Hemorrhoids

What are hemorrhoids

Hemorrhoids also called piles, are swollen, inflamed veins around the anus and lower rectum 1). Hemorrhoids are either inside the anus or under the skin around the anus. Hemorrhoids have a number of causes, although often the cause is unknown. They often result from straining to have a bowel movement or from the increased pressure on these veins during pregnancy. Other factors include aging and chronic constipation or diarrhea. Hemorrhoids may be located inside the rectum (internal hemorrhoids), or they may develop under the skin around the anus (external hemorrhoids).

If you have a hemorrhoid, you may feel a tender lump on the edge of your anus. You may also see blood on the toilet paper or in the toilet after a bowel movement.

Hemorrhoids are very common in both men and women. Nearly half of Americans have hemorrhoids by age 50 2). Nearly 5% of the US population (15,000,000 people) has sought medical care for symptomatic hemorrhoids. Many more have problems with hemorrhoids, but never seek formal medical attention.

The most common symptom of hemorrhoids inside the anus is bright red blood covering the stool, on toilet paper or in the toilet bowl. Symptoms usually go away within a few days.

  • If you have rectal bleeding you should see a doctor.
  • You need to make sure bleeding is not from a more serious condition such as colorectal or anal cancer.

Sometimes hemorrhoids don’t cause symptoms but at other times hemorrhoids cause itching, discomfort and bleeding.

Occasionally, a clot may form in a hemorrhoid (thrombosed hemorrhoid). These are not dangerous but can be extremely painful and sometimes need to be lanced and drained.

Treatment may include warm baths and a cream or other medicine.

If you have large hemorrhoids, you may need surgery and other treatments.

Types of hemorrhoids

The type of hemorrhoid you have depends on where it occurs.

  • Internal hemorrhoids involve the veins inside your rectum. Internal hemorrhoids usually don’t hurt but they may bleed painlessly.
  • Prolapsed hemorrhoids may stretch down until they bulge outside your anus. A prolapsed hemorrhoid may go back inside your rectum on its own, or you can gently push it back inside.
  • External hemorrhoids involve the veins outside the anus. They can be itchy or painful and can sometimes crack and bleed.

Internal hemorrhoids

Painless rectal bleeding or prolapse of anal tissue is often associated with symptomatic internal hemorrhoids. Prolapse is hemorrhoidal tissue coming from the inside that can often be felt on the outside of the anus when wiping or having a bowel movement. This tissue often goes back inside spontaneously or can be pushed back internally by the patient. The symptoms tend to progress slowly over a long time and are often intermittent.

Internal hemorrhoids are classified by their degree of prolapse 3), which helps determine management:

  • Grade One: No prolapse
  • Grade Two: Prolapse that goes back in on its own
  • Grade Three: Prolapse that must be pushed back in by the patient
  • Grade Four: Prolapse that cannot be pushed back in by the patient (often very painful)

Bleeding attributed to internal hemorrhoids is usually bright red and can be quite brisk. It may be found on the wipe, dripping into the toilet bowl, or streaked on the bowel movement itself. Not all people with symptomatic internal hemorrhoids will have significant bleeding. Instead, prolapse may be the main or only symptom. Prolapsing tissue may result in significant irritation and itching around the anus. People with internal hemorrhoids may also complain of mucus discharge, difficulty with cleaning themselves after a bowel movement or a sense that their stool is “stuck” at the anus with bowel movements. People without significant symptoms from internal hemorrhoids do not require treatment based on their appearance alone.

Most patients with grade 1 or 2 hemorrhoids, and many with grade 3 hemorrhoids, can be treated in primary care offices. Patients in whom office-based treatment is ineffective (see below under Treatment) and those with mixed hemorrhoids may require treatment in surgical suites with facilities for anesthesia. The most common surgical treatments are ligation or tissue destruction, fixation techniques (i.e., hemorrhoidopexy – hemorrhoid stapling), and excision (i.e., hemorrhoidectomy).

