebula) and lajjalu (Mimosa pudica), providing a wide range of therapeutic benefits including stool regulation, systemic detoxification, and wound healing enhancement. Clinical research shows that multi-herbal preparations surpass single-herbal extracts because of their combined pharmacological activities from flavonoids, tannins, and saponins.
Therapeutically notable plants such as witch hazel, horse chestnut, and triphala have shown beneficial therapeutic effects on pain, bleeding, and swelling, as well as in preventing recurrence. Triphala Guggulu and Pilex are polyherbal formulations that offer synergistic benefits.
Evidence strength: Preliminary. Traditional use is extensively documented in Ayurvedic literature, but controlled clinical trials meeting Western methodological standards are limited in number and scope.
Vitamin C-rich foods and preparations have been recommended historically in European and traditional systems to strengthen blood vessel walls and support wound healing.
Rutin and vitamin C have antioxidant properties relevant to hemorrhoidal disease, where capillary permeability and oxidative stress play roles in symptom development. Vitamin C is required as a cofactor in collagen synthesis, and vitamin C is a well-known antioxidant involved in collagen synthesis and many other cellular repair processes relevant to connective tissue integrity in the anal cushions.
Evidence strength: Indirect/preliminary for hemorrhoids specifically. The mechanistic role of vitamin C in collagen synthesis is well established at a biochemical level, but human RCT data specifically targeting hemorrhoidal disease with vitamin C supplementation as a primary intervention are lacking. It is typically studied as a component of multi-ingredient preparations.
Bilberry has been used in European folk medicine as a remedy for circulatory disorders. Its dark pigments (anthocyanins) were traditionally recognized as supportive of vascular integrity.
A retrospective study evaluated the efficacy and safety of a compound consisting of micronized flavonoids in combination with vitamin C and extracts of Centella asiatica, Vaccinium myrtillus (bilberry), and Vitis vinifera for Grade II and III hemorrhoidal disease, finding improvements in patient-reported symptoms. Bilberry extract has been shown to be useful for blood circulation, along with the triterpene fraction of Centella asiatica.
Evidence strength: Preliminary for hemorrhoids specifically. Both bilberry anthocyanins and oligomeric proanthocyanidins from grape seed have established vascular-supportive properties, but controlled trials in hemorrhoid-specific populations are limited and most data come from multi-ingredient formulations or studies in chronic venous insufficiency.
Conservative management of hemorrhoidal disease includes diet and lifestyle modification to increase fiber and fluid intake, increase physical activity, avoid constipation, and avoid straining during defecation. Both soluble and insoluble fiber are relevant: insoluble fiber increases stool bulk and transit speed, while soluble fiber forms a gel that softens stool consistency. Psyllium (Plantago ovata) is the most studied supplemental fiber form for hemorrhoidal disease.
Multivariate analysis identified daily water intake below 2 L as an independent risk factor significantly increasing the risk of internal hemorrhoidal disease (OR 8.68; 95% CI 3.07–24.51; p<0.001). Fiber and water work hand in hand: without adequate hydration, a high-fiber diet can backfire, causing harder stools and making constipation worse. Proper hydration softens stool, making it easier to pass and reducing the need to strain.
Many dietary factors including low fiber diet, spicy foods, and alcohol intake have been implicated, but reported data are inconsistent. In one case-control study, consumption of pepper and chili powder was found to be significantly less frequent in patients than in controls, calling into question the assumption that spicy food increases hemorrhoidal risk. Spicy foods contain capsaicin, which may not be completely digested by the intestines; as the leftover spice leaves the body in stool, it may pass over swollen hemorrhoids and worsen burning and pain in those with existing disease. The relationship between spicy food and hemorrhoid onset versus symptom exacerbation thus remains an open question in the literature.
In a comparative dietary survey, the hemorrhoid group had significantly higher alcohol intake (p=0.01) and lower water intake (p=0.008) than controls. Alcohol can affect digestion in a few different ways: first, alcohol consumption can slow down the intestines, making it harder for them to move things along, which can lead to constipation and worsened hemorrhoids.
