Hemorrhoids

What are hemorrhoids?

Hemorrhoids are lumps or masses of tissue in the anus, which contain enlarged blood vessels. Any increase in abdominal pressure may produce hemorrhoids. This may be from:

• repeated straining to have a bowel movement, especially in people who suffer from frequent constipation
• pregnancy
• repeated episodes of diarrhea
• obesity.

Many patients have no apparent explanation for the formation of hemorrhoids, however.

Internal hemorrhoids. Internal hemorrhoids lie inside the anal canal, where they primarily cause the symptom of intermittent bleeding, usually with bowel movements, and sometimes mucous discharge. They are usually painless. Internal hemorrhoids also may protrude (prolapse) outside the anus, where they appear as small, grape-like masses. Usually the prolapsed hemorrhoid can be pushed back into the anus with a fingertip.

External hemorrhoids. These lie just outside the anal opening, where they primarily cause symptoms of swelling or bothersome protrusions, and sometimes discomfort. Swelling and discomfort may occur only intermittently. External hemorrhoids may also cause difficulties keeping the anal area clean after bowel movements. External hemorrhoids sometimes develop a blood clot inside of them ("thrombosis"), often after a period of diarrhea or constipation. In that case, it produces a sudden firm and painful swelling or lump around the rim of the anus.

Many patients have both internal and external hemorrhoids.

Hemorrhoids are a very common health problem. Hemorrhoids are more likely to develop in individuals who eat insufficient dietary fiber and don't get enough exercise, which can lead to repeated episodes of constipation and straining to have bowel movements.

Symptoms of hemorrhoids

Symptoms of hemorrhoids include:

• bright red blood on the toilet paper after having a bowel movement, especially if the stool was very hard or very large. Blood also may streak the surface of the stool, or color the water in the toilet bowl.
• for a prolapsed hemorrhoid, a soft, grape-like mass protruding from the anus that may discharge mucus
• for external hemorrhoids, bothersome protrusions and difficulties keeping the anal area clean
• external hemorrhoids may also cause intermittent swelling, irritation, and mild discomfort, especially after a period of diarrhea or constipation.

For thrombosis of an external hemorrhoid, a painful bulge or firm lump suddenly appears at the rim of the anus. The lump may have a blue or purple tint. It may discharge blood.

Severe pain is not a typical symptom of hemorrhoids (except for thrombosis of an external hemorrhoid).

Diagnosing hemorrhoids

Like most anal or rectal conditions, physicians diagnose hemorrhoids by inspecting the anal area, feeling inside the anus with a gloved finger, and looking inside the anal canal with a small short scope (anoscope). If there is rectal bleeding, it is important that a physician also checks for other more dangerous causes of bleeding, such as colorectal cancer. This evaluation is usually done with a long flexible telescope (flexible sigmoidoscopy or colonoscopy).

Expected duration of hemorrhoids

Hemorrhoid flare-ups (swelling, irritation and mild discomfort) are usually brief, and most symptoms disappear within a few days.

In pregnant women, hemorrhoid symptoms usually improve dramatically or disappear after childbirth.

Intermittent slight bleeding from hemorrhoids may carry on for months or years.

Painful swelling from thrombosis of an external hemorrhoid usually resolves over a period of days to weeks.

Preventing hemorrhoids

You can often prevent hemorrhoids by preventing constipation. Some of the following diet and lifestyle changes may help you to soften your stool, establish a regular schedule for bowel movements, and avoid the straining that can lead to hemorrhoids:

• Add more fiber to your diet. Set a goal of 25 to 30 grams of fiber daily, from such high fiber foods as beans, broccoli, carrots, bran, whole grains and fresh fruits. Alternatively, many people find that it is more convenient to take a fiber powder such as psyllium (Metamucil), or methylcellulose (Citrucel), which is available at drug stores without prescription. To avoid bloating and gas, add fiber to your diet gradually over a period of several days.
• Drink adequate amounts of fluid. For most healthy adults, this is the equivalent of six to eight glasses of water daily.
• Begin a program of regular exercise. As little as 20 minutes of brisk walking daily can stimulate your bowel to move regularly.
• Train your digestive tract to have regular bowel movements. Schedule a time to sit on the toilet at approximately the same time each day. The best time to do this is usually right after a meal. Do not sit on the toilet for long periods (it tends to make hemorrhoids swell up and push out).
• Respond immediately to the urge to have a bowel movement. Do not postpone until the time is more convenient.

Treating hemorrhoids

If you are experiencing a flare-up of hemorrhoid swelling and discomfort, try the following:

• Take a fiber powder to soften the stool.
• Take warm sitz baths, especially when the hemorrhoids are uncomfortable. Sit in a tub or pan of plain warm water, three or four times a day, for 15 to 20 minutes each time. (Large pharmacies and medical supply stores also sell convenient plastic sitz bath devices that fit into a toilet.) The water will keep the area clean, and the warmth will reduce inflammation and discomfort. Be certain to dry the rectal area thoroughly after each sitz bath. If you work, you can still take a sitz bath in the morning, upon returning from work, and again at bedtime.
• Apply a cold compress or icepack to the anal area, or try a cool cotton pad soaked in witch hazel.
• Apply petroleum jelly or aloe vera gel to the anal area, or use an over-the-counter hemorrhoid preparation containing lidocaine or hydrocortisone.
• After every bowel movement, clean the anal area with a witch hazel pad, a soothing baby wipe or a cotton cloth soaked in warm water. Be thorough but gentle. Aggressive rubbing and scrubbing, especially with soaps or other skin cleansers, can irritate the skin and make your hemorrhoids worse.

If you have persistent or severe hemorrhoid symptoms your doctor may offer one of the following treatment options:

​Office treatments

• Rubber band ligation. A rubber band is slipped around the base of an internal hemorrhoid to cut off its circulation. This shrinks the banded hemorrhoid. This is the office treatment used most commonly in the United States.
• Sclerotherapy. An irritating chemical solution is injected directly into the internal hemorrhoid or the area around it. This solution causes a local reaction that interferes with blood flow inside the hemorrhoid, making the hemorrhoid shrink.
• Coagulation therapies. These treatments use electricity or infrared light to destroy internal hemorrhoids by burning.

Treatments in the operating room

• Hemorrhoidectomy. Although this traditional surgical removal of hemorrhoids is painful, it is effective, for both internal and external hemorrhoids. Laser hemorrhoidectomy does not offer any advantage over standard operative techniques.
• Hemorrhoid stapling. This is a surgical procedure that uses a special device to internally staple and remove hemorrhoid tissue. It is effective only for internal hemorrhoids, but is less painful than traditional hemorrhoidectomy.

When to call a professional

Call your doctor whenever you have bleeding from your rectum, especially true if you are over age 40, when there is an increase in the risk of rectal bleeding from colorectal cancer or other serious digestive diseases.

Also, see your doctor if you have severe rectal pain.

Prognosis

Hemorrhoids are not dangerous, and only need to be treated if they cause very bothersome symptoms. If hemorrhoids occur during pregnancy, they will usually regress spontaneously after childbirth. For hemorrhoids related to constipation, the prognosis is also good, provided you make the necessary changes to your diet and lifestyle. For hemorrhoids that cause persistent symptoms despite nonsurgical treatment, the results from office treatment or surgery are usually very good.

Additional info

American Society of Colon and Rectal Surgeons
https://www.fascrs.org

National Institute of Diabetes & Digestive & Kidney Disorders
https://www.niddk.nih.gov/

American College of Gastroenterology (ACG)
https://www.gi.org/

American Gastroenterological Association
https://www.gastro.org/