RightRep EN · PT Open the app
BLOG

Can You Train With Hemorrhoids? The Pressure-Door Audit: The 4.4% Census, the Constipation Acquittal, and Your Squat (What the Research Says)

By RightRep AI Assistant · · 24 min read

The pressure wing of this library is already built: the hernia door for the abdominal-wall file, the pelvic organ prolapse door for the pelvic-floor file, the acid reflux door for the upward-pressure file, and the breath-holding audit for the Valsalva itself. But the hemorrhoid — the single most common "can I still lift" question nobody asks out loud — has no door anywhere in this library. The reader arrives as one of three people. The mid-block flarer: the session that felt fine, the evening on a donut cushion, the quiet arithmetic about whether next Tuesday's squats made it worse. The diagnosed lifter: grade II or III on an office chart, a clinician's sentence that said "avoid straining," translated internally into "deadlifts are over." The post-op returner: banded or cut weeks ago, formally cleared, and terrified of the first heavy set back. None of them holds a diagnosis they understand, and all of them are being answered by two opposite internet scripts. The fear script says straining causes hemorrhoids, so never lift heavy again; the dismissal script says it is just a pain in the butt, train through it. Both scripts are priced wrong, and in opposite directions.

Two numbers frame the audit before the receipts. The first is a census: hemorrhoids are not rare, not new, and not the exclusive property of lifters — 10 million Americans complained of hemorrhoids, a prevalence of 4.4%, peaking between ages 45 and 65 and falling after 65, and the authors noticed that this curve does not track constipation's, which rises exponentially after 65 [1]. The second is a case-control that took the causal story apart: among 325 consecutive proctoscopy patients (168 cases, 157 controls), constipation was not associated with hemorrhoids at all — but diarrhea and obesity were [2]. Read those together and the fear script's central plank collapses, while the dismissal script's comes under pressure from another direction: the strongest measured association in the modern literature is not the squat, it is the toilet, where smartphone use carried a +46% hemorrhoid risk (p=0.044) after adjustment for age, sex, BMI, exercise activity, straining and fiber intake [6]. What follows is a census, a mechanism, a risk-factor ledger, an office ladder, a surgical file, an honest recurrence column, a pregnancy column, a fence section and a six-rule protocol — every number sourced to the abstract it came from, every limit the study authors printed carried forward.

The scale of the door: 4.4%, 45–65, and a curve that does not behave

The first honest number at this door is a plain census of complaint. Drawing on four US and UK data sources, hemorrhoids accounted for roughly 10 million Americans and a prevalence of about 4.4%, with the age curve rising to a peak between 45 and 65 and then falling in older age groups [1]. The authors then did something this guide exists to copy: they compared that curve with constipation's, which climbs exponentially after age 65 while hemorrhoid complaint falls — and the paper used that divergence to openly challenge the presumption that constipation causes hemorrhoids [1]. A causal factor that moves in the opposite direction from its supposed consequence is in trouble, and that observation has sat in the literature since 1990 without being overturned. The second lesson is about who the reader is: a 4.4% complaint prevalence makes this a common condition in the exact age bracket that fills commercial gyms. The census sets the scale; the next study sets the mechanism question on fire.

The case-control that acquitted constipation

The strongest single study against the fear script is a case-control that asked the mechanism question directly. 325 consecutive patients undergoing proctoscopy — 168 with hemorrhoids and 157 controls — were assessed for a range of potential etiological agents, and the analysis returned a surprising ledger: constipation was not associated with hemorrhoids, and neither were age, cirrhosis, or varicose veins, while diarrhea carried an odds ratio of 2.1 (95% CI 1.2–3.7) and obesity an odds ratio of 1.7 (95% CI 1.1–2.7) [2]. Note what that means for the reader lying awake after leg day. The mechanism the whole internet sells — hard stool, hard push, cushions blow out — failed to appear in the one controlled comparison designed to find it, while frequency of stool and body mass did appear. This is not a licence to ignore straining: straining is not the whole story [2], and the causality the culture assumes has been challenged at the census level [1] and failed to replicate here [2]. That admission does more work than any reassuring sentence, because it moves the reader off a guilt model ("my last heavy set did this") and onto a risk-factor model they can manage. The next sections assemble that model from the fiber, sitting and pressure data.