Fiber-rich diets, adequate fluids, and moderate physical activity improve bowel function and reduce mechanical stress on the anorectal region. The evidence on sedentary behavior and hemorrhoids is complex. A large cross-sectional study found that higher sedentary time was associated with a lower risk of hemorrhoids on colonoscopy — a counterintuitive finding that may reflect confounding by diet quality, body habitus, or healthcare-seeking behaviors in that population. Multivariate logistic regression found smartphone use on the toilet was associated with a 46% increased risk of hemorrhoids; the most common activity on the toilet was reading "news" (54.3%), followed by "social media" (44.4%) — suggesting that prolonged engagement with smartphones while using the toilet may be associated with an increased prevalence of hemorrhoids.
Prolonged time on the toilet, excessive straining, and defecation posture are discussed in the literature as mechanically relevant. Scientific evidence regarding lifestyle and risk factors in hemorrhoidal disease remains limited, and many recommendations are based on physiological reasoning rather than high-quality trial data.
It has previously been published that Caucasians of higher socioeconomic class were afflicted with hemorrhoids with greater frequency, and this was theorized to be diet related; however, it remains unclear if this represents limitations to the reporting of symptoms or healthcare-seeking practices. The aggregate picture from dietary literature is that a Western-pattern diet low in plant fiber and high in processed foods, fat, and alcohol creates conditions — particularly habitual constipation and straining — that predispose to hemorrhoidal disease, while plant-rich, high-fiber, adequately hydrated diets appear to be protective.
Aescin is the active triterpenoid saponin from horse chestnut (Aesculus hippocastanum) with well-documented venotonic, anti-inflammatory, and anti-edematous properties. A double-blind, placebo-controlled RCT in 72 hemorrhoid patients showed improvement in 82% of aescin-treated subjects versus 32% with placebo. Reviews confirm clinical efficacy comparable to synthetic flavonoid therapies for reducing perianal edema and venous congestion.
Alexandrian senna (Cassia acutifolia) is the pharmaceutical botanical source of sennosides, explicitly advocated by European Society of Coloproctology guidelines among natural therapies for hemorrhoid symptoms and bleeding. Its laxative sennosides reduce defecatory straining, addressing the principal mechanical cause of hemorrhoid exacerbation.
A placebo-controlled, double-blind trial in 80 patients with first- and second-degree hemorrhoids evaluated a topical combination preparation containing allantoin (with standardized leech extract and polidocanol). Both subjective and objective symptoms improved significantly faster under the active preparation versus placebo over one week, with histologically confirmed reduced inflammation.
Aloe Vera is widely used topically in gels, creams, and suppositories for hemorrhoids. A 2025 PMC comprehensive review reports that aloe preparations improve pain scores and healing time in combination with standard hemorrhoidal therapies, and lists aloe vera among botanical agents demonstrating anti-inflammatory, venotonic, and astringent effects addressing hemorrhoid symptoms.
Anthocyanosides are flavonoid pigments from bilberries and related berries with capillary-strengthening and venoprotective properties relevant to hemorrhoids. EBSCO Research Starters identifies bilberry anthocyanosides as a principal proposed natural treatment for hemorrhoids. A 2021 PMC retrospective study incorporating Vaccinium myrtillus extract (anthocyanosides) achieved 89.8% hemorrhoid grade reduction in grade II–III disease.
Asiaticoside is the principal triterpene glycoside of Centella asiatica used in hemorrhoid management. It promotes collagen synthesis, strengthens venous walls, and reduces capillary permeability. It is the key active component in Centella asiatica preparations evaluated in clinical trials showing 89.8% grade reduction in grade II–III hemorrhoidal disease.
Bioflavonoids as a class (principally diosmin, hesperidin, rutin, troxerutin, and quercetin) are among the most evidence-supported natural treatments for hemorrhoids. A 2006 British Journal of Surgery meta-analysis confirmed bioflavonoid phlebotonics significantly reduce hemorrhoidal bleeding, pain, and itching. The American Society of Colon and Rectal Surgeons includes flavonoids in its Clinical Practice Guidelines for hemorrhoid management.
