Psychological burden of hemorrhoidal disease: Association with depression, anxiety, and quality of life impairment

Abstract

BACKGROUND

Hemorrhoidal disease (HD) is one of the most common benign anorectal conditions worldwide. It is typically diagnosed by physical symptoms such as pain, bleeding, pruritus, and discomfort; however, its psychological and psychosocial impact is not well understood. Chronic anorectal symptoms often cause psychological distress driven by pain-related anxiety, embarrassment, and social withdrawal. While psychological comorbidities are well-documented in other gastrointestinal conditions, there is limited evidence directly investigating the impact of depression, anxiety, and quality of life (QoL) in patients with HD.

AIM

To investigate the association between HD and depression, anxiety, and QoL.

METHODS

This cross-sectional case-control study included 74 patients with grade I-II HD and 74 age- and sex-matched healthy controls at Malatya Training and Research Hospital. Participants completed the Beck Depression Inventory, Beck Anxiety Inventory, and World Health Organization Quality of Life Instrument-Short Form questionnaire. Group comparisons were performed using parametric or non-parametric tests as appropriate. Spearman correlation and path analysis were used to evaluate the associations between HD and psychological outcomes.

RESULTS

Patients with HD demonstrated significantly higher depression (11.92 ± 10.48 vs 5.54 ± 4.16) and anxiety (11.76 ± 10.13 vs 6.77 ± 5.07) scores compared with healthy controls (P < 0.001 for both). QoL analysis revealed significantly lower scores in the general health, physical, and social domains (P < 0.05). No significant differences were observed in the psychological or environmental domains. Correlation analysis demonstrated that HD had a low-to-moderate positive correlation with anxiety and depression, while inversely correlating with specific aspects of QoL. Path analysis confirmed significant direct effects of HD on depression, anxiety, and several QoL domains.

CONCLUSION

HD is associated with increased depression and anxiety and reduced QoL, highlighting the importance of psychosocial assessment in clinical management.

Key Words: Hemorrhoidal disease; Depression; Anxiety; Quality of life; Psychosocial impact

Core Tip: Hemorrhoidal disease (HD) is commonly evaluated based on physical symptoms, whereas its psychological burden remains underrecognized. In this cross-sectional case-control study, patients with early-stage HD exhibited significantly higher depression and anxiety scores, assessed using the Beck Depression Inventory and Beck Anxiety Inventory, along with reduced quality of life as measured by the World Health Organization Quality of Life Instrument-Short Form, compared with healthy controls. Path analysis demonstrated significant associations between HD status and adverse psychosocial outcomes, supporting the integration of mental health screening into routine colorectal care.

INTRODUCTION

Hemorrhoidal disease (HD) is a widespread global condition known to significantly impair daily functioning, social interactions, and work productivity[1]. It represents one of the most common anorectal disorders, with population-based prevalence estimates ranging from 4% to 8%, and even higher rates reported in colonoscopy-based studies[2,3]. Although primarily defined by physical symptoms such as pain, bleeding, discharge, and pruritus, the psychological and psychosocial impact of this disease remains underrecognized.

Psychiatric symptoms and quality of life (QoL) are particularly relevant in chronic, stigmatized conditions[4]. Persistent hemorrhoidal symptoms can serve as persistent stressors, creating a psychological burden through various, interconnected pathways. Chronic pain and discomfort intensifies symptom awareness, creates fear of defecation, and promotes avoidance behaviors, thereby exacerbating anxiety and depressive symptoms. Furthermore, altered pain perception—characterized by increased pain sensitivity or reduced pain thresholds—may exacerbate physical symptom severity and amplify emotional distress. Shame, perceived social stigma, and the reluctance to discuss hemorrhoidal symptoms can hinder people from seeking help and foster social isolation, ultimately compromising psychological well-being[5,6].

