Hemorrhoids “come out” when the cushions of tissue inside your anal canal lose their structural support and slide downward under pressure. Everyone has these cushions from birth. They’re clusters of blood vessels, smooth muscle, and connective tissue that help with continence. Problems start when the connective tissue anchoring them in place breaks down, blood pools and swells the cushions, and straining or gravity pushes them through the anal opening.
What Hemorrhoids Actually Are
Hemorrhoids aren’t varicose veins, though they’re often described that way. They’re vascular cushions made of small arteries, veins, smooth muscle, and connective tissue that sit inside the anal canal. There are three main cushions positioned around the canal, and they serve a purpose: they help seal the anus shut and cushion the passage of stool.
These cushions are held in place by a muscle and ligament system that anchors them to the wall of the anal canal. Think of it like a hammock suspended by ropes. As long as the ropes hold, the hammock stays put. When those anchoring structures weaken or stretch, the cushions start to slide downward, and that’s when you feel or see something protruding.
How the Anchoring System Breaks Down
The muscle fibers and connective tissue holding hemorrhoidal cushions in place deteriorate over time. In aging, the collagen that gives these tissues their strength becomes looser and less resilient. Research on hemorrhoid tissue shows elevated activity of enzymes that break down elastic fibers, accelerating the process. This is one reason hemorrhoids become more common with age: the “ropes” of the hammock fray.
Genetics play a role too. The tendency for these support structures to weaken earlier or faster can run in families. People with connective tissue conditions that cause looser collagen throughout the body are more prone to hemorrhoid problems for the same reason.
Pressure Is the Main Driver
Even when the support tissue is intact, repeated or sustained pressure in the pelvic area engorges the cushions with blood and pushes them downward. Several everyday situations create this pressure.
Straining during bowel movements is the most common trigger. Low-fiber diets produce smaller, harder stools that require more effort to pass. That sustained pushing increases pressure inside the abdomen, which interferes with blood draining out of the hemorrhoidal veins. Blood pools, the cushions swell, and over time the repeated force stretches them beyond what the supporting tissue can hold.
Prolonged sitting on the toilet creates what’s sometimes called a tourniquet effect. When you sit on a toilet seat, your rectum drops lower than the rest of your body. Gravity pulls blood downward into the veins around the anus, and the longer you sit, the more blood pools there. Scrolling your phone for 15 or 20 minutes on the toilet is one of the most common modern contributors.
Pregnancy combines multiple risk factors at once. The growing uterus puts direct weight on pelvic veins, making it harder for blood to flow freely back toward the heart. Hormonal changes slow digestion, leading to constipation, which leads to straining. The extra weight of backed-up stool further compresses the veins. This is why hemorrhoids are especially common in the second and third trimesters.
Heavy lifting, chronic coughing, and obesity all increase abdominal pressure through similar mechanisms. Any activity that forces you to bear down hard and often can push hemorrhoidal cushions toward the opening of the anal canal.
The Four Stages of Prolapse
Not all hemorrhoids “come out.” Doctors grade internal hemorrhoids on a four-point scale based on how far the cushions have displaced.
- Grade I: The cushions bulge into the anal canal during a bowel movement but don’t exit the body. You might notice bleeding but feel nothing protruding.
- Grade II: The cushions push out during straining but slide back in on their own once you stop. This is the most common grade, affecting roughly 17% of people with hemorrhoids in large population studies.
- Grade III: The cushions come out and stay out until you push them back in manually.
- Grade IV: The cushions are permanently outside the anal canal and can’t be pushed back in at all.
The progression from one grade to the next isn’t inevitable. Many people stay at grade I or II for years or improve with lifestyle changes. But without addressing the underlying pressure, the support tissue continues to stretch, and the cushions can gradually descend further.
How Common This Is
About one in four adults worldwide has hemorrhoids at any given time, according to a large systematic review. Internal hemorrhoids, the kind that prolapse, are roughly four times more common than external ones. Children are affected at about half the rate of adults, reflecting the role that years of pressure and connective tissue aging play in development.
What Keeps Them From Coming Back
Since the core problem is too much pressure on weakening tissue, prevention targets both sides of that equation. The single most effective change is getting enough fiber. U.S. dietary guidelines recommend 14 grams of fiber per 1,000 calories you eat, which works out to about 28 grams a day on a standard diet. Fiber bulks up stool and softens it, so bowel movements require less straining. Drinking enough water helps fiber do its job.
Beyond diet, the biggest practical change is spending less time on the toilet. If you don’t have an urge to go, don’t sit and wait for one. Put the phone down. Aim to be on and off in under five minutes. When you do go, avoid bearing down hard. Placing your feet on a small stool to raise your knees above your hips straightens the rectal angle and reduces the effort needed.
For hemorrhoids that have already prolapsed, the tissue changes aren’t fully reversible on their own, especially at grades III and IV. But reducing pressure can stop the progression, shrink swelling, and in many grade II cases, allow the cushions to stay in place during bowel movements again. When prolapse is persistent or painful, a range of office and surgical procedures can remove or reposition the tissue, with recovery times ranging from a few days to a few weeks depending on the approach.