Butcher's broom (Ruscus aculeatus) is recognized by the EMA as a traditional herbal medicinal product for symptomatic relief of hemorrhoid itching and burning. Clinical studies show reduction in edema, bleeding, and analgesic requirement with ruscogenin-based formulations. It activates alpha-adrenergic receptors to enhance vascular resistance and lymphatic drainage.
Centella triterpenes (asiaticoside, asiatic acid, madecassoside from Centella asiatica) have been evaluated in clinical trials for hemorrhoidal disease. A 2020 PMC RCT compared a Centella triterpene complex against flavonoids for hemorrhoid management, and a 2021 PMC retrospective study incorporating Centella asiatica extract achieved 89.8% hemorrhoid grade reduction in grade II–III patients (p<0.001).
Cissus quadrangularis is listed in the Thai National List of Herbal Products for the oral treatment of hemorrhoids and has been evaluated in a PMC clinical pilot study (n=105) and a comparative RCT versus MPFF. It exhibits analgesic, anti-inflammatory, and venotonic effects with a superior safety profile versus hydrocortisone/cinchocaine suppositories.
Diosmin is a flavonoid glycoside with the strongest clinical evidence base for hemorrhoid management, endorsed by multiple RCTs, meta-analyses, and professional guidelines including the American Society of Colon and Rectal Surgeons. A 2006 British Journal of Surgery meta-analysis confirmed phlebotonics including diosmin significantly reduce hemorrhoid bleeding (RR 0.33), pain (RR 0.35), and itching (RR 0.65).
Escin (variant spelling of aescin) is the principal saponin of horse chestnut used for hemorrhoids. A double-blind, placebo-controlled RCT in 72 patients showed 82% improvement with escin versus 32% with placebo. Reviews confirm venotonic and anti-inflammatory efficacy comparable to synthetic flavonoid therapies for hemorrhoidal disease.
Gotu Kola (Centella asiatica) contains triterpenes (asiaticoside, asiatic acid, madecassoside) that promote connective tissue repair and venous tone. A 2020 PMC RCT compared Centella asiatica extract versus flavonoids for hemorrhoidal disease, and a 2021 PMC retrospective study incorporating 300 mg Centella asiatica extract achieved 89.8% hemorrhoid grade reduction in 49 patients (p<0.001).
Hesperidin is a flavanone glycoside that is the key co-component of MPFF (micronized purified flavonoid fraction) with diosmin, supported by meta-analyses and multiple RCTs for hemorrhoidal disease. A 2021 PMC retrospective study using a hesperidin-containing compound achieved 89.8% grade reduction in hemorrhoid severity (p<0.001) in 49 patients.
Horse chestnut seed extract (standardized to aescin/escin) is one of the best-studied natural treatments for hemorrhoids, with a double-blind RCT showing 82% improvement versus 32% placebo and reviews confirming efficacy comparable to synthetic flavonoid therapies. The 2025 PMC Cureus comprehensive review lists it among botanicals with demonstrated beneficial effects on hemorrhoid pain, bleeding, and swelling.
Clinical studies including RCTs have documented Pycnogenol's efficacy in reducing acute hemorrhoidal episodes and postpartum hemorrhoid symptoms. The mechanism relates to venous tone improvement, anti-inflammatory action, and strengthening of capillary walls. Studies by Belcaro et al. are cited as primary evidence.
Psyllium husk (Plantago ovata) is clinically documented to reduce hemorrhoid-related symptoms by softening stool, reducing straining, and increasing anal resting pressure. It is listed by multiple reviews and the PMC 2024 publication among conditions where psyllium provides measurable clinical benefit.
Psyllium (Plantago ovata husk) has documented clinical benefits for hemorrhoids, listed alongside constipation, IBS, and diarrhea in a 2024 PMC systematic review of clinical evidence. By softening stools and reducing straining, psyllium fiber directly reduces hemorrhoidal irritation and recurrence. Traditional use of P. major for hemorrhoids is also documented.
