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Introduction

Hemorrhoids are vascular structures in the anal canal that, when symptomatic, cause bleeding, prolapse, pain, and pruritus. Globally, they affect nearly 4.4% of the population, predominantly in the age group 30–60 years [1]. Risk factors include chronic constipation, pregnancy, obesity, and sedentary lifestyle. In Ayurveda, hemorrhoids are referred to as Arsha, one of the Ashtamahagada (eight grave diseases) due to chronicity, recurrence, and impact on quality of life [2]. Ancient texts describe multiple types of Arsha based on Dosha predominance, bleeding tendency, and prognosis, paralleling modern classification by grade and type

Epidemiology

• Global prevalence: ~4.4% [1].
• More common in males, though pregnancy increases risk in females.
• Peak incidence between 30–50 years.
• Risk factors: chronic constipation, prolonged straining, hereditary predisposition, obesity, pregnancy, portal hypertension [3].

Classification

Ayurvedic Classification

1. Dosha-based: Vataj, Pittaj, Kaphaj, Raktaj, Sannipataj, Sahaj [2].
2. Based on bleeding: Ardra (bleeding) vs Shushka (dry) [4].
3. By prognosis: Sadhya (curable), Yapya (palliative), Asadhya (incurable) [2].
4. By anatomical position: Internal, External, Mixed [5].

Clinical features:

• Vataj: hard, painful masses, constipation.
• Pittaj: bluish-red, burning, bleeding.
• Kaphaj: fleshy, non-bleeding, pruritus.
• Raktaj: profuse bleeding, anemia.
• Sannipataj: mixed features.
• Sahaj: congenital, resistant to treatment [2,4

Modern Classification

• Internal hemorrhoids:
  • Grade I: bleeding only.
  • Grade II: prolapse, spontaneously reduce.
  • Grade III: prolapse, require manual reduction.
  • Grade IV: irreducible prolapse [6].
• External hemorrhoids: skin-covered, painful, may thrombose.
• Mixed type: combination of internal and external [6].

Etiopathogenesis

Ayurvedic Perspective

• Vitiation of Vata–Pitta Dosha and deranged Agni leads to Ama accumulation and obstruction of channels at Guda pradesha, causing varicosity and mass formation [2].

Modern Perspective

• Hemorrhoids develop due to degeneration of supportive connective tissue, increased venous pressure, and hyperperfusion of arteriovenous plexus [7].
• Risk factors include prolonged straining, chronic constipation, pregnancy, low-fiber diet, and sedentary lifestyle [3]

Management

Ayurvedic Approach

1. Nidana Parivarjana (Avoidance of causative factors): Correction of bowel habits, avoidance of heavy foods, sedentary habits [2].
2. Bheshaja Chikitsa (Medicinal therapy):

Piles which are not chronic, having mild aggravation of dosas , symptoms and complications (secondary diseases) are treatable with medicines. Acharya charaka has mentioned basic line of treatment in charak samhita as i.e. Abhyang, Swedan,Dhum, Avgahan, Pralep, Raktmokshan, Deepan, Pachan, Anuloman, Samshman yoga, Sarpi , Basti etc.Shushruta has advised Panchakarma treatment in piles having predominance of vata,Virechan (purgation) in Pitta pradhan arsha and rakta pradhan arsha.Kaphaj arsha can be treated with sringvera(Zingiber officinale)  and kulattha (Macrotyloma Uniflorum)6. Vagbhata has told that checking Agni (Digestion) of patient is very important in Arsha, Atisar and Grahani diseases as these are inter dependent diseases. As per Vagbhata use of Bhallatak(Aconitum ferox) in non bleeding piles is very effective, while bleeding piles can be treated with Vatsak(Holearhena Antidysentrica).Use of Takra(Butter Milk) is aslo beneficial in Arsha(piles)

1. Kshara Karma (Alkaline cauterization):

Piles which are soft,broad,deep and bulged up are to be treated with Kshara(alkali).Sushruta has told to use kshar in rakta and pitta dominant arsha (piles).Kshar karma should be done in patient who is Balwan (Strong) .After giving proper position lubricate the anus with Ghee, instrument smeared with ghee is pushed into the anus.After applying the Kshar the mouth of the speculum is kept closed by the hand for the period of one hundred mantra( time required to pronounce 100 vowels)  and close Ashoyarika the color of Arsha should be like ripen Syzygium (Pakwajambuphala). When this sign is achieved wash pile mass with kanji or curd or phalamla(juice of sour fruits) bathed with ghee mixed with Yasthimadhuka(Glycyrrhiza labra) and then speculum is taken out. After this treatment patient should be advised to take proper diet and treatment should be repeated after seven days if required.