While extensive literature establishes a strong association between gastrointestinal disorders and mental health issues like anxiety and depression, studies focusing specifically on HD remain limited[7]. Existing literature is frequently limited by small sample sizes and a lack of comprehensive psychosocial assessment, particularly within controlled comparative study designs. Furthermore, inflammatory mechanisms may contribute to this relationship, as inflammation-related pathways have been increasingly implicated in the pathophysiology of depression and may also play a role in the chronic inflammation observed in HD.

QoL is a multidimensional construct encompassing physical, psychological, social, and environmental well-being[8]. Given its chronic and distressing nature, HD severely impacts mental health and QoL. This negative impact is further amplified by accompanying anxiety and depression[9].

This study investigated the associations between HD and depression, anxiety, and QoL compared with healthy controls. By providing a comprehensive, multidimensional assessment of HD that includes psychological burden and QoL alongside clinical features, this study addresses an important gap in the literature and supports a more holistic approach to patient care.

MATERIALS AND METHODS

Study design and participants

This study utilized a cross-sectional case-control design. It comprised 74 patients diagnosed with grade I-II HD who were managed exclusively with medical treatment at the General Surgery Outpatient Clinic of Malatya Training and Research Hospital (Malatya, Turkey) between May and October 2025. Diagnosis was established clinically and confirmed by physical and/or proctologic examination. To minimize confounding factors from advanced anatomical severity and potential surgical needs, patients with grade III-IV HD were excluded, ensuring a more controlled assessment of psychosocial burden in early-stage disease.

Healthy controls consisted of 74 age- and sex-matched individuals with no prior history of HD. Controls were recruited from individuals presenting to the same hospital for routine health evaluations or acute, non-chronic conditions. To reduce confounding, individuals with known psychiatric conditions, chronic pain disorders, or other long-term illness that could affect psychological outcomes were excluded.

Eligible patients had hemorrhoidal symptoms starting within the last 90 days. This timeframe was selected to focus on the early (subacute) phase and its initial psychosocial impact, while limiting confounding factors from long-term disease progression or previous treatments.

The sample size of the study was calculated using a priori power analysis performed with G*Power software (version 3.1.9.4). The primary objective of the analysis was to compare Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and World Health Organization Quality of Life Instrument-Short Form (WHOQOL-BREF) scores between patients with HD and healthy controls, with sample size calculation based on the independent samples t-test.

According to Cohen’s (1988) effect size classification, d = 0.20 represents a small effect size, d = 0.50 a medium effect size, and d = 0.80 a large effect size. To ensure adequate statistical power to detect meaningful differences between groups, a medium effect size (Cohen’s d = 0.50) was assumed[10]. The power analysis was conducted using a two-tailed significance level of α = 0.05, a group allocation ratio (n₂/n₁) of 1, and a statistical power of 85.5% (1 - β = 0.855). Based on these parameters, a minimum required sample size of 74 participants per group was calculated, resulting in a total of 148 after applying exclusion criteria.

Patients diagnosed with HD by a general surgeon were referred for psychiatric evaluation, which was conducted by the study psychiatrist. Self-report measures were administered under psychiatric supervision. Psychiatric exclusions were assessed and determined by the psychiatrist.

Patients and controls were matched by age category and sex at the group level, rather than one-to-one individual pairing.

Inclusion criteria were age ≥ 18 years, provision of informed consent, cognitive capacity to complete the questionnaires, and a clinical diagnosis of grade I-II HD with symptom onset within the preceding 90 days. Exclusion criteria comprised a history of severe psychiatric disorders (including psychotic disorders, bipolar disorder, and major neurocognitive disorders), active malignancy, chronic inflammatory bowel disease, acute infectious conditions, and prior anorectal surgery.