Psyllium is the most well-studied fiber supplement for hemorrhoids and is endorsed by European Society of Coloproctology guidelines. A 2006 systematic review and meta-analysis in the American Journal of Gastroenterology showed fiber supplementation (psyllium being the most studied form) reduced risk of persistent hemorrhoid symptoms by approximately 47% and hemorrhoidal bleeding by approximately 50%.
Quercetin is a flavonol included in evidence-based multi-flavonoid combinations for hemorrhoidal disease. A 2018 double-blind multicenter RCT (n=154) using a flavonoid mixture including quercetin showed safe and effective reduction in hemorrhoidal bleeding. A 2021 PMC retrospective study incorporating quercetin 140 mg/day achieved 89.8% hemorrhoid grade reduction in grade II–III disease.
Ruscogenins are the active steroidal saponins from Ruscus aculeatus (butcher's broom), with a long history of use specifically for hemorrhoids and varicose veins recognized by the EMA. They reduce capillary permeability via anti-elastase activity and exert vasoconstrictive effects through alpha-adrenergic mechanisms, supported by in vitro, animal, and clinical studies.
Rutin, a bioflavonoid glycoside with antioxidant and capillary-strengthening properties, has been studied in multiple clinical trials for hemorrhoidal disease. A 2018 double-blind multicenter RCT (n=154) confirmed that a flavonoid mixture including rutin, diosmin, troxerutin, hesperidin, and quercetin safely and effectively reduced grades I–III hemorrhoidal bleeding.
Senna is a stimulant laxative endorsed by the European Society of Coloproctology guidelines as a natural therapy for hemorrhoid symptoms and bleeding. By softening stools and reducing defecatory straining—a principal mechanical cause of hemorrhoids—senna addresses key pathophysiological triggers. It is included in the 2024 Molecules PMC review of natural products for hemorrhoid management.
Sophora japonica is one of the most historically documented remedies for hemorrhoids in TCM, listed in both the Chinese Pharmacopoeia and European Pharmacopoeia for this use. Its rutin content strengthens capillary walls and reduces venous inflammation. Hydroxyethylrutosides—semisynthetic derivatives of rutin originally sourced from S. japonica—have demonstrated clinical benefit in venous disorders including hemorrhoids.
Troxerutin (hydroxyethylrutoside) is listed among hemorrhoid medications with established clinical evidence of effectiveness in a 2024 Molecules PMC review, and appeared in the 2006 British Journal of Surgery meta-analysis of phlebotonics for hemorrhoidal disease. A PubMed-listed clinical study on troxerutin specifically for hemorrhoids and post-hemorrhoidectomy RCTs further support its use.
Witch hazel (Hamamelis virginiana) is listed in the FDA OTC anorectal drug products monograph as a recognized active ingredient for hemorrhoidal symptom relief. Its astringent tannins constrict blood vessels, reduce local inflammation, and alleviate minor bleeding and irritation. It is also recognized by the EMA and EBSCO among evidence-supported natural treatments for hemorrhoids.
Agrimony is traditionally used as an external compress to relieve haemorrhoids, with cooled agrimony infusions applied via cloth to reduce swelling and improve local circulation. This use appears in European herbal traditions and is described in folk medicine references. No clinical trial data exist.
Hemorrhoids ('piles') are explicitly listed as a traditional indication of ajwain in Ayurvedic and Unani medicine. Its carminative, antispasmodic, and anti-inflammatory properties are invoked. No clinical evidence exists; the relationship is documented in traditional ethnopharmacological sources.
Barberry has traditional use for hemorrhoids, attributed to its effects on hepatic portal vein congestion and its vascular-toning properties. European and Persian herbal medicine traditions connect barberry's liver and vascular effects to relief of hemorrhoidal conditions.
External application of a bayberry decoction or tincture is a documented traditional remedy for hemorrhoids. The astringent tannins are proposed to reduce swelling and inflammation of hemorrhoidal tissue. This use is recorded in multiple herbal references and folk medicine texts.