1. Agnikarma (Thermal cauterization): As per Sushruta Agni chikitsa (Teatment with thermal cautery) is advised in the pile mass which are rough,immovable,big and hard.Arshas(piles) which are produced by vata and kapha should be treated with agni [10].
2.   Shalya Karma (Surgery): As per shusruta Shastra karma (Operative treatment) is indicated in piles which have thin root, bulged up and exuding (fluids). Sushruta has mentioned to excise such piles with the help of instrument and should be cauterized immediately10[2].
3.  Ksharasutra ligation: Medicated thread ligation; controlled necrosis and sloughing of mass with minimal recurrence [11].

Modern Approach

1. Conservative therapy: High-fiber diet, sitz baths, stool softeners, topical corticosteroids, flavonoids [3].
2. Office-based procedures:
   • Rubber band ligation :
   •  In this method each haemorrhoid is grasped at its base by the grasping forceps.It is important that the point selected for application of the forceps atleast 6mm above the Dentate Line. When the bands are seen in position, then banding instruments are released and removed.This treatment indicated in the case of 1st and 2nd degree of internal haemorrhoids.(success ~87%, recurrence ~5% at 2 years) [6].
   • Sclerotherapy -Sclerosant injection has been the method of treatment of small vascular haemmorrhoids.The commonly used sclerosant is 5% phenol in almond oil in upper and of hemorrhoid above level of anoretal ring. This injection causes fibrous tissue reaction in the submucosa of anal canal. This treatment is suitable for the 1st and 2nd degree of haemmhorhids
   • Cryo surgery -Liquid nitrogen or carbon dioxide is applied to the hemorrhoid .This produces a liquefactive necrosis of tissue. Problems with cryosurgery are poor control of depth of freezing and profuse seropurulent discharges
   • Infrared coagulation and laser therapy [7].
3. Minimally invasive surgery:
   • Stapled hemorrhoidopexy: Stapled Hemorrhoidectomy is one of the newer surgical technique for treating   haemorrhoial artery ligation it has rapidly became the treatment of choice for third and fourth degree hemorrhoid. Since the surgery does not remove the hemorrhoids but rather the abnormally lax and expanded haemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse down, is tightened.less pain, faster recovery, comparable efficacy [12].
   • Doppler-guided hemorrhoidal artery ligation (DGHAL/THD): >90% bleeding control, low recurrence [12].
   • Hemorrhoidal artery embolization (HAE/Emborrhoid): 90% bleeding reduction, minimal complications [13].

Conventional hemorrhoidectomy (Milligan-Morgan): Gold standard for Grade III–IV, lowest recurrence but painful recovery [7].

Discussion

Ayurveda and modern medicine both recognize hemorrhoids as a multifactorial disease influenced by diet, bowel habits, and vascular factors. Ayurveda emphasizes prevention and root-cause correction through Agni balance, bowel regulation, and minimally invasive procedures like Kshara Karma and Ksharasutra. Modern techniques provide advanced options like stapled hemorrhoidopexy and arterial ligation with quick recovery. Integration of both systems—Ayurvedic diet, lifestyle, and herbal formulations with modern minimally invasive interventions—may reduce recurrence, improve patient compliance, and optimize outcomes.

Conclusion

Hemorrhoids (Arsha) remain a common anorectal disease with significant global burden. Ayurveda provides a holistic, preventive, and minimally invasive approach, while modern medicine contributes advanced surgical precision and evidence-based protocols. Collaborative, integrative research can lead to comprehensive, patient-centered care with lower recurrence and better quality of life.