Measurement tools

Participants completed several instruments to collect sociodemographic and psychological data. A custom sociodemographic information form was utilized to record variables such as age, sex, educational status, marital status, chronic disease, and medication use. Depressive symptoms were assessed using the BDI, a widely used 21-item self-report questionnaire that assesses the presence and intensity of depressive symptoms. The Turkish validity and reliability of the BDI were established by Hisli[11]. Anxiety levels were evaluated with the BAI, which also consists of 21 self-report items designed to measure the severity of anxiety symptoms; its Turkish validity and reliability of the BAI were established by Ulusoy et al[12]. QoL was assessed using the WHOQOL-BREF, a 26-item instrument that evaluates QoL across four domains: Physical health, psychological health, social relationships, and environmental conditions.

Data collection process

Written informed consent was obtained from all participants who agreed to take part in the study. The questionnaires were administered by the researchers through face-to-face interviews. All collected data were anonymized and used solely for scientific purposes.

Statistical analysis

Data analyses were performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, United States) and AMOS software (version 24.0; Swiss AviationSoftware, Allschwil, Switzerland). Descriptive statistics included frequency, percentage, mean, standard deviation, median, minimum, and maximum values. For between-group comparisons, the normality of continuous variables was assessed using skewness and kurtosis values. Only BAI scores did not conform to normal distribution. A reference range of ± 1.96 was accepted for skewness and kurtosis. Independent samples t-test was used for normally distributed variables, whereas the Mann-Whitney U test was applied to variables that did not meet normality assumptions. The χ² test was employed for categorical data comparisons.

To examine the relationships between HD status and BDI, BAI, and WHOQOL-BREF QoL scores, Spearman correlation analysis was conducted. Correlation coefficients were categorized as low (0.00-0.30), moderate (0.30-0.70), or high (0.70-1.00).

In addition, path analysis was performed to evaluate the direct effects of the independent variable (presence of HD) on the dependent variables, namely, depression, anxiety, and QoL domains.

For clinical interpretation, the BAI scores were characterized as follows: 0-7 (minimal or no anxiety), 8-15 (mild), 16-25 (moderate), and 26-63 (severe). These established cut-off values were applied to assess the severity of depressive symptoms. WHOQOL-BREF domain scores were interpreted independently, with higher scores indicating better QoL in the respective domains, thereby allowing assessment of clinical relevance alongside statistical significance. P < 0.05 was considered statistically significant.

RESULTS

Baseline characteristics of the study population

The age distribution was similar between the groups. In the control group, 35% of participants were aged 18-29 years, 43% were aged 30-44 years, and 22% were ≥ 45 years; whereas in the HD group, these proportions were 31%, 38%, and 31%, respectively. The mean age was 36 ± 11 (median: 35; range: 19-63) years in the control group and 39 ± 13 (median: 36; range: 19-68) years in the HD group, with no statistically significant difference between the groups.

Regarding sex distribution, 54.1% of the control group were female and 45.9% were male, compared with 44.6% female and 55.4% male in the HD group; this difference was not statistically significant (P > 0.05). Similarly, no significant differences were observed between the two groups regarding chronic disease status, medication use, history of psychiatric illness, or current psychiatric treatment (P > 0.05; Table 1).

Table 1 Comparison of descriptive characteristics between patients and controls.

Descriptive characteristics		Patients (HD) (n = 74)		Controls (n = 74)		P value
		n	%	n	%
Age (year)	mean ± SD	39 ± 13		36 ± 11
	Median (range)	36 (19-68)		35 (19-63)
	18-29	23	31	26	35	0.43
	30-44	28	38	32	43
	≥ 45	23	31	16	22
Sex	Female	33	45	40	54	0.32
	Male	41	55	34	46
Presence of chronic disease	Yes	21	28	15	20	0.34
	No	53	72	59	80
Medication use	Yes	17	23	19	26	0.85
	No	57	77	55	74
History of mental illness	Yes	4	5	3	4	1
	No	70	95	71	96
Receiving psychiatric treatment	Yes	2	3	3	4	1
	No	72	97	71	96

P values were calculated using the χ² test or Fisher’s exact test for categorical variables and the independent samples t-test for continuous variables. HD: Hemorrhoidal disease.