External hemorrhoids

Symptomatic external hemorrhoids often present as a bluish-colored painful lump just outside the anus and they tend to occur spontaneously and may have been preceded by an unusual amount of straining. The skin overlying the outside of the anus is usually firmly attached to the underlying tissues. If a blood clot or thrombosis develops in this tightly held area, the pressure goes up rapidly in these tissues often causing pain. The pain is usually constant and can be severe. Occasionally the elevated pressure in the thrombosed external hemorrhoid results in breakdown of the overlying skin and the clotted blood begins leaking out. Patients may also complain of intermittent swelling, pressure and discomfort, related to external hemorrhoids which are not thrombosed.

Thrombosed external hemorrhoids

Thrombosed external hemorrhoids cause acute, severe pain. Without intervention, the pain typically improves over two to three days, with continued improvement as the thrombus gradually absorbs over several weeks. Analgesics and stool softeners may be beneficial. Topical therapy with nifedipine and lidocaine cream is more effective for pain relief than lidocaine (Xylocaine) alone 4).

In patients with severe pain from thrombosed hemorrhoids, excision or incision and evacuation of the thrombus within 72 hours of symptom onset provide more rapid pain relief than conservative treatment 5). Both procedures can be performed under local anesthesia, and the resulting wound can be left open or sutured 6).

Hemorrhoids in Pregnancy

Pregnancy predisposes women to symptomatic hemorrhoids that usually resolve after delivery. Surgical intervention is contraindicated because of the risk of inducing labor 7). Conservative treatment is recommended, with excision of thrombosed external hemorrhoids if necessary.

Anal skin tags

Patients often complain of painless, soft tissue felt on the outside of the anus. These can be the residual effect of a previous problem with an external hemorrhoid. The blood clot stretches out the overlying skin and remains stretched out after the blood clot is absorbed by the body, thereby leaving a skin tag. Other times, patients will have skin tags without an obvious preceding event. Skin tags will occasionally bother patients by interfering with their ability to clean the anus following a bowel movement, while others just don’t like the way they look. Usually, nothing is done to treat them beyond reassurance. However, surgical removal is occasionally considered.

Figure 1. Rectum

rectum

Figure 2. Rectum anatomy and Anus (anal canal)

anal canal

What do hemorrhoids look like

Hemorrhoids are swollen veins in your lower rectum. Internal hemorrhoids are usually painless, but tend to bleed. External hemorrhoids may cause pain.

Figure 3. Hemorrhoids 

hemorrhoids

Hemorrhoids symptoms

Signs and symptoms of hemorrhoids may include:

  • Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet
  • Itching or irritation in your anal region
  • Pain or discomfort
  • Swelling around your anus
  • A lump near your anus, which may be sensitive or painful (may be a thrombosed hemorrhoid)

Hemorrhoid symptoms usually depend on the location.

Internal hemorrhoids. These lie inside the rectum. You usually can’t see or feel these hemorrhoids, and they rarely cause discomfort. But straining or irritation when passing stool can damage a hemorrhoid’s surface and cause it to bleed. When they cause symptoms, the most common are painless rectal bleeding, which usually is seen as bright red blood on the toilet paper or in the toilet bowl. It is important to know that just a few drops of blood in toilet water can change the color of the water dramatically.

Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids. These are under the skin around your anus and cause no symptoms. When they cause symptoms, the most common are pain, itching, pressure and bleeding; they can often be felt as a bulge in the skin near the anal opening.

Thrombosed hemorrhoids. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus) that can result in severe pain, swelling, inflammation and a hard lump near your anus.
When to see a doctor

Bleeding during bowel movements is the most common sign of hemorrhoids. Your doctor can do a physical examination and perform other tests to confirm hemorrhoids and rule out more-serious conditions or diseases.

Also talk to your doctor if you know you have hemorrhoids and they cause pain, bleed frequently or excessively, or don’t improve with home remedies.

