What Are Hemorrhoids?
Hemorrhoids are clumps of blood vessels (veins) in the rectum. The hemorrhoidal veins are located in the lowest area of the rectum just above the anus. Sometimes they swell when the veins enlarge and their walls become stretched, thin, and irritated by passing stool. Hemorrhoids are classified into two general categories, 1) internal, and 2) external.
Internal hemorrhoids are located higher in the inside lining of the rectum and cannot be felt unless they are substantially enlarged. They usually are painless and make their presence known by causing bleeding with a bowel movement. Sometimes internal hemorrhoids prolapse or protrude outside the anus. If so, you may be able to see or feel them as moist pads of skin that are pinker than the surrounding area. Prolapsed hemorrhoids may hurt because the anus is dense with pain-sensing nerves. Prolapsed hemorrhoids usually recede into the rectum on their own; if they don't, they can be gently pushed back into place.
External hemorrhoids are located underneath the skin that surrounds the anus (lower than internal hemorrhoids). They can be felt when they swell, and may cause itching, pain, or bleeding with a bowel movement. If an external hemorrhoid prolapses to the outside (usually in the course of passing a stool), you can see and feel it. Blood clots sometimes form within prolapsed external hemorrhoids, which can cause an extremely painful condition called a thrombosis. If an external hemorrhoid becomes thrombosed, it can look rather frightening, turning purple or blue, and could possibly bleed. Despite their appearance, thrombosed hemorrhoids usually are not serious though they can be very painful. They will resolve on their own in a couple of weeks. If the pain is unbearable, your doctor can remove the blood clot from the thrombosed hemorrhoid, which stops the pain.
Everyone Has Hemorrhoids
Although most people think hemorrhoids are abnormal, they are present in everyone. It is only when the hemorrhoidal clumps enlarge that hemorrhoids can cause problems and be considered abnormal or a disease.
Although hemorrhoids occur in everyone, they can become large and cause serious problems in about 4% of the general population. Hemorrhoids that cause problems are found equally in men and women, and their prevalence peaks between 45 and 65 years of age.
What Causes Hemorrhoids?
Researchers are not certain what causes hemorrhoids. It's likely that extreme abdominal pressure causes the veins to swell by blocking the flow of blood through them. They then become susceptible to irritation. The increased pressure can be caused by obesity, pregnancy, standing or sitting for long periods, straining on the toilet, coughing, sneezing, vomiting, and holding your breath while straining to do physical labor.
Hemorrhoids and Diet
Diet is believed to have a pivotal role in causing -- and preventing -- hemorrhoids. People who consistently eat a high-fiber diet are less likely to get hemorrhoids, while those people who prefer a diet high in processed foods are at higher risk. A low-fiber diet can cause constipation, which can contribute to hemorrhoids in two ways:
- it promotes straining on the toilet; and
- it also aggravates the hemorrhoids by producing hard stools that further irritate the swollen veins.
What Are the Symptoms of Hemorrhoids?
The most common symptom and sign from hemorrhoids is painless bleeding. There may be bright red blood on the outside of the stools, on the toilet paper, or dripping into the toilet. The bleeding usually is self-limiting. Bleeding with a bowel movement is never normal and should prompt a visit to a health care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons to have bleeding including inflammatory bowel disease, infection, and tumors.
Symptoms of internal and external hemorrhoids are described on the following slides.
Stages of Hemorrhoids
For convenience in describing the severity of internal hemorrhoids, many physicians use a grading system:
- First-degree hemorrhoids: Hemorrhoids that bleed, but do not prolapse.
- Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or without bleeding).
- Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back in by a finger.
- Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in the anal canal. Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the lining of the rectum through the anus.
Symptoms of Prolapsed Internal Hemorrhoids
Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell and extend from their location in the rectum through the anus. In the anal canal, the hemorrhoid is exposed to the trauma of passing stool, particularly hard stools associated with constipation. The trauma can cause bleeding and sometimes pain when stool passes. The presence of stool, inflammation, and constant moisture can lead to anal itchiness (pruritus ani), and occasionally the constant feeling of needing to have a bowel movement. The prolapsing hemorrhoid usually returns into the anal canal or rectum on its own or can be pushed back inside with a finger, but it prolapses again with the next bowel movement.
Symptoms of Thrombosed External Hemorrhoids
External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids. External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as thrombosis. Thrombosis of an external hemorrhoid causes an anal lump that is very painful and tender, and often requires medical attention. The thrombosed hemorrhoid may heal with scarring, and leave a tag of skin protruding in the anus. Occasionally, the tag is large, which can make anal hygiene (cleaning) difficult or irritate the anus.
How Are Hemorrhoids Diagnosed?
Most individuals who have hemorrhoids discover them by either feeling the lump of an external hemorrhoid when they wipe themselves after a bowel movement, note drops of blood in the toilet bowl or on the toilet paper, or feel a prolapsing hemorrhoid (protruding from the anus) after bowel movements. By the history of symptoms, the physician can be diagnosed on the basis of a careful examination of the anus and anal canal. Although the physician should try his or her best to identify the hemorrhoids, it is perhaps more important to exclude other causes of hemorrhoid-like symptoms that require different treatment such as anal fissures, fistulae, perianal (around the anus) skin diseases, infections, and tumors.
Internal Hemorrhoid Diagnosis
The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, the rectal examination is more helpful in excluding rare cancers that begin in the anal canal and adjacent rectum. A more thorough examination for internal hemorrhoids is done visually using an anoscope. Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude other important causes of bleeding other than hemorrhoids such as colon cancer, polyps, and colitis.
