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Hemorrhoids
What are hemorrhoids?
Hemorrhoids are a condition that develops when veins in or around your anus become inflamed and swollen, usually due to straining during bowel movements or the pressure of blood collecting in them for other reasons. Another common name for them is piles.
Although it's estimated that approximately half of all people develop hemorrhoids by the age of 50, they usually represent more of a discomfort than a danger. You could have them without experiencing any symptoms whatever. For many of us, hemorrhoids are more a problem of occasional-to-chronic, minor-to-moderate pain, itching, irritation and bleeding.
Hemorrhoids can either be internal (inside the anus) or external (under the skin around the anus). In rare cases, a large internal hemorrhoid will protrude through the anus, become squeezed by the anal muscles and become strangulated — that is, have its blood supply cut off. In addition to being extremely painful, this is a dangerous situation and the presence of severe pain should spur you to seek immediate treatment.
In most cases, however, you are more likely to want to have your hemorrhoids treated — medically or surgically — in order to eliminate the less-serious but generally annoying pain, itching and irritation of having them.
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What causes hemorrhoids?
Hemorrhoids develop when pressure in your lower rectum and anus causes blood to pool in the veins in the area and make them become enlarged. As this process causes surrounding tissue to be stretched, it irritates nerves, producing pain, itching and bleeding.
The most common cause of all this is straining during bowel movements due to either frequent constipation or diarrhea, but being excessively overweight, sitting or standing for long periods of time, lifting heavy objects and engaging in anal intercourse can all also create pressure on the veins.
If you're pregnant, you also have a good chance of developing hemorrhoids from about the fourth month on. This can be due both to hormonal changes that increase blood flow in your pelvic area during your pregnancy and to the increased pressure your blood vessels experience as the fetus develops. In addition, the pressures involved in childbirth itself can cause hemorrhoids. Fortunately, for most women, hemorrhoids developed during pregnancy are only temporary.
Underlying these bio-mechanical causes is the diet factor. A major issue in the straining that produces hemorrhoids is the low-fiber diet of refined grains and sugars common in our society. The small, hard stools of a low fiber diet are difficult to pass, and contribute to the pressure that results in hemorrhoid development. One of the principal steps to prevent hemorrhoids is a diet high in fiber.
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What are the symptoms of hemorrhoids?
Internal hemorrhoids
An internal hemorrhoid is one that has developed in the wall of the anal canal itself. Usually, you don't feel any discomfort from small internal hemorrhoids, and the most noticeable symptom is likely to be blood on the toilet paper or in the toilet bowl, or on the stool itself following a bowel movement.
Large internal hemorrhoids can cause itching in the area of the anus due to mucus they secrete that causes irritation. You may feel a continued urge to defecate following a bowel movement due to the pressure of the hemorrhoid on the anal canal. In some cases, straining can cause larger internal hemorrhoids to protrude through the anal opening, resulting in itching, bleeding or dull pain. It may be necessary to push the hemorrhoid back into the anus, and in some cases it may protrude permanently.
In rare cases, a large internal hemorrhoid that is protruding through the anus will be squeezed by the anal muscles and become strangulated — that is, have its blood supply cut off. In addition to being extremely painful, this is a dangerous situation that requires immediate treatment.
External hemorrhoids
External hemorrhoids form in the skin tissue surrounding the anal opening. As a rule, their symptoms tend to be itching, burning, irritation and bleeding more than pain. Excessive straining, scratching, rubbing or attempts at cleaning this area can actually stimulate these symptoms to continue.
In a small percentage of cases, blood from an external hemorrhoid may pool under the skin to form a clot. The hard lump, called a thrombosis or clotted hemorrhoid, can be quite painful, and may require a doctor's attention.
A note about symptoms
Many of the symptoms of hemorrhoids are also potential signs of other, sometimes serious disorders, including colorectal cancer and diverticulitis. If you experience symptoms such as rectal bleeding not associated with bowel movements, or black or dark red stools, you should consult your doctor sooner rather than later.
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What are the tests for hemorrhoids?
Your doctor can determine if you have external hemorrhoids simply by a visual examination of the anal area. For internal hemorrhoids, he or she may do a digital rectal examination to feel for them with a gloved finger, although the softness of hemorrhoidal tissue can make them difficult to detect in this manner.
He or she is likely to decide to examine your anal canal and rectum with an anoscope, a hollow lighted tube. If the symptoms warrant ruling out other factors higher up in the large intestine, you could be referred for a sigmoidoscopy or a colonoscopy, tests with flexible fiber-optic instruments.
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What can be done to diminish the symptoms of hemorrhoids?
There are a number of things that can be done to shrink hemorrhoids and reduce their symptoms, but eliminating them permanently and altogether will require surgery or more likely what are called fixative treatments by a surgeon.
Measures you can take to relieve your symptoms include sitz baths — tub baths with several inches of warm water — for about 10 minutes at a time several times a day, and using over-the-counter corticosteroidal ointments, pads or suppositories.
Equally as important is changing your dietary and toilet habits to minimize the pressures that cause hemorrhoids to develop and grow. Drinking plenty of water and other fluids and adding fiber to your diet will help create larger, softer stools that will pass more easily and eliminate problems of constipation.
If you find it difficult to consume the daily 25 to 30 grams of soluble and insoluble fiber that doctors recommend, you may want to consider taking psyllium supplements, available at most grocery or drug stores.
Healthy toilet habits mean using the toilet as soon as you feel a need to have a bowel movement, avoiding straining while there, and not staying on it for excessive periods of time. Blotting with toilet paper rather than wiping or rubbing strenuously may be desirable.
