Mixed hemorrhoids: Symptoms, causes, prevention, and effective treatment

Mixed hemorrhoids: Symptoms, causes, prevention, and effective treatment

17-03-2023
Gastroenterology – Hepatobiliary

Mixed hemorrhoids are considered more serious than the other two types of internal and external hemorrhoids. So, what exactly are mixed hemorrhoids? How dangerous can they be? And what is the most effective treatment method available today? Let us explore the answers in the following article.

What are mixed hemorrhoids? 

Mixed hemorrhoids are a complex form of hemorrhoidal disease, in which internal and external hemorrhoidal cushions coexist and interlace with one another.

Mixed hemorrhoids consist of both internal and external hemorrhoids interlacing with each other.
Mixed hemorrhoids consist of both internal and external hemorrhoids interlacing with each other.

This condition occurs when a patient develops both internal and external hemorrhoids. As the internal hemorrhoids prolapse, they adhere to the external hemorrhoids, forming a continuous mass that extends from the anal canal to the outside of the anus, known as a mixed hemorrhoidal mass. According to medical experts, the treatment of mixed hemorrhoids is generally more complex and challenging than that of isolated types. In most cases, physicians must combine both surgical and medical approaches simultaneously to achieve optimal treatment outcomes.

Signs and symptoms of mixed hemorrhoids

Because mixed hemorrhoids consist of both internal and external hemorrhoids interlacing with each other, patients usually experience symptoms of both conditions simultaneously. This often leads to significant discomfort and inconvenience in daily activities. Typical symptoms may include:

  • Rectal bleeding: Bright red blood during bowel movements is the most common and easily recognized symptom. In the early stages, bleeding may only be noticed as streaks of blood on toilet paper. If left untreated, bleeding can become more severe, presenting as blood drops or even spurting. In some cases, excessive bleeding may lead to anemia, causing pale or yellowish skin, dizziness, and fatigue during physical activity.
  • Mucous discharge from the anus: This symptom often occurs in advanced stages, leaving the patient with a persistent feeling of dampness, discomfort, and sometimes foul odor.
  • Anal itching: The presence of mucus and hemorrhoidal tissue often causes constant itching, irritation, and discomfort. In some cases, anal fissures may also develop, further aggravating symptoms.
  • Prolapsed hemorrhoids during bowel movements: Hemorrhoidal masses may prolapse outside the anus. At first, they may retract spontaneously, later requiring manual reduction, and in advanced cases, may remain irreducible.
  • Anal pain and burning sensation: Chronic constipation and straining often cause trauma to the anal canal, resulting in pain, soreness, and a burning sensation around the anus.
Anal itching is one of the typical symptoms of hemorrhoidal disease in general and mixed hemorrhoids in particular.
Anal itching is one of the typical symptoms of hemorrhoidal disease in general and mixed hemorrhoids in particular.

The severity of mixed hemorrhoids is classified according to the progression of hemorrhoidal masses:

  • Grade 1 mixed hemorrhoids: This is the initial stage of hemorrhoid formation. Internal hemorrhoids inside the rectum cause rectal bleeding during bowel movements, which may be noticed as blood streaks on toilet paper. At the same time, external hemorrhoids begin to develop, leading to itching, a sense of fullness, and discomfort around the anus.
  • Grade 2 mixed hemorrhoids: Symptoms from grade 1 become more pronounced. Bleeding during defecation is more frequent and easier to detect. Patients may also experience burning pain, mild swelling of the perianal skin, which becomes thinner and smoother. The anal region often feels persistently moist and uncomfortable.
  • Grade 3 mixed hemorrhoids: This stage represents progression from moderate to severe disease. Internal hemorrhoids enlarge and, when combined with external hemorrhoids, form a prolapsed mass extending outside the anus. The hemorrhoidal mass may retract spontaneously or require manual reduction. Severe pain occurs due to enlargement of the hemorrhoids and spasm of the anal sphincter. Rectal bleeding during bowel movements may increase, sometimes appearing as drops of blood.
  • Grade 4 mixed hemorrhoids: The most advanced and dangerous stage. Hemorrhoidal masses become very large, prolapsing almost completely outside the anus, and cannot be reduced. Patients experience profuse rectal bleeding during defecation, posing a high risk of complications.

Causes of mixed hemorrhoids

Similar to hemorrhoids in general, there are still no clearly defined causes to fully explain the development of mixed hemorrhoids. However, several contributing factors have been identified, including:

Chronic constipation: prolonged straining leads to progressive dilation and weakening of the supporting structures of the hemorrhoidal plexus, including the anal sphincter muscles, levator ani muscles, and surrounding ligaments. Over time, this loss of elasticity facilitates the formation of both internal and external hemorrhoids, resulting in mixed hemorrhoids.