Belleric myrobalan fruit pulp is documented in Ayurvedic texts and ethnobotanical records as a traditional remedy for piles (hemorrhoids). The astringent action of tannins is thought to reduce venous engorgement and inflammation of hemorrhoidal tissue. References appear consistently across Ayurveda, Unani, and traditional medicine sources from South Asia.
Bilberry (Vaccinium myrtillus) has a long history of traditional use in European herbal medicine for vascular conditions including hemorrhoids. Rich in anthocyanins, it is listed by EBSCO Research Starters as a principal proposed natural treatment for hemorrhoids. It was incorporated in a 2021 PMC retrospective study compound that achieved 89.8% grade reduction in hemorrhoid severity.
Walnut leaves (Juglans regia, pharmacopoeially related) are officially recognized by ESCOP for hemorrhoidal symptomatology due to their astringent tannins. Black walnut hull shares this tannin-rich profile and is used similarly in traditional herbalism for hemorrhoids and venous insufficiency.
Blackberry root and leaves have been applied topically as astringent washes for hemorrhoid discomfort in Cherokee and European folk medicine traditions. The tannin content is considered to reduce local inflammation and swelling. A Modern Herbal (Gerard) specifically notes blackberry leaves as 'a most useful application for piles.'
Ayurvedic texts list Boswellia (Shallaki) as indicated for Arsha (hemorrhoids). The anti-inflammatory and astringent properties of the resin support this traditional use, but no human clinical trials have evaluated Boswellia specifically for hemorrhoids.
Buckthorn bark has a long documented traditional use for hemorrhoids, primarily by softening stool and reducing straining. The German Commission E and ESCOP monographs identify constipation associated with hemorrhoids as an indication for buckthorn. The mechanism is indirect: by promoting softer, easier-to-pass stools, pressure on the anorectal venous plexus is reduced. No controlled clinical trials specifically targeting hemorrhoid outcomes have been conducted.
In TCM, B. falcatum's 'lifting action' (raising Spleen Qi) is traditionally used in formulas for hemorrhoids and prolapse, specifically in the formula Bu Zhong Yi Qi Tang. This is well-documented traditional use; no clinical scientific evidence for hemorrhoid treatment with B. falcatum has been identified.
Calendula (Calendula officinalis) is used topically for hemorrhoids based on its anti-inflammatory, wound-healing, and astringent properties. A 2025 PMC review lists it among botanical agents with demonstrated effects on hemorrhoid symptoms, and a PMC observational study confirmed improved QoL with a rectal product containing calendula, witch hazel, and chamomile.
Capsicum has a traditional history of use for hemorrhoids, attributed to its circulatory stimulant properties and local counterirritant effects. Capsaicin is listed among traditional applications in the ethnobotanical and medical literature, though controlled clinical trial evidence specifically for hemorrhoids is lacking.
Cascara sagrada has been used traditionally to relieve the constipation and straining that precipitate and worsen hemorrhoids. By softening stool and accelerating transit, it reduces the anorectal pressure associated with hemorrhoidal flare-ups. A 19th-century physician's case series (published in the British Medical Journal, 1884) described its use specifically for hemorrhoid management. No modern RCTs evaluate cascara directly for hemorrhoid outcomes.
Cat's claw is listed in traditional and ethnobotanical sources as a remedy for hemorrhoids, attributed to its anti-inflammatory properties. RxList and other referenced sources include hemorrhoids among the digestive conditions for which cat's claw is traditionally used. No clinical trials for this indication exist.
Chaff flower is documented in Ayurveda, Siddha, and other traditional systems for the management of hemorrhoids (piles). The astringent and anti-inflammatory properties of the plant are traditionally cited as the basis. No controlled clinical data exist.
Chamomile (Matricaria chamomilla) is used as warm sitz baths, compresses, and in topical hemorrhoid products for its anti-inflammatory, antioxidant, and soothing properties. A 2025 PMC comprehensive review reports evidence of reduced inflammation and faster resolution of itching and irritation. A PMC observational study confirmed improved QoL with a rectal product containing chamomile.