Comparison of depression and anxiety scores between groups

Mean BDI and BAI scores were significantly higher in the HD group (11.92 ± 10.48 and 11.76 ± 10.13, respectively) compared with the control group (5.54 ± 4.16 and 6.77 ± 5.07, respectively), indicating a greater burden of depressive and anxiety symptoms (P < 0.001; Table 2).

Table 2 Comparison of Beck Anxiety Inventory, Beck Depression Inventory, World Health Organization Quality of Life Instrument-Short Form domains and the general health facet between the patient and controls.

Scale and domain	Patients (HD; n = 74)		Controls (n = 74)		P value
	mean ± SD	Median (range)	mean ± SD	Median (range)
BDI1	11.92 ± 10.48	9 (0-45)	5.54 ± 4.16	5 (0-17)	< 0.001
BAI2	11.76 ± 10.13	9.5 (0-51)	6.77 ± 5.07	6 (0-22)	< 0.001
General health (facet)1	6.20 ± 1.51	6 (2-9)	6.81 ± 1.36	7 (2-10)	< 0.01
Physical health (domain)1	23.92 ± 4.39	25 (14-33)	25.88 ± 3.98	26 (19-34)	< 0.001
Psychological (domain)1	21.27 ± 4.5	21 (11-32)	21.74 ± 3.66	22 (11-30)	0.484
Social relationships (domain)1	10.11 ± 2.32	10 (5-15)	10.96 ± 2.33	11 (5-15)	< 0.01
Environment (domain)1	27.78 ± 4.67	27.5 (18-37)	28.54 ± 5.03	29 (13-38)	0.345

¹Independent samples t-test.

²Mann-Whitney U test.

HD: Hemorrhoidal disease; BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory.

QoL assessment revealed that the general health facet and physical health and social relationships domains were significantly lower in the HD group (P < 0.05), whereas no significant differences were observed in the psychological and environmental domains (P > 0.05; Table 2).

Correlation analysis

Spearman correlation analysis demonstrated low-to-moderate positive associations between HD status and BDI (ρ = 0.311, P < 0.001) and BAI (ρ = 0.250, P = 0.002) scores. Across QoL domains, overall negative correlations were observed. Specifically, significant low-level negative correlations were identified for general health (ρ = -0.197, P = 0.017), physical health (ρ = -0.215, P = 0.009), and social relationships (ρ = -0.203, P = 0.013), whereas no significant associations were found for the psychological and environmental domains (Table 3).

Table 3 Spearman’s ρ correlation between hemorrhoidal disease and Beck Anxiety Inventory, Beck Depression Inventory, and World Health Organization Quality of Life Instrument-Short Form.

Variable	Spearman correlation coefficient (ρ)	P value
BDI	0.311	< 0.001
BAI	0.250	0.002
General health	-0.197	0.017
Physical health	-0.215	0.009
Psychological	-0.073	0.379
Social relationships	-0.203	0.013
Environment	-0.101	0.220

Control group coded as 0 and hemorrhoidal disease group coded as 1. BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory.

Path analysis

In this study, BDI, BAI, and WHOQOL-BREF QoL domains (general health, physical health, psychological, social relationships, and environmental) were considered dependent variables, whereas the presence of HD was treated as the independent variable.

Path analysis indicated that HD status had a significant positive effect on BDI scores (β = 0.37, R² = 0.140, P < 0.05), accounting for 14% of the variance in depressive symptoms. Similarly, a positive and significant effect was observed on BAI scores (β = 0.30, R² = 0.089, P < 0.05).

Regarding QoL domains, HD exerted significant negative effects on physical health (β = -0.23, R² = 0.053, P < 0.05), general health (β = -0.21, R² = 0.043, P < 0.05), and social relationships (β = -0.18, R² = 0.033, P < 0.05). Conversely, no significant associations were observed for the psychological (β = -0.06, R² = 0.003, P > 0.05) and environmental (β = -0.08, R² = 0.006, P > 0.05) domains.