Lifestyle modifications that would help include avoiding prolonged standing or sitting, not holding your breath while lifting and generally exercising more. Exercise helps make you more regular in your bowel habits.
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What are treatments to eliminate hemorrhoids?
External hemorrhoids rarely need to be treated surgically unless the hemorrhoid becomes clotted — that is, blood has pooled in the tissue and it becomes hard and painful. Removal of the clot by a simple incision should result in immediate relief.
For internal hemorrhoids, the goal of fixative treatments is to cut off the supply of blood to the hemorrhoid so that it will wither, die and fall off. Surgical treatments include hemorrhoidectomy, the straightforward excision of hemorrhoidal tissue.
Rubber band ligation is widely regarded as the most effective fixative treatment for the problem of internal hemorrhoids. It works best on small to medium hemorrhoids and uncomplicated large hemorrhoids. Repeat treatment is not usually needed. The procedure can be performed in the doctor's office, and it avoids many of the issues — such as the need for general or spinal anesthesia — involved in having surgery performed in a hospital.
In the procedure, the doctor uses an anoscope to tie one or two tiny rubber bands around the base of a hemorrhoid to eliminate its blood supply. The procedure usually is relatively painless (if there is significant pain at the time or later, you should let the doctor know). The hemorrhoid should fall away in 3 to 7 days. Some bleeding, usually minimal, should occur at this time.
Sclerotherapy is a fixative treatment in which a chemical solution is injected around the vein to shrink the hemorrhoid.
Infrared coagulation is another fixative treatment that uses an infrared light device to cut off circulation at the base of a hemorrhoid.
Electric current treatment is similar to infrared coagulation, using bursts of electric current to eliminate blood circulation.
Hemorrhoidectomy is the removal of hemorrhoids through a surgical procedure. Surgery is more likely to be indicated for the removal of a large hemorrhoid, or for hemorrhoids that still produce symptoms after nonsurgical treatment.
After the administration of anesthesia to offset pain, the surgeon excises tissue surrounding the hemorrhoid in order to tie off the affected vein and then removes the hemorrhoid. Although the likelihood of recurrence is diminished as more tissue is removed, the more that is removed, the greater the discomfort that is likely to be experienced during recovery. Usually it is performed as a day-surgery procedure but for some patients, one or two days of hospitalization may be required. You can expect a recovery time of two to three weeks.
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How can I prevent hemorrhoids from recurring?
The most important element in diminishing hemorrhoids or preventing them from recurring is to change the factors that led to the straining that created them in the first place.
Eating high fiber foods, such as whole grain breads and fruits and vegetables, rather than foods with refined white flour and refined sugars, will help you create larger, softer stools that can be passed more easily. Most doctors recommend 25 to 30 grams of soluble and insoluble fiber daily (You should transition to this level of fiber gradually in order to avoid becoming constipated). Similarly, you should drink at least eight glasses of water or other fluids each day. It should be noted that alcohol and caffeinated beverages are not recommended, as they tend to cause dehydration.
Over-the-counter fiber supplements containing psyllium can be used if you have trouble eating 25 grams of fiber-rich foods each day. In that case, drinking water is especially important, since otherwise you may experience constipation.
Exercise is important for many reasons — it makes you more regular in your bowel movements, and it reduces pressure on your veins. Since excessive weight is also an important contributor to the pressure that leads to hemorrhoids, exercise can help you lose weight.
Avoid standing or sitting for prolonged periods, since this immobility can increase pressure in the veins in your rectal/anal area.
Don't sit on a "donut" cushion. It actually increases the pressure on veins that you are trying to avoid.
Practice better toilet habits, such as going to the bathroom as soon as you feel an urge, avoiding straining to pass stool and avoiding sitting on the toilet for extended periods. Don't read while sitting on the toilet.
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Questions and Answers
Are there age issues involved in the decision for type of treatment for hemorrhoids?
For patients over the age of 70, sclerotherapy, the injection of a chemical solution around the affected vein or veins to shrink the hemorrhoid, would most likely be the treatment of choice. Neither surgery not rubber band ligation is usually recommended for patients in this age group.
How do the various treatments compare in terms of results?
Hemorrhoidectomy surgery actually seems to provide the longest-lasting results. Rubber band ligation is a faster and less disrupting treatment and its results seem to be longer-lasting than other ligation treatments.
How do surgery and rubber band ligation compare in terms of side effects?
Obviously, there is a risk of complications associated with any surgery involving anesthesia. And surgery can involve more pain and bleeding following the procedure. There are small risks of urinary retention — an inability to urinate — and infection involved with both procedures.
My doctor has recommended surgery for my hemorrhoids. Should I get a second opinion?
You should always get a second opinion concerning any decision involving possible surgery.
Is there anything I can do during my pregnancy to minimize the development of hemorrhoids?
You should be able to diminish the growth of hemorrhoids by sleeping on your side. This will reduce the pressure on the veins in your pelvic area.
I don't get constipation — which is often described as linked to hemorrhoids. I get diarrhea a lot, and I have hemorrhoids anyway. How come?
Any bowel habit that promotes straining in the pelvic/anal area can lead to the enlargement of veins that causes hemorrhoids. The same advice about relaxing and not straining applies to diarrhea as to constipation.
Do hemorrhoids run in families?
They can. At least, it's believed that a tendency to develop hemorrhoids is hereditary.
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For additional information
You can find additional information about hemorrhoids at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.
A likely source includes:
The National Digestive Diseases Information Clearinghouse (www.niddk.nih.gov)
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