Collinsonia (stone root, Collinsonia canadensis) is listed by EBSCO Research Starters as a proposed natural treatment for hemorrhoids. It has been used in 19th-century North American eclectic medicine specifically for hemorrhoids and rectal venous congestion. No controlled clinical trials have been identified; use is entirely traditional.
Geranium has a documented traditional use for hemorrhoids (piles) across multiple herbal medicine traditions. Its hemostatic, astringent, and anti-inflammatory properties provide mechanistic support. No human clinical trials for this indication have been identified.
Goldenrod is listed in traditional herbal medicine texts for hemorrhoids, including the Commission E monographs and A.D.A.M. health database. Astringent tannins and anti-inflammatory flavonoids, especially rutin (which supports venous endothelial integrity), provide pharmacological rationale. No clinical trials on goldenrod for hemorrhoids have been published.
Goldenseal is traditionally used topically and internally for hemorrhoids, attributed to its astringent and anti-inflammatory properties. The USPTO patent review of goldenseal traditional uses specifically cites hemorrhoids, and the herb has been used to treat a variety of hemorrhagic disorders in herbal tradition.
In Ayurveda, guggul-based formulations — particularly Triphala Guggulu — are among the primary treatments for hemorrhoids (Arsha). The anti-inflammatory, astringent, and venotonic properties of guggul are invoked for this indication. No standalone clinical trials for guggul in hemorrhoids have been published.
Gymnema sylvestre is documented in classical Ayurvedic texts as a traditional treatment for hemorrhoids (piles), with multiple authoritative reviews corroborating this traditional indication. No human clinical or preclinical experimental data specifically for hemorrhoids exist.
Classical Ayurvedic texts, including those attributed to Vagabhatta, identify kutaj as a primary herb for bleeding piles (hemorrhoids). The bark and seeds are described as arshoghna (destroys hemorrhoids) and anti-hemorrhagic. Preclinical studies cite anti-haemorrhoidal activity among documented pharmacological properties.
Traditional medicine practitioners in Indonesia, China, Pakistan, and Cameroon use leaves, seeds, flowers, and roots of Impatiens balsamina to treat hemorrhoids. This is recorded in multiple ethnobotanical reviews but has not been evaluated in clinical trials.
Acacia nilotica has traditional use for hemorrhoids documented in multiple ethnobotanical surveys. Tannins with anti-hemorrhagic and astringent properties provide a pharmacological rationale. The Biochemistry review of A. nilotica lists hemorrhoids among treated conditions.
Adhatoda vasica is documented in Ayurveda and Unani for bleeding hemorrhoids, a use repeated consistently across multiple ethnopharmacological reviews. The hemostatic and anti-inflammatory properties of the plant provide mechanistic support.
Mango bark and skin are used in Ayurvedic medicine for hemorrhoids, attributed to their strong astringent (Kashaya) properties, which tone and tighten vascular tissues. Bark decoctions are documented as being used traditionally in India for hemorrhoids and other conditions involving tissue laxity.
Momordica charantia is documented in traditional African and Asian folk medicine as a remedy for hemorrhoids (piles). Multiple ethnopharmacological databases include hemorrhoids among its traditional uses. No human clinical evidence exists.
Traditional herbal literature records mullein leaf poultices as a topical remedy for hemorrhoids, attributed to astringent tannins and anti-inflammatory mucilage. This use is documented across Turkish, Spanish, and early American folk medicine. No clinical studies exist.
TC is specifically cited in Ayurvedic Materia Medica as useful for hemorrhoids (piles), including bleeding piles, based on its astringent properties that reduce mucosal hemorrhage and tissue inflammation. Folk medicine use across South Asia is consistently documented.
Nattokinase is listed among traditional uses of natto for circulatory conditions including hemorrhoids, based on the rationale that hemorrhoids involve local venous congestion and fibrin deposition akin to thrombotic conditions. No controlled human clinical trials specifically targeting hemorrhoids have been identified in the peer-reviewed literature. The association rests on documented traditional and folk use of natto in Japan and the theoretical fibrinolytic mechanism.