These findings suggest that HD is associated with significantly higher depression and anxiety scores and reduced QoL in several domains (Table 4 and Figure 1).

Figure 1 Path analysis model illustrating the relationships between hemorrhoidal disease and psychological outcomes. The model demonstrates the direct effects of hemorrhoidal disease on depression and anxiety scores, as well as on quality-of-life domains measured by the World Health Organization Quality of Life Instrument-Short Form questionnaire. Standardized path coefficients are shown on the arrows.

Table 4 Path analysis results for the effects of hemorrhoidal disease on depression, anxiety, and World Health Organization Quality of Life Instrument-Short Form domains.

Dependent variable	Path	Independent variable	Β	SE	β	P value	R2
Beck depression	<---	Presence of HD	6.38	1.31	0.37	< 0.01	0.140
Beck anxiety	<---	Presence of HD	4.99	1.31	0.30	< 0.01	0.089
Psychological	<---	Presence of HD	-0.47	0.67	-0.06	0.481	0.003
Physical health	<---	Presence of HD	-1.96	0.69	-0.23	< 0.01	0.053
General health	<---	Presence of HD	-0.61	0.24	-0.21	< 0.01	0.043
Social relationships	<---	Presence of HD	-0.85	0.38	-0.18	< 0.05	0.033
Environment	<---	Presence of HD	-0.76	0.80	-0.08	0.342	0.006

B: Unstandardized path coefficient; β: Standardized path coefficient. Explained variance in the dependent factors: R². HD: Hemorrhoidal disease.

DISCUSSION

This study represents one of the limited investigations between HD and depression, anxiety, and QoL. Our findings demonstrated that patients with HD exhibited significantly higher BDI and BAI scores, along with markedly reduced QoL scores—particularly in physical health, general health, and social relationships—compared to healthy controls[13]. Collectively, these findings show that HD imposes a considerable burden is not limited to physical morbidity, but encompasses significant psychosocial, emotional, and social consequences[14]. These observations are well aligned with the existing literature in similar patient populations. Emerging evidence suggests that HD is associated with elevated rates of depression and anxiety, with large population-based cohort studies demonstrating an increased subsequent risk of depressive disorders[15]. In parallel, recent work on anal incontinence in a Norwegian cohort showed that fecal incontinence is strongly associated with impaired QoL, contributing to social withdrawal, embarrassment, and emotional distress[16]. The elevated depression and anxiety scores observed in our study reinforce these associations and emphasize the psychosocial burden linked to HD. Although participants were not evaluated using standardized psychiatric diagnostic systems due to the study design, elevated depression, and anxiety scale scores suggest that individuals with HD are at increased risk for these mood disorders.

From a psychosomatic perspective, increased psychological distress may accelerate the progression of HD by promoting autonomic dysregulation, increasing pain sensitivity, and triggering inflammatory processes. Central sensitization and dysfunctional pain modulation have been implicated in chronic pain states and are strongly associated with anxiety and depression symptoms, reflecting shared neurobiological pathways[17,18]. Psychological distress has also been linked to altered autonomic nervous system activity, including reduced heart rate variability and exaggerated stress responses, which may contribute to symptom perception and coping processes in patients with chronic somatic conditions[19]. Furthermore, it is increasingly recognized that low-grade systemic inflammation and elevated pro-inflammatory cytokines contribute to anxiety and depression, potentially driving the persistence of somatic symptoms through neuroimmune interactions[20]. While definitive causal inferences cannot be drawn from the present cross-sectional design, these biological and psychosocial interactions underscore the importance of considering psychological factors in the clinical assessment and management of HD. Future longitudinal studies with structured psychiatric evaluations are warranted to clarify the nature and clinical relevance of this relationship.