What intra-abdominal pressure actually does

The mechanism question deserves a precise answer, because "pressure" is where this conversation usually goes wrong. When you brace and pull, intra-abdominal pressure rises — that is real and useful — and the one study in this file that measured it in lifters did so narrowly: intra-abdominal pressure surges during a deadlift at 90% of maximum, and is significantly greater when a lifting belt is worn, from which the authors' functional conclusion is that the belt's purpose is spinal support [7]. The belt finding is the only claim this file borrows from that study; the record does not show that pressure rises in a graded way with load, and says nothing about rectus abdominis activation, so neither claim is made here [7]. What the pressure physics means for the anal cushions is the next link in the chain, and it is the mechanism the fear script assumes: sustained intra-abdominal pressure opposes venous return through the hemorrhoidal plexus, engorging the cushions, and it loads the supporting tissue that holds them in place — a plausible chain that the best clinical file in this guide nevertheless could not confirm as the whole story, since the case-control searching for exactly that mechanism found constipation unassociated and diarrhea and obesity associated instead [2]. That is why the strongest measured association in the modern literature is not barbell load but duration and behaviour with the pressure gradient — the toilet file — and why the Valsalva audit is the correct sibling door. A braced lift is a brief, controlled pressure event; a long, distracted sit is a sustained one. The file prices them differently because the data does.

The toilet-phone file: the sitting variable nobody audits

If the fear script belongs to the squat, the data's strongest association belongs to the bathroom, and this is the modern file the guide exists to deliver. A colonoscopy-based study screened 125 adults, visualizing hemorrhoids endoscopically in 43% of them, found that 66% used a smartphone on the toilet, and — the number that matters — 37.3% of smartphone users sat for more than five minutes per visit versus 7.1% of non-users (p=0.006) [6]. Multivariate analysis put smartphone use at a 46% higher hemorrhoid risk (p=0.044) after adjusting for age, sex, BMI, exercise activity, straining and fiber intake [6]. Read the adjustment set again, because it is why this study belongs in a lifting guide: the analysis controlled for exercise activity and straining and fiber — and the toilet-phone association survived all three. The behavioural flag that outlived the controls was not the barbell; it was the sustained sit with a pressure gradient and a screen. One honesty asterisk rides along as printed by the authors: only a p-value is reported for that association, not a confidence interval, so the effect size here is directional, not precisely bounded [6]. The gym translation is unglamorous and highest-yield: stop the phone, cap the sit, and get off the toilet when you are done — a change that costs nothing, requires no clinician, and removes the risk factor the best-adjusted study in this file actually found [6]. The session at the squat rack is a two-second pressure event; the scroll on the toilet is a fifteen-minute one, repeated daily, and it was measured.

The risk-factor ledger: fiber, sedentary work, obesity

The manageable risk ledger at this door has one intervention with a meta-analytic receipt and one with a cross-sectional dose curve. The receipt first: a systematic review and meta-analysis of 7 randomized trials and 378 patients found that fiber cut the risk of persisting symptoms (RR 0.53, 95% CI 0.38–0.73) and of bleeding (RR 0.50, 0.28–0.89), with the effect consistent at both 6 weeks and 3 months [3]. That is a modest, well-reproduced effect, and it is the strongest supplement-shelf claim in the file — a deliberately unglamorous crown. The dose curve comes from a cross-sectional study of sedentary professionals with a hemorrhoid prevalence of 38.95%, where the highest versus lowest fiber quartile (more than 18.5 versus less than 13.1 g/day) carried an adjusted odds ratio of 0.56 (0.32–0.98) after adjustment for age, BMI, exercise habits and sedentary duration — and where the authors themselves caveat that the flattening near 25 g/day is a descriptive pattern, not a validated threshold [5]. Then the factors that keep appearing in every well-adjusted model: obesity, at odds ratio 1.7 (1.1–2.7) in the case-control [2], and sedentary sitting duration, which the fiber study adjusted for precisely because it matters [5]. The gym translation needs no heroics: fiber to a defensible daily number, body composition managed like any other training goal, and total sitting time treated as a training variable rather than background furniture [2][3][5]. None of those three requires stopping a single lift, which is why the fear script's "give up the deadlift" answer fails as medicine and as behaviour change.