The Indian Journal of Dermatology review documents hemorrhoids among the traditional indications for neem in South Asian folk medicine. The anti-inflammatory and astringent properties of neem bark tannins provide mechanistic plausibility. Human clinical studies for this indication are absent.
Nopal flowers have documented traditional use as an oral anti-hemorrhoid medication in sub-Saharan traditional medicine. No human clinical trial evidence for nopal in hemorrhoid treatment has been identified. The anti-inflammatory and fiber-normalizing properties of nopal provide biological plausibility.
Oligomeric proanthocyanidins (OPCs) from grape seed and pine bark are listed by EBSCO Research Starters as proposed natural treatments for hemorrhoids. A 2021 PMC retrospective study incorporating Vitis vinifera extract (OPCs) in a multi-ingredient phlebotonic achieved 89.8% hemorrhoid grade reduction in grade II–III patients. Mechanistic evidence supports capillary-stabilizing and anti-inflammatory effects relevant to hemorrhoidal disease.
Oriental arborvitae is documented in NLM/WebMD databases as a traditional treatment for hemorrhoids. Its hemostatic properties—recognized in the Chinese Pharmacopoeia—provide the primary rationale, as hemorrhoidal bleeding is one of the bleeding conditions the plant is traditionally used to address.
P. foetida has been used in folk medicine for piles (hemorrhoids) across South and Southeast Asia, including Bangladesh, India, and in Chinese traditional medicine. Roots and barks are specifically cited for this use. The plant's anti-inflammatory and astringent properties provide mechanistic rationale.
Pineapple/bromelain is included in traditional formulas for hemorrhoids due to its fibrinolytic, anti-edematous, and phlebotonic properties. It has been used as a venous and lymphatic decongestant. Formal clinical trials dedicated to hemorrhoids are lacking.
Traditional use of prickly pear flowers as an oral anti-hemorrhoid medication is specifically documented in sub-Saharan African pharmacopeia. The plant's anti-inflammatory and mucosal-protective properties are mechanistically relevant. No clinical trial evidence has been published.
Proanthocyanidins (oligomeric proanthocyanidins, OPCs) from grape seed and pine bark are proposed natural treatments for hemorrhoids based on their capillary-stabilizing and anti-inflammatory properties. EBSCO Research Starters lists oligomeric proanthocyanidins among proposed natural treatments for hemorrhoids. Evidence is primarily mechanistic and indirect via chronic venous insufficiency studies.
Constipation is a primary driver of hemorrhoid development; prunes' well-documented laxative action (softening stool, reducing straining) makes them a traditional and logically supported remedy for hemorrhoid prevention and management. No clinical trials have directly studied prunes specifically for hemorrhoid outcomes, but the constipation link is scientifically established.
Radish has been used in Ayurvedic and folk medicine traditions for hemorrhoids, attributed to its bile-stimulating and gentle laxative properties that reduce straining at stool. TCM similarly uses radish for intestinal Qi stagnation associated with hemorrhoidal conditions. No clinical evidence supports this use.
Rhubarb root is traditionally used for hemorrhoids in both TCM and Western herbalism, primarily by softening stool to reduce straining and by topical astringent action. It is listed for this use by major reference sources including RxList, though specific RCTs targeting hemorrhoids are lacking.
Topical use of figwort/Scrophularia root for hemorrhoids is one of the plant's best-attested European folk applications, so prominent that the common name 'figwort' derives from an old term for hemorrhoids. Medieval and Renaissance herbalists applied poultices of the root directly to hemorrhoids. No modern clinical trials have assessed this use.
Herbalists have traditionally recommended sheep's sorrel for hemorrhoids, likely due to its astringent properties which may help tone inflamed venous tissue. This is documented in folk herbal practice but unsupported by any clinical evidence.
