Hemorrhoids – Your Guide To What Works (And What Doesn’t!)
Hemorrhoids (say HEM-uh-roids) are an uncomfortable, often embarrassing condition that is all too common, with three out of every four adults experiencing symptoms at some point. But just what are hemorrhoids? Actually, they are very much like the varicose veins you sometimes see on a person’s legs or you may have yourself. Hemorrhoids are simply swollen veins in the very lowest part of your anus or rectum.
As you age, you are more likely to develop hemorrhoids because the tissues of the anus and rectum that support the veins weakens and allows the veins to bulge. Fortunately, there are a lot of treatment choices for this common condition, including simple things you can do at home such as changes to your diet and the use of over the counter medications.
Before we delve into what to do about hemorrhoids, let’s learn a little more about the anatomy and the different types of hemorrhoids, as this will help you understand your treatment options better. The walls of the anus and rectum are lined with smooth muscle and connective tissue. There are blood vessels located within the smooth muscle of the rectum and anus, which are a totally normal part of your anatomy. Only when these veins begin to swell and cause problems are they generally referred to as hemorrhoids, or sometimes as piles.
There are two kinds of hemorrhoids; internal and external and the difference is in where they are located in relation to an anatomic structure called the pectinate (say PECK-ta-nate) line. This line divides the upper two thirds of the anal canal from the lower third.
A hemorrhoid which is above this line is called an internal hemorrhoid and any hemorrhoid below the line is referred to as external. Internal hemorrhoids are covered with the same type of cells that line the intestines and external hemorrhoids are covered with cells that more closely resemble skin.
The most common symptom of a hemorrhoid is painless bright red bleeding from the rectum. It’s important to note that rectal bleeding of any kind is never normal and could indicate something more ominous, such as cancer.
While this bleeding may come from something as non-life threatening as a hemorrhoid, if you experience rectal bleeding, you should always make an appointment with your healthcare provider, in particular if you are taking blood thinning medications. Other symptoms of a hemorrhoid are anal itching, pain and sensing swelling or feeling a lump at the anus.
Internal hemorrhoids and external hemorrhoids may cause somewhat different symptoms. Remember when we discussed internal hemorrhoids as being located higher up in gastrointestinal tract, above the pectinate line? When internal hemorrhoids swell, this does not actually cause you any pain, as there are no pain nerves attached to the veins above the pectinate line. If you were to pass a hard stool, it’s possible it could scrape off the thin wall of the swollen vein and cause painless bleeding.
Plus, the swollen vein can cause the muscles of the rectum and anus to go into spasm and this can cause pain, especially if the hemorrhoid droops down and actually protrudes into or out the anus. Also, internal hemorrhoids can become thrombosed (develop a clot) and this can be intensely painful.
The hemorrhoid can also leak mucus and this can be very irritating to the skin which surrounds the anus, causing intense and extremely uncomfortable itching. This intense itching of the anal area due to a hemorrhoid is called pruritus ani. You can’t see an internal hemorrhoid, unless they are prolapsed, as it remains inside the anus.
External hemorrhoids, which are located below the pectinate line, behave a little differently. For one thing, they have pain nerve fibers attached to them, so when they swell, it hurts. And when a clot develops in an external hemorrhoid, it can be very painful as well.
A clot within the vein, just as in the internal hemorrhoid, is known as a thrombosed hemorrhoid, causing a hard, extremely painful lump at the anus. External hemorrhoids, if they are not thrombosed, look like rubbery appearing lumps. Thrombosed external hemorrhoids protrude from the anal canal and look bluish due to the clotted blood inside the vein.
Because hemorrhoids are caused by swelling of the veins in the anal area, anything that causes increased pressure within those veins can lead to a hemorrhoid. A diet low in fiber may promote constipation. This, in turn, may cause you to strain when having a bowel movement, increasing the pressure in the veins. Chronic diarrhea can also predispose you to hemorrhoids.
Pregnancy is another cause, due to pressure of the growing uterus on the rectum and anus. Obesity is also another causative factor, similar to pregnancy, in that the extra weight puts pressure on the veins. Prolonged sitting on the toilet, which is sometimes just a bad habit and not done out of necessity, can cause increased pressure on the veins. People who have had prior rectal surgery also may be at increased risk for developing hemorrhoids.
Your medical professional will take a thorough history, concentrating on your symptoms, diet and bowel movement habits. A physical examination will be performed, including a digital rectal exam, where the provider will insert his gloved finger into the anus to feel for lumps and masses and check for bleeding. If you have really intense pain or swelling, the rectal exam may have to be delayed.
If your provider is concerned that hemorrhoids don’t adequately explain the cause of your symptoms, especially rectal bleeding, then an anoscope may be performed. This is a lighted tube that is inserted into the rectum to give the physician an adequate view of the tissues and is performed right in the office.
If a colonoscopy or sigmoidoscopy is indicated, you will be referred to a gastroenterologist. If you have had a lot of bleeding, a blood test may be ordered to test your blood count as well as your clotting time, especially if you take blood thinning medications.
Internal hemorrhoids are treated based on their grade:
Grade One hemorrhoids simply bulge into the anal canal and they may bleed. These are just treated symptomatically with warm sitz baths a couple of times a day and avoiding spicy foods which may aggravate itching. Over the counter medications, such as creams, ointments or suppositories may be helpful. Some of these medications contain a numbing medicine to help with pain, or steroids to reduce swelling and inflammation or astringents to reduce swelling. Stool softeners can help as well.
Grade Two hemorrhoids protrude down into the anal canal on straining but go back to their original position when straining is finished. Grade Three hemorrhoids may protrude so far that you actually have to push them back inside.
Both Grade Two and Grade Three hemorrhoids are treated the same, with a technique designed to destroy the hemorrhoid. These techniques can include injecting the hemorrhoid with a medication to make the tissue shrivel or harden or can include cutting off the circulation to the tissue with a rubber band.
Grade Four hemorrhoids are always protruded and are at risk from thrombosis and also getting strangulated by spasm of the anal musculature. Grade Four hemorrhoids or patients with lesser grades whose hemorrhoids have not responded to conservative therapy are candidates for hemorrhoid surgery.
Surgical options include removal of the hemorrhoid with a laser or hemorrhoidectomy using a scalpel. There is also another procedure called a stapled hemorrhoidectomy using a surgical staple gun. Hemorrhoids which have been treated conservatively, without surgery, will recur about fifty percent of the time. The recurrence rate after surgery for hemorrhoids is only about five percent.
External hemorrhoids are treated like Grade One internal hemorrhoids with stool softeners, warm sitz baths and over the counter creams, ointment or suppositories. For an external hemorrhoid that has become thrombosed, an incision is made in the hemorrhoid and the clot evacuated, relieving the pain.
Eating a diet high in fiber and staying hydrated by drinking plenty of fresh, pure water can prevent constipation, which can lead to hemorrhoids. If you suffer from chronic constipation and you already stay hydrated and eat a high fiber diet, you may want to consider adding a stool softener to your regimen to prevent straining and the buildup of pressure in the veins of the rectum and anus.
If you have chronic diarrhea (and please see your physician if this is the case) the addition of anti-diarrheal medicines may be indicated as well as dietary changes. Keeping your weight under control and avoiding prolonged sitting on the toilet are other helpful measures which may prevent hemorrhoids.
Once you have hemorrhoids, unless you have surgery, they are a lifelong, chronic condition and need to be managed just like any other chronic health problem. Your goal in this case would be to keep your hemorrhoids from becoming inflamed and swollen by staying hydrated and by eating an adequate diet.
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