Beyond these biological and neurophysiological mechanisms, research indicates that chronic hemorrhoids impose a psychological burden, resulting from persistent stress responses, sleep disruption, and reduced social interactions. Chronic pain and discomfort have been linked to alterations in emotional regulation and stress-related neurobiological pathways, thereby increasing vulnerability to anxiety and depressive symptoms[21,22]. Inflammation-related pathways and cytokine-mediated immune responses have also been implicated in the pathophysiology of depression and may be relevant in chronic inflammatory processes associated with HD. These mechanisms, observed in patients with gastrointestinal and anorectal disorders, provide a plausible framework for interpreting the present findings[23].

In this study, depression and anxiety were accompanied by significantly lower QoL scores in individuals with HD compared with controls. The observed decline in physical health, general health, and social relationships indicates that the disease impacts not only physical well-being but also social participation and subjective health perceptions. Supporting this view, studies on patients with chronic anal fissure show that lateral internal sphincterotomy significantly improves QoL, indicating that resolving anorectal symptoms can effectively restore overall well-being[24]. In our cohort, overall QoL—which reflects physical, psychological, social, and spiritual well-being—was lower in patients with HD compared with the control group. This decline appears linked to both the inherent clinical burden of HD and high levels of anxiety and depression.

Furthermore, the persistent elevation of anxiety and depression scores in the HD group suggests a significant additional psychological burden[25]. Although our path analysis supports significant associations between HD status and psychological outcomes, it does not establish a causal relationship. Therefore, future longitudinal studies with comprehensive psychosocial assessments are needed to clarify these relationships and better understand the bidirectional interactions between psychological distress and HD.

The clinical implications of these findings are noteworthy. Although surgical and medical treatment remain the primary focus in the management of HD, psychosocial aspects are often underestimated and insufficiently integrated into routine clinical care. Accordingly, management strategies should not be limited to surgical and medical approaches but should also incorporate systematic assessment of patients’ mental health and QoL. Integrating psychological support services, and when indicated, psychiatric consultation into patient management may enhance treatment outcomes and patient satisfaction[26,27]. Brief, validated mental health tools are feasible for routine outpatient colorectal consultations, allowing for screening without substantially extending visit duration. Early identification of psychological distress enables timely referral and multidisciplinary management, promoting a more holistic approach to patient care.

A key limitation of this study is its exclusive focus on HD, which restricts the generalizability of our findings to other anorectal disorders—such as anal fissures or anal fistulas—that may present with distinct symptom burdens, chronicity, and psychosocial impacts. Future studies, including comparative analyses across different anorectal disease subtypes, may provide a broader understanding of the psychosocial burden associated with these conditions. Another limitation relates to the restriction of symptom duration. Limiting symptom duration to the past 90 days, while increasing sample homogeneity and capturing subacute impacts, may fail to fully capture the cumulative psychosocial burden experienced by individuals with chronic or recurrent HD. Finally, participant recruitment from a single General Surgery Outpatient Clinic may have introduced selection bias. While the Turkish healthcare system allows direct access to specialists, potentially facilitating a diverse range of disease severity, the single-center design may limit the generalizability of these findings. Therefore, caution is needed when applying these results to the broader population of patients with HD. Relying on self-report scales may introduce reporting bias and cannot substitute for structured diagnostic interviews.

Finally, as direct research on the link between HD and psychological status remains limited, this study offers valuable evidence to this emerging area. By simultaneously assessing depression, anxiety, and multiple domains of QoL, and utilizing path analysis to map out these relationships, we provide a deeper understanding of these crucial connections. One of the major strengths of this study is its use of a matched case-control design to integrate validated psychiatric measures with QoL assessments for a comprehensive evaluation of psychological burden.

CONCLUSION

This study demonstrates that HD imposes a significant psychosocial burden beyond its physical manifestations, correlating with higher rates of depression, anxiety and decreased QoL. Notably, these associations persist in patients with early-stage disease under medical care, highlighting the broader impact of the condition. While the cross-sectional design prevents establishing causality, these findings underscore the need for a comprehensive, biopsychosocial approach to evaluate and treat individuals with HD. Cultural differences in the perception of hemorrhoidal symptoms and psychological distress should be considered when generalizing these results to other populations.