External Hemorrhoid Diagnosis
External hemorrhoids appear as a bump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Any lump needs to be carefully followed, however, and should not be assumed to be a hemorrhoid since there are rare cancers of the anal area that may masquerade as external hemorrhoids.
What Is the Treatment for Hemorrhoids?
Hemorrhoids are treated with a variety of measures including, diet, over-the-counter medicine (creams, lotions, gels, pads, wipes, etc.), procedures (sclerotherapy, rubber band ligation, etc.), and surgery.
Hemorrhoid Treatment - Diet
It is recommended that individuals with hemorrhoids soften their stools by increasing the fiber in their diets. Fiber is found in numerous foods including fresh and dried fruits, vegetables, grains, and cereals. Generally, 20 to 30 grams of fiber per day is recommended, whereas the average American diet contains less than 15 grams of fiber. Supplemental fiber (psyllium, methylcellulose, or calcium polycarbophil) also may be used to increase the intake of fiber. Stool softeners and increased drinking of liquids also may be recommended. Nevertheless, there is no strong, scientific support for the benefits of fiber, liquids, or stool softeners.
Hemorrhoid Treatment – Over-the-Counter Medications
Products used for the treatment of hemorrhoids are available as ointments, creams, gels, suppositories, foams, and pads. Ointments, creams, and gels - when used around the anus - should be applied as a thin covering. When applied to the anal canal, these products should be inserted with a finger or a "pile pipe." Pile pipes are most efficient when they have holes on the sides as well as at the end. Pile pipes should be lubricated with ointment prior to insertion. Suppositories or foams do not have advantages over ointments, creams, and gels.
Hemorrhoid Treatment – Warm Sitz Baths
Sitting in a few inches of warm water three times a day for 15 to 20 minutes (sitz bath) may help decrease the inflammation of the hemorrhoids. It is important to dry off the anal area completely after each sitz bath to minimize moisture that irritates the skin surrounding the anus.
Hemorrhoid Treatment – Stool Softeners
Stool softeners may help, but once hemorrhoids are present, even liquid stools may cause inflammation and infection of the anus. Your health care professional and pharmacist are good resources for discussing their use..
Hemorrhoid Treatment – Sclerotherapy
Sclerotherapy is one of the oldest forms of treatment for hemorrhoids. During sclerotherapy, a liquid (phenol or quinine urea) is injected into the base of the hemorrhoid. The veins thrombose, inflammation sets in, and ultimately scarring takes place. Pain may occur after sclerotherapy, but usually subsides by the following day. Symptoms of hemorrhoids frequently return after several years and may require further treatment.
Hemorrhoid Treatment – Rubber Band Ligation
The principle of ligation with rubber bands is to encircle the base of the hemorrhoidal clump with a tight rubber band. The tissue cut off by the rubber band dies, and is replaced by an ulcer that heals with scarring. It can be used with first-, second-, and third-degree hemorrhoids, and may be more effective than sclerotherapy. Symptoms frequently recur several years later, but usually can be treated with further ligation. The most common complication of ligation is pain. However, bleeding one or two weeks after ligation or bacterial infection in the tissues surrounding the hemorrhoids (cellulitis) may occur.
Hemorrhoid Treatment – Heat Coagulation
There are several treatments that use heat to destroy hemorrhoidal tissue, and promote inflammation and scarring, including bipolar diathermy, direct-current electrotherapy, and infrared photocoagulation. Such procedures destroy the tissues in and around the hemorrhoids and cause scar tissue to form. They are used with first-, second-, and third-degree hemorrhoids. Pain is frequent, though probably less frequent than with ligation and bleeding occasionally occurs.
Hemorrhoid Treatment – Surgery
The vast majority of patients with symptom-causing hemorrhoids are able to be managed with non-surgical techniques. Non-operative treatment is preferred because it is associated with less pain and fewer complications than operative treatment. It is estimated that less than 10% of patients require surgery if the hemorrhoids are treated early.
Surgical removal of hemorrhoids, known as a hemorrhoidectomy or stapled hemorrhoidectomy, is reserved for patients with third- or fourth-degree hemorrhoids.
During a hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are cut out. The wounds left by the removal may be sutured (stitched) together (closed technique) or left open (open technique). The results with both techniques are similar. A proctoplasty, which extends the removal of tissue higher into the anal canal so that redundant or prolapsing anal lining also is removed, is sometimes performed in addition. Postsurgical pain is a major problem with hemorrhoidectomy, and potent pain medications (narcotics) usually are required.
A newer surgical technique is rapidly becoming the treatment of choice for third-degree hemorrhoids. This surgery does not remove the hemorrhoids but, rather, the expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward. In this procedure, a circular, hollow tube is inserted into the anal canal and a suture (a long thread) is placed through it and woven circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler is placed through the hollow tube and the ends of the suture are pulled expanding the hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler is then fired, cutting off the circumferential ring of expanded hemorrhoidal supporting tissue trapped within the stapler. At the same time staples bring together the upper and lower edges of the cut tissue. Stapled hemorrhoidectomy is less painful and faster than a traditional hemorrhoidectomy, taking approximately 30 minutes.
The best way to prevent hemorrhoids is to keep your stools soft so they are easy to pass and don't require straining. Eating a high-fiber diet and drinking plenty of fluids (six to eight glasses each day) can help you stay regular and your stools soft, and may reduce constipation and the need to strain on the toilet, lowering your risk of developing new hemorrhoids.
More Reading on Hemorrhoids
Reviewed by Avrom Simon, MD on Tuesday, June 21, 2016
Slideshow: Hemorrhoids Causes, Symptoms & Treatment
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