The office ladder: banding, HAL, and the cost of the fancy rung

For the diagnosed lifter whose file needs an office procedure, the treatment ladder has been randomized, and the results are more honest than the marketing. The HubBLe trial randomized 370 patients with symptomatic second- and third-degree hemorrhoids to haemorrhoidal artery ligation (HAL) or rubber band ligation (RBL) and found that at one year, recurrence was 30% with HAL versus 49% with RBL — an adjusted odds ratio of 2.23 (95% CI 1.42–3.51) favoring HAL [8]. That is the headline clinics quote. The rest of the trial is the part that should reach patients: repeat RBL closed the gap — recurrence settled at 37.5%, adjusted odds ratio 1.35 (0.85–2.15, p=0.20), no longer statistically significant — RBL was less painful, and HAL cost £104,427 per additional quality-adjusted life-year [8]. A cheap, repeatable, more painful procedure given a second attempt matched a more expensive one on recurrence at a price that no health system calls a bargain [8]. There is a second receipt in the drug column: the micronized purified flavonoid fraction (MPFF) meta-analysis against placebo or no treatment reported bleeding odds ratio 0.082 (0.027–0.250), discharge or leakage odds ratio 0.12 (0.04–0.42), overall improvement odds ratios of 5.25 (2.58–10.68) by patient report and 5.51 (2.76–11.0) by investigator report, and a pain trend at odds ratio 0.11 (0.01–1.11, P=0.06) [4]. Those are large numbers, and the file's own asterisk must travel with them: the pooled bleeding and improvement analyses drew on only a small subset of the included studies, so the precision those intervals imply is softer than it looks [4]. The office rungs work, the cheap rung works twice, and the choice between them belongs to a clinician's hands and a health system's arithmetic — not to a gym forum [4][8].

The surgical file: eTHoS, LigaSure, thrombosed excision

For the reader who has been told an operation is next, three randomized files price that decision with unusual clarity. The largest is eTHoS, which randomized 777 patients to stapled haemorrhoidopexy or traditional excisional surgery and found that the stapled route was less painful in the short term, which is what sells it — but that at 24 months the EQ-5D-3L quality-of-life area under the curve favored traditional excisional surgery (mean difference −0.073, 95% CI −0.140 to −0.006, p=0.0342), with serious adverse events in 7% (24/338) of stapled patients versus 9% (33/352) of excisional patients, leading the authors to conclude that traditional excisional surgery should be considered the surgical treatment of choice [9]. The recovery-oriented file is a meta-analysis of 43 randomized trials and 3,277 participants comparing LigaSure with conventional excisional haemorrhoidectomy, which found less pain on days 1–2 and across weeks 1–2, fewer analgesics, less operative blood loss, and a shorter time to return to daily activities — with no difference in recurrence or long-term anorectal outcomes [11]. That is the only surgical claim in this guide that touches the gym directly: the modality with the faster return to daily activity did not trade away recurrence to get it [11]. And the acute flag nobody plans for — the thrombosed external hemorrhoid, the sudden, exquisitely painful lump — has its own meta-analysis of 6 studies and 851 patients, where surgery lowered recurrence (RR 0.49, 95% CI 0.26–0.91, I²=54%) with bleeding no different (RR 0.96, 0.27–3.44), inside a within-72-hour door after which the calculus shifts toward conservative care [10]. All three files point the same way for the lifter: the operation is a scheduling decision with a documented trade-off, not the end of training.

The recurrence honesty column

Any guide that promised a permanent fix would be lying, and this file does not need to: the recurrence data is printed and it is wide. A systematic review of 44 publications found that recurrence after surgery or phlebotonic treatment ranges from 0% to 56.5% — but that 19 of 23 real-world studies report 20% or less [12]. The wide range is not a scandal; it reflects differences in follow-up length, definitions, procedure mix and populations, and the review itself flags that recurrence and epidemiological data in this field are inconsistent [12]. The second reading closes the loop of this entire guide: the risk factors for recurrence are simply the disease's own risk factors [12] — the same items in the ledger above (fiber, sitting, body mass, stool pattern) [2][3][5]. There is one claim this guide specifically refuses to make, and it is worth stating why: the suggestion that MPFF reduces recurrence appears only in the plain-language summary of a manufacturer-linked review, not in its results, so it is not carried here as a finding [12]. What is carried is the range, the ≤20% real-world mode, and the inconsistency caveat [12]. The gym translation is the least dramatic sentence in the file: plan for recurrence like you plan for a deload — a procedure is a reset, not an amnesty; keep the fiber and sitting habits, and do not read a recurrence as proof that lifting caused any of it [12].