Sedentary lifestyle or frequent heavy lifting: prolonged sitting, lack of physical activity, or repeated heavy lifting impair the function of the anorectal arterial and venous circulation. Increased pressure and venous congestion contribute to engorged and swollen hemorrhoidal veins.

Unbalanced diet: dietary habits play a significant role in hemorrhoid development. Diets high in meat but low in vegetables, fruits, and fiber cause chronic constipation, a major risk factor. Consumption of unsafe or unhygienic foods may also disturb gastrointestinal function, increasing rectal venous pressure and anal secretions, thereby predisposing to mixed hemorrhoids.

Inadequate fluid intake: insufficient hydration results in harder, bulkier stools, worsening constipation. Persistent dehydration increases the risk of mixed hemorrhoids.

Failure to properly treat internal or external hemorrhoids: due to embarrassment about the sensitive location, many patients avoid medical consultation and instead self-medicate or rely on unverified folk remedies. This often delays effective treatment and allows progression to mixed hemorrhoids.

Pregnancy and postpartum period: approximately 80% of pregnant women develop hemorrhoids. Increased blood volume during pregnancy to support fetal growth, combined with the mechanical pressure of the enlarging uterus on the pelvic veins, leads to venous engorgement in the anorectal region. Vaginal delivery further exacerbates this through intense straining, causing significant stress on rectal veins and capillaries, thereby worsening hemorrhoids.

Other risk factors: obesity, advanced age, and chronic psychological stress or fatigue may also increase susceptibility to mixed hemorrhoids.

How dangerous are mixed hemorrhoids?

According to medical experts, mixed hemorrhoids characterized by the simultaneous occurrence of both internal and external hemorrhoids are more serious than a single type of hemorrhoid. The potential complications vary depending on the patient’s condition; the more advanced the disease, the higher the risk of severe complications.

  • Anorectal infection: prolapsed hemorrhoids increase the risk of vascular obstruction, necrotizing inflammation of the perianal skin and mucosa, and secondary infection involving the surrounding anorectal tissue. If left untreated, such infections may progress to superinfection and even anal necrosis.
  • Severe pain: in advanced stages, simultaneous prolapse of internal and external hemorrhoids often causes intense pain, anal inflammation, and hemorrhoidal obstruction. These conditions significantly impair both health status and quality of life.
  • Anemia: recurrent bleeding associated with mixed hemorrhoids may gradually lead to chronic anemia. Patients often present with dizziness, headaches, blurred vision, and generalized fatigue.
  • Strangulated hemorrhoids: prolapsed hemorrhoidal veins may become compressed, preventing normal venous outflow. Without timely intervention, the hemorrhoidal masses can become increasingly swollen, edematous, and thrombosed.
  • Risk of gynecological infections (in women): due to the close anatomical proximity of the anus and vagina, poor perianal hygiene in female patients with hemorrhoidal infection may facilitate ascending infections, leading to conditions such as vaginitis or cervical erosions.

Watch the detailed video on hemorrhoid complications, presented by People’s Physician, Assoc. Prof. Dr. Nguyễn Xuân Hùng:

How to prevent mixed hemorrhoids

Based on the aforementioned causes of mixed hemorrhoids, it is evident that in order to prevent hemorrhoids in general and mixed hemorrhoids in particular, everyone should adopt the following measures:

Maintain a healthy, balanced diet: increase fiber intake, drink sufficient water, and limit hard-to-digest foods or protein-rich meals late in the evening.

Avoid prolonged sitting: especially for office workers, take a short walk or stand up every 30–60 minutes.

Establish regular bowel habits: aim for at least one bowel movement per day, preferably in the morning after waking, and maintain a consistent routine.

Stay physically active: engage in regular exercise, maintain personal hygiene, and avoid tight or restrictive clothing that causes discomfort.

Do not strain during defecation: and use medications for constipation only under the guidance of a specialist.

Seek medical consultation promptly: if experiencing warning signs such as rectal bleeding, pain, itching, or the appearance of a perianal mass.

Increasing fiber intake and staying well-hydrated help prevent mixed hemorrhoids.
Increasing fiber intake and staying well-hydrated help prevent mixed hemorrhoids.

Can mixed hemorrhoids be cured?

Mixed hemorrhoids can be treated through various methods. However, specialists emphasize that patients should not self-medicate at home, as mixed hemorrhoids are complex in nature and require treatment under the guidance of qualified physicians.

Depending on the severity of the condition, doctors may recommend different approaches to achieve effective management and resolution of hemorrhoids:

In early stages: patients are often prescribed conservative (medical) therapy combined with lifestyle and dietary modifications, including:

  • Oral medications: prescribed to shrink hemorrhoidal tissue, reduce inflammation, and relieve swelling.
  • Topical therapy: application of medicated ointments or suppositories to promote faster regression of hemorrhoids.
  • Dietary modification: adopting a healthy diet with increased intake of fiber from vegetables, fruits, and whole grains.
  • Adequate hydration: maintaining sufficient daily fluid intake.
  • Regular exercise: engaging in physical activity for 30–60 minutes per day, 5–7 days per week.
  • Proper hygiene: keeping the anal area clean, especially after each bowel movement.

