Hemorrhoids, also spelled haemorrhoids, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term "hemorrhoid" is often used to mean the disease. The signs and symptoms of hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless, bright red rectal bleeding when defecating. External hemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs it is usually darker. Symptoms frequently get better after a few days. A skin tag may remain after the healing of an external hemorrhoid. While the exact cause of hemorrhoids remains unknown, a number of factors which increase pressure in the abdomen are believed to be involved. This may include constipation, diarrhea, and sitting on the toilet for a long time. Hemorrhoids are also more common during pregnancy. Diagnosis is made by looking at the area. Many people incorrectly refer to any symptom occurring around the anal area as "hemorrhoids" and serious causes of the symptoms should be ruled out. Colonoscopy or sigmoidoscopy is reasonable to confirm the diagnosis and rule out more serious causes. Often, no specific treatment is needed. Initial measures consists of increasing fiber intake, drinking fluids to maintain hydration, NSAIDs to help with pain, and rest. Medicated creams applied to the area are poorly supported by evidence. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Surgery is reserved for those who fail to improve following these measures. Half to two thirds of people have problems with hemorrhoids at some point in their lives. Males and females are affected about equally commonly. Hemorrhoids affect people most often between 45 and 65 years of age. It is more common among the wealthy. Outcomes are usually good. The first known mention of the disease is from a 1700 BC Egyptian papyrus.