The pregnancy column

The pregnant lifter with a flare is the reader this file routes most carefully, because the physiology and the treatment calculus both change. The relevant study examined 53 pregnant patients with thrombosed external hemorrhoids — 26 managed conservatively and 22 surgically — and reported re-thrombosis in 38% (3/8) after thrombectomy versus 7% (1/14) in the conservatively managed group, with surgery relieving anal pain faster [13]. Surgery can relieve pain faster when the presentation is severe enough to justify it, and the conservative route carried a lower re-thrombosis rate in this small series — a single study of 53 patients, cited for the flare door rather than for any general prescription [13]. The practical consequence is a routing rule: a thrombosed flare in pregnancy belongs to an obstetric-clinician conversation, and the training file runs alongside it — the same structure the pregnancy training door and the postpartum return door already use for every other pressure-related decision. Nothing here licenses a pregnant lifter to train through a bleeding flare, a thrombosed hemorrhoid, or the days immediately after a procedure without explicit clearance. It routes her, and states what the two arms measured [13].

The Brazilian ledger: the home market's own file

The home market's most useful contribution to this door is not an epidemiology statistic — it is authorship and procedure access. The largest surgical meta-analysis in this guide, 43 randomized trials and 3,277 participants comparing LigaSure with conventional excisional haemorrhoidectomy, was led by a Brazilian author group spanning São Caetano do Sul, Heliópolis, UFMG and Santa Casa de São Paulo alongside UNC [11]. Read that as an access fact rather than a patriotic one: the recovery-oriented evidence that most directly answers "posso treinar depois?" — less pain in the first days and weeks, fewer analgesics, shorter time to return to daily activities, no recurrence trade-off [11] — was assembled by the clinicians most Brazilian readers will actually be referred to. The rest of the file is imported but not foreign. The complaint census of 4.4%, peaking 45–65 is a US/UK file [1], and the case-control that acquitted constipation while flagging diarrhea at OR 2.1 and obesity at OR 1.7 is a general-population file [2], but the mechanism they both point at is behavioural and portable: the toilet-phone association survived adjustment for age, sex, BMI, exercise, straining and fiber (p=0.044) [6], and fiber intake's adjusted odds ratio of 0.56 for the highest versus lowest quartile was measured in sedentary workers who sit at desks all day [5]. The Portuguese-language search terms that lead to this door — treinar com hemorroida, pode fazer academia com hemorroida — are asked by the same desk-bound, gym-going adult the fiber study recruited [5], which is why the protocol below is written in behaviours (fiber, sitting, bracing, load progression) rather than in procedures. Between the Brazilian-led surgical file [11], the portable behavioral ledger [2][5][6] and the honest recurrence column [12], the reader can build a plan that survives the referral, whichever rung they land on.

The fences: red flags, referrals, and honest limits

The fences at this door are hard, and the first one is non-negotiable: rectal bleeding is not self-diagnosable. Bleeding that a reader attributes to hemorrhoids can be colorectal cancer, and the mapping from symptom to cause is clinical work — examination, and colorectal cancer screening where indicated — not a search engine's job. This guide is not a diagnostic service, and it never will be. The red-flag set stops the program and opens a medical door now: bleeding with weight loss or anaemia; a change in bowel habit in someone over 45 to 50; a palpable mass; fever with a hot, swollen perianal area; rapidly worsening pain; immunosuppression or anticoagulation; and pregnancy. Next are the training fences, stated as plainly as the house can state them: do not train through a bleeding flare, do not train through a thrombosed hemorrhoid, and do not return to loading in the days right after a banding or an excision without your clinician's explicit clearance. A banded pedicle and a fresh excision are healing tissue with defined failure modes, and the return schedule belongs to the person who did the procedure [8][9]. The honesty fence follows: the case-control that acquitted constipation was a single case-control of 325 patients [2]; the fiber effect is modest at RR 0.53 and 0.50 [3]; the MPFF numbers rest partly on a small subset of studies [4]; the toilet-phone association is a p-value without a confidence interval [6]; the fiber dose curve's bend near 25 g/day is the authors' own descriptive caveat [5]; recurrence spans 0–56.5% with inconsistent data [12]; and the pregnancy study is 53 patients [13]. None of those limits reverses the direction of the file; all of them set the confidence this guide is entitled to.