  • Don’t assume rectal bleeding is due to hemorrhoids, especially if you are over 40 years old.
  • Rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer.
  • If you have bleeding along with a marked change in bowel habits or if your stools change in color or consistency, consult your doctor.
  • These types of stools can signal more extensive bleeding elsewhere in your digestive tract.

Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness or faintness.

What causes hemorrhoids ?

Hemorrhoids are caused by increased pressure in the veins of your anus or rectum. One of the main causes is straining when you’re trying to have a bowel movement. This may happen if you’re constipated or if you have diarrhea. It may also happen if you sit on the toilet too long. Hemorrhoids can also be caused by obesity, heavy lifting or any other activity that caused you to strain.

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop from increased pressure in the lower rectum due to:

  • Straining during bowel movements
  • Sitting for long periods of time on the toilet
  • Chronic diarrhea or constipation
  • Obesity
  • Pregnancy
  • Anal intercourse
  • Low-fiber diet

Hemorrhoids are more likely with aging because the tissues that support the veins in your rectum and anus can weaken and stretch.

Who gets hemorrhoids ?

Just about everyone has hemorrhoids at some time. But some things may make you more likely to get them. People whose parents had hemorrhoids may be more likely to get them. Pregnant women often get hemorrhoids because of the strain from carrying the baby and from giving birth. Being very overweight or standing or lifting too much can make hemorrhoids worse.

Complications of hemorrhoids

Complications of hemorrhoids are very rare but include:

  • Anemia. Rarely, chronic blood loss from hemorrhoids may cause anemia, in which you don’t have enough healthy red blood cells to carry oxygen to your cells.
  • Strangulated hemorrhoid. If the blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be “strangulated,” another cause of extreme pain.

Prevention of hemorrhoids

The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
  • Consider fiber supplements. Most people don’t get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular. If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.
  • Don’t strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
  • Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
  • Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
  • Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.

Diagnosis of hemorrhoids

Your doctor may be able to see if you have external hemorrhoids simply by looking. Tests and procedures to diagnose internal hemorrhoids may include examination of your anal canal and rectum:

  • Digital examination. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as growths. The exam can suggest to your doctor whether further testing is needed.
  • Visual inspection. Because internal hemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope.

Your doctor may want to examine your entire colon using colonoscopy if:

  • Your signs and symptoms suggest you might have another digestive system disease
  • You have risk factors for colorectal cancer
  • You’re middle-aged and haven’t had a recent colonoscopy.

The American Society of Colon and Rectal Surgeons recommends taking the patient history and performing a physical examination with anoscopy and further endoscopic evaluation if there is concern for inflammatory bowel disease or cancer 8). A complete evaluation of the colon is warranted in the following groups 9):

  • Patients who are 50 years or older and have not had a complete examination of the colon within the past 10 years
  • Patients who are 40 years or older and have not had a complete examination of the colon within the past 10 years, and who have one first-degree relative in whom colorectal cancer or adenoma was diagnosed at age 60 years or younger
  • Patients who are 40 years or older and have not had a complete examination of the colon within the past five years, and who have more than one first-degree relative in whom colorectal cancer or adenoma was diagnosed at age 60 years or younger
  • Patients with iron deficiency anemia
  • Patients who have a positive fecal occult blood test.

Treatment of hemorrhoids

Home remedies

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

Eat high-fiber foods. Eat more fruits, vegetables and whole grains – it is usually recommended you eat 20-35 grams of fiber per day. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.

Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.

Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.

Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Avoid alcohol-based or perfumed wipes. Gently pat the area dry or use a hair dryer.

Don’t use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn’t contain perfume or alcohol.

Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.

Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don’t get relief in a week, or sooner if you have severe pain or bleeding.

Medications

If your hemorrhoids produce only mild discomfort, your doctor may suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel, or hydrocortisone and lidocaine, that can relieve pain and itching, at least temporarily.