In moderate stages: physicians often recommend minimally invasive procedures, all of which share the common goal of causing hemorrhoidal tissue to shrink or slough off:

  • Sclerotherapy: injection of a sclerosing solution into the submucosal layer of the hemorrhoidal plexus, inducing localized inflammation and fibrosis. This reduces blood flow and secures the hemorrhoidal mucosa to the underlying sphincter muscle.
  • Rubber band ligation: placement of a small elastic band around the base of the hemorrhoid to cut off its blood supply, leading to necrosis and detachment within 5–7 days.

In severe stages, when the disease progresses to cause significant pain, heavy bleeding, or complications such as anal infection, perianal edema, or even tissue necrosis, surgical hemorrhoidectomy is indicated. Currently, two common surgical techniques are widely applied in the management of mixed hemorrhoids: stapled hemorrhoidopexy (PPH), which involves excision of hemorrhoidal tissue using a circular stapler after laser-assisted removal combined with mucosal lifting and fixation; and radiofrequency ablation (HCPT), which utilizes high-frequency waves to coagulate the blood supply around the hemorrhoid before excising the hemorrhoidal tissue.

Laser hemorrhoidectomy
Laser hemorrhoidectomy

The choice of treatment method must be carefully evaluated based on the condition of the hemorrhoidal tissue as well as the patient’s overall health status and treatment response. Therefore, it is essential for patients to undergo examination by a specialist at a reputable medical facility, where proper diagnostic tests can be performed to determine the most appropriate treatment approach.

In addition, patients should strictly adhere to the prescribed treatment regimen, make necessary lifestyle adjustments, and attend follow-up visits as directed by their physicians to ensure the treatment process is both safe and effective. Patients are strongly advised not to self-medicate or seek care at small, unaccredited facilities, as doing so may increase the risk of serious complications.

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Where to seek reliable and effective care for mixed hemorrhoids

Mixed hemorrhoids are a complex form of hemorrhoidal disease, making accurate diagnosis and proper treatment critically important for complete recovery. With more than 20 years of trusted service, Hong Ngoc General Hospital has established itself as a reputable and dependable destination for patients seeking effective management of mixed hemorrhoids.

  • Accurate diagnosis and definitive treatment are ensured by a team of highly qualified and experienced physicians, including: People’s Physician, Assoc. Prof. Dr. Nguyễn Xuân Hùng – Former Director of the Center for Colorectal and Perineal Surgery at Viet Duc University Hospital, Vice President of the Vietnam Association of Colorectal Surgeons, and Member of the French Society of Coloproctology; MSc. Dr. Cù Trung Kiên – specialized training in gastrointestinal surgery in Hong Kong, former physician at Bach Mai Hospital, currently Deputy Head of the Department of Gastrointestinal Surgery at Hong Ngoc General Hospital – Yen Ninh; and Specialist Level I Dr. Bạch Phúc Huy – over 15 years of experience, Head of the Gastrointestinal Surgery Unit at Hong Ngoc General Hospital – Phuc Truong Minh, among others.
People’s Physician, Assoc. Prof. Dr. Nguyễn Xuân Hùng examining and consulting with a patient.
People’s Physician, Assoc. Prof. Dr. Nguyễn Xuân Hùng examining and consulting with a patient.
  • Modern surgical techniques are applied in the treatment of hemorrhoids, including advanced methods such as radiofrequency hemorrhoidectomy, stapled hemorrhoidopexy (PPH), and the Longo procedure.
  • Pain-free hemorrhoid surgery is ensured through a comprehensive pain management protocol developed by Dr. Nguyễn Thị Thu Ba, MSc who completed specialized residency training in France. A highly skilled team of anesthesiologists provides continuous monitoring throughout the surgical process.
  • A multimodal pain prevention strategy is implemented: patients undergo thorough pre-anesthesia assessment, are closely monitored during the procedure, and receive pain control measures even before symptoms appear. Modern surgical techniques target non-sensitive areas, minimizing tissue damage and discomfort.
  • Patients benefit from attentive 24/7 supportive care throughout their hospital stay, in addition to spacious, hotel-standard inpatient facilities fully equipped for comfort and recovery.

For detailed consultation, please contact: Hotline for specialist appointments: 0911 908 856 Hotline for hemorrhoidectomy consultation: 0949 646 556

You may also register to receive information and consultation at:

Note: The information provided in this article by Hong Ngoc General Hospital is for reference only and is not a substitute for medical diagnosis or treatment. Patients should not self-medicate. For an accurate assessment of your condition, please visit a hospital for direct examination, diagnosis, and treatment planning by a physician.

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