The protocol: six rules

  1. Triage before you train. Bleeding with weight loss or anaemia, a change in bowel habit over 45–50, a mass, fever with a hot swollen perianal area, rapidly worsening pain, immunosuppression or anticoagulation, pregnancy — the program stops and the right clinician starts. Everything below is for the reader without a red flag, and nothing below is a diagnosis.
  2. Stop auditing the squat; audit the toilet. The best-adjusted association in this file was smartphone use on the toilet, at +46% risk (p=0.044) after adjustment for age, sex, BMI, exercise, straining and fiber [6]. Cap the sit at a few minutes, leave the phone outside, and drop the straining habit — the highest-yield, zero-cost change available without a clinician's appointment [6].
  3. Fix the ledger before you cut the lift. Fiber cut persisting symptoms (RR 0.53) and bleeding (RR 0.50) across 7 trials and 378 patients [3], with the highest quartile of intake (>18.5 g/day) at adjusted OR 0.56 in sedentary workers [5] — while obesity sat at OR 1.7 [2] and diarrhea at OR 2.1 [2]. Body composition and stool pattern are training variables, not background noise, and none of them requires giving up a lift [2][3][5].
  4. Brace like a lifter, not like a strainer. Intra-abdominal pressure rises during a heavy deadlift and is higher with a belt — the belt is spinal equipment, not anal protection [7]. Breathe and brace on purpose, keep the pressure event brief and controlled, and treat a sustained, distracted sit as the bigger pressure exposure of the day; the breath-holding audit covers the mechanics, and the belt audit covers the tool [6][7].
  5. If it flares, down-shift — do not stop, and do not push through. Cut load and volume around the flare, keep the non-aggravating work in the plan, and progress back with progressive overload inside a proper warm-up [3][12]. Bleeding flares, thrombosed hemorrhoids, and the days after a banding or excision are fences, not dose dials — clearance first, loading second [8][9][10][11].
  6. Set the deadline and route the file. If six to twelve weeks of ledger-fixed, braced, progressed training has not bent the trend — or if the grade and symptoms demand it — route by pattern: persisting symptoms with a diagnosable grade to the office ladder (banding first, repeat banding included, with HAL's cost and recurrence trade-off on the table) [4][8]; a thrombosed external hemorrhoid inside 72 hours to the excision-versus-conservative decision [10]; a planned operation to an explicit recovery conversation about return to daily activity [9][11]; and recurrence to the routine that treats a procedure as a reset, at ≤20% for most real-world files [12].

How RightRep fits into this

The hard part of training through a hemorrhoid file is not courage; it is calibration — knowing whether this week's bracing and volume are tolerable dosing or quiet provocation, whether the flare is actually receding across weeks, and whether the ledger changes are landing. That is a measurement problem, and it is what the app does:

  • The rep score trend is the tolerability graph. A flare makes every session feel unreliable; an objective per-session quality score, trending week over week against symptoms, shows whether the down-shifted program is holding — the six-week re-check runs on data, not on how the cushion felt this morning [3][12].
  • Form checks catch the protective drift. A guarded brace shows up as shortened range, rushed eccentrics and a bar path that quietly changes — a camera that grades every set notices the compensation before it becomes the way you lift [7].
  • Tempo control keeps the pressure event brief. Slower, controlled reps remove the grind-and-hold that a flaring reader is most likely to overdo, and the rest timer keeps honest spacing between sets [6][7].
  • The log makes the ledger auditable. Fiber, sitting time, symptoms and training load, tracked in one place, turn "I think it is getting better" into a week-over-week table — which is exactly what the recurrence column demands of anyone planning for the reset rather than pretending it will not come [12].

Run it at rightrep.app — with the ledger fixed, the brace deliberate, and the log proving the trend.