Shepherd's purse is traditionally used both internally and topically for hemorrhoids, exploiting its astringent, hemostatic, and venous-toning properties. Historical sources including the King's American Dispensatory document its use for 'bleeding piles.' Its capacity to support venous integrity and reduce local bleeding underpins this application.
Slippery elm is listed across multiple traditional and herbal pharmacopoeial references as a remedy for hemorrhoids, used both orally and topically. Its mucilage is thought to soothe anorectal mucosa and soften stool, reducing straining. No clinical trials specifically evaluate this use.
Slippery elm bark is listed in multiple traditional medicine references for hemorrhoid relief, both orally and topically. The mucilage softens stool to reduce straining, and topical preparations may soothe inflamed anorectal tissue. No clinical trials specific to hemorrhoids have been conducted.
Hemorrhoids represent one of the oldest and most geographically widespread traditional indications for smartweed, documented across Asian and European folk medicine. The plant's astringent, styptic, and rutin-mediated capillary-strengthening properties provide a plausible mechanistic basis.
European folk medicine records the use of snapdragon poultices and infusions to treat hemorrhoids, attributed to the plant's mild astringent and anti-inflammatory effects. The traditional use is documented in multiple herbalism and pharmacological review sources. The 2018 in vivo wound-healing study specifically cited hemorrhoids as part of the traditional context motivating the research.
Solomon's seal is documented for topical and internal use in hemorrhoids by European herbalists from Gerard onward, and in eclectic medical texts. Drugs.com confirms topical application for hemorrhoids. The astringent, anti-inflammatory, and demulcent properties of the rhizome underpin this traditional use.
Hemorrhoids are among the conditions listed in Ayurvedic texts for S. indicus (Gorakhmundi). Traditional use is well-documented though no clinical evidence exists.
Squawvine is listed in folk medicine references as a remedy for hemorrhoids, consistent with its documented astringent and anti-inflammatory properties from tannin-rich constituents. Traditional herbal practice also combined it with witch hazel for bleeding piles. No clinical evidence exists.
SJW oil has been used topically for hemorrhoids in European and Turkish folk medicine to ease itching, burning, and discomfort. Its anti-inflammatory and antimicrobial properties provide pharmacological plausibility. No controlled clinical trials for this specific indication have been conducted.
Stillingia's root has been documented in traditional medicine texts and Eclectic pharmacopeias as a remedy for hemorrhoids. It appears alongside bronchitis and constipation in MSKCC's herb monograph. No human clinical evidence supports this use.
Charaka Samhita classifies Vacha as arsoghna (anti-hemorrhoidal), making this among the most formally documented traditional indications in Ayurvedic pharmacopoeia. Its use for hemorrhoids appears in Ayurvedic texts spanning millennia. No clinical trial data exist.
T. chebula (haritaki) is one of the most consistently cited Ayurvedic remedies for hemorrhoids ('arsha'). Traditional texts and the Ayurvedic Pharmacopoeia of India document its use for bleeding piles. Its astringent tannins are considered to reduce bleeding and shrink hemorrhoidal tissue. No dedicated clinical RCTs were identified.
Triphala is a classical Ayurvedic polyherbal formula (Terminalia chebula, Terminalia bellirica, Phyllanthus emblica) used for at least 2,000 years in Indian medicine for hemorrhoids. A 2025 PMC comprehensive review (Cureus) confirms Triphala demonstrates beneficial effects on hemorrhoid pain, bleeding, and swelling, and Triphala Guggulu is a recognized Ayurvedic hemorrhoid formulation.
White oak bark has well-documented traditional use for hemorrhoids, used topically as a sitz bath, compress, or enema to tighten engorged venous tissue and reduce bleeding. Germany's Commission E approves this topical indication. Limited exploratory studies suggest reduced pain and inflammation, but no rigorous clinical trials have been completed.
Yarrow is used traditionally for hemorrhoids in West Azerbaijani, Persian, and European folk medicine. Its astringent, anti-inflammatory, and hemostatic properties provide a pharmacological rationale, and it appears alongside hemorrhoids in traditional indication lists in the published literature.
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