Don’t use an over-the-counter steroid cream for more than a week unless directed by your doctor because it may cause your skin to thin.

External hemorrhoid thrombectomy

If a painful blood clot (thrombosis) has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision and drainage, which may provide prompt relief. This procedure is most effective if done within 72 hours of developing a clot.

Minimally invasive procedures

For persistent bleeding or painful hemorrhoids, your doctor may recommend one of the other minimally invasive procedures available. These treatments can be done in your doctor’s office or other outpatient setting and do not usually require anesthesia.

Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week, at which time you may notice a small amount of bleeding. This procedure is effective for many people.

Your doctor may place anywhere from one to three rubber bands per visit and this may require several short visits to achieve relief of your symptoms, but is not associated with any significant recovery time for most people. Rubber band can be associated with a dull ache or feeling of pressure lasting 1-3 days that is usually well-treated with Ibuprofen or Tylenol. Upon completion of your banding session(s), you likely will not need further treatment, provided you continue the previously described dietary and lifestyle changes. If your symptoms return, repeat banding certainly can be considered. Hemorrhoidectomy is always an option if significant progress is not made with banding. Complications are very uncommon, but may include bleeding, pain and infection, among others.

Figure 4. Hemorrhoids rubber band ligation

Hemorrhoids rubber band ligation

Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. Sclerotherapy is similarly quick, often painless, has few complications, and may take several short sessions to achieve relief of symptoms. This has the potential to be used in patients taking blood thinners such as Coumadin, Heparin, or Plavix, but would need to be discussed with your physician.

While the injection causes little or no pain, it may be less effective than rubber band ligation.

Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel. This procedure is usually quick, painless, has few complications, but may take several short sessions to achieve relief of symptoms.

While coagulation has few side effects and may cause little immediate discomfort, it’s associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Surgical procedures

If other procedures haven’t been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Your surgery may be done as an outpatient or may require an overnight hospital stay.

Hemorrhoid removal. In this procedure, called hemorrhoidectomy, your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic.

Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids. Complications may include temporary difficulty emptying your bladder and resulting urinary tract infections.

Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a warm bath also may help.

Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. It is typically used only for internal hemorrhoids.

Stapling generally involves less pain than hemorrhoidectomy and allows for earlier return to regular activities. Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Complications can also include bleeding, urinary retention and pain, as well as, rarely, a life-threatening blood infection (sepsis). Talk with your doctor about the best option for you.

Moving your bowels after hemorrhoid surgery is always a concern for patients. Most colon and rectal surgeons recommend having a bowel movement within the first 48 hours after surgery. You should already be taking a diet high in fiber, a fiber supplement, and increased liquid intake. If this does not produce a bowel movement, you may need to take laxatives to achieve this. Your doctor should make recommendations as to the best medications to use in this situation, given your particular medical issues. Expect to have some bleeding with bowel movements for several weeks after surgery. Call your surgeon if you are experiencing bleeding that doesn’t seem to stop after the bowel movement.

Table 1. Surgical Treatment by Hemorrhoid Type

Hemorrhoid type/gradeOffice-based proceduresHospital-based procedures

External (not graded)

In patients with severe symptoms, excision or incision under local anesthesia within 72 hours of onset; after 72 hours use medical treatment

Combined external and internal

Excisional hemorrhoidectomy

Internal grade 1

Rubber band ligation, infrared coagulation

Rubber band ligation; excisional hemorrhoidectomy if primary treatment is ineffective

Internal grade 2

Rubber band ligation, infrared coagulation

Rubber band ligation; stapled hemorrhoidopexy; excisional hemorrhoidectomy if primary treatment is ineffective

Internal grade 3

Rubber band ligation

Rubber band ligation; excisional hemorrhoidectomy; stapled hemorrhoidopexy

Internal grade 4

Excisional hemorrhoidectomy; stapled hemorrhoidopexy

[Source 10)]

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