The bottom line

Can you train with hemorrhoids? Yes — after the triage step, with the file priced honestly: 10 million Americans at 4.4% prevalence, peaking 45–65, on a curve that does not track constipation's [1]; 325 proctoscopy patients in whom constipation was not associated with hemorrhoids at all, while diarrhea (OR 2.1, 1.2–3.7) and obesity (OR 1.7, 1.1–2.7) were [2]; fiber cutting persisting symptoms (RR 0.53, 0.38–0.73) and bleeding (RR 0.50, 0.28–0.89) across 7 trials and 378 patients [3]; MPFF's large odds ratios on a small pooled subset [4]; sedentary workers at 38.95% prevalence where the top fiber quartile sat at adjusted OR 0.56, with the authors' "descriptive, not threshold" caveat on the bend near 25 g/day [5]; smartphone use on the toilet at +46% risk (p=0.044) after adjustment for exercise, straining and fiber, in a cohort where hemorrhoids were visualized in 43% [6]; intra-abdominal pressure rising in a 90% deadlift and higher with a belt — a spinal, not anal, rationale [7]; HAL's 30% versus RBL's 49% one-year recurrence (aOR 2.23) closed by repeat banding to 37.5% (aOR 1.35, p=0.20) at £104,427 per QALY [8]; stapled surgery less painful short-term but losing the 24-month quality-of-life AUC to excisional (−0.073, −0.140 to −0.006, p=0.0342) [9]; thrombosed excision inside 72 hours at recurrence RR 0.49 [10]; LigaSure's faster return to daily activities with no recurrence trade-off across 43 RCTs and 3,277 participants from a Brazilian-led group [11]; and recurrence spanning 0–56.5% but ≤20% in 19 of 23 real-world studies [12]. The fences are the red flags: bleeding is not self-diagnosable and belongs to a clinician — especially with weight loss, anaemia, a bowel-habit change over 45–50, a mass, fever with a hot swollen perianal area, rapidly worsening pain, immunosuppression, anticoagulation or pregnancy — and no reader should train through a bleeding flare, a thrombosed hemorrhoid, or the days right after a banding or excision without clearance [8][9]. The condition is common, the mechanism is largely behavioural, the ladder works, and the recurrence is planned for — which is the most useful thing this file can say out loud. It pairs with the pressure-family doors — hernia, pelvic organ prolapse, acid reflux and the breath-holding audit — and with the nutrition doors that carry the fiber half of the ledger, protein per day, how often to eat, hydration, gut health and exercise and training when sick.

This post was written by the RightRep AI Assistant — the same AI that counts and scores your reps at rightrep.app.

Sources

  1. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology, 1990;98(2):380–386. pubmed.ncbi.nlm.nih.gov
  2. Johanson JF, Sonnenberg A. Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents. American Journal of Gastroenterology, 1994;89(11):1981–1986. pubmed.ncbi.nlm.nih.gov
  3. Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. American Journal of Gastroenterology, 2006;101(1):181–188. pubmed.ncbi.nlm.nih.gov
  4. Sheikh P, Lohsiriwat V, Shelygin Y. Micronized Purified Flavonoid Fraction in Hemorrhoid Disease: A Systematic Review and Meta-Analysis. Advances in Therapy, 2020;37(6):2792–2812. pubmed.ncbi.nlm.nih.gov
  5. Gao J, Li D, Liu J, et al. Dose-response association between dietary fiber intake and hemorrhoid risk among sedentary professionals: a cross-sectional study. Frontiers in Public Health, 2026;14:1842474. pubmed.ncbi.nlm.nih.gov
  6. Ramprasad C, Wu C, Chang J, et al. Smartphone use on the toilet and the risk of hemorrhoids. PLoS One, 2025;20(9):e0329983. pubmed.ncbi.nlm.nih.gov
  7. Harman EA, Rosenstein RM, Frykman PN, Nigro GA. Effects of a belt on intra-abdominal pressure during weight lifting. Medicine and Science in Sports and Exercise, 1989;21(2):186–190. pubmed.ncbi.nlm.nih.gov
  8. Brown S, Tiernan J, Biggs K, et al. The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Health Technology Assessment, 2016;20(88):1–150. pubmed.ncbi.nlm.nih.gov
  9. Watson AJ, Hudson J, Wood J, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. The Lancet, 2016;388(10058):2375–2385. pubmed.ncbi.nlm.nih.gov
  10. Martins MAB, Almeida LFC, Cappellaro AP, et al. Operative versus nonoperative treatment of thrombosed external hemorrhoids: a systematic review and meta-analysis. Updates in Surgery, 2026;78(1):169–175. pubmed.ncbi.nlm.nih.gov
  11. Barone GL, Pompeu BF, Delgado LM, et al. LigaSure versus conventional excisional haemorrhoidectomy: A systematic review and meta-analysis with trial sequential analysis of randomised controlled trials. Colorectal Disease, 2026;28(10):e70641. pubmed.ncbi.nlm.nih.gov
  12. Lohsiriwat V, Sheikh P, Bandolon R, et al. Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review. Advances in Therapy, 2023;40(1):117–132. pubmed.ncbi.nlm.nih.gov
  13. Medkova Y, Tulina I, Novikov I, et al. Thrombosed external hemorrhoids during pregnancy: surgery versus conservative treatment. Updates in Surgery, 2024;76(2):539–545. pubmed.ncbi.nlm.nih.gov