Hemorrhoids

Hemorrhoids are engorged, often painful veins located in your anus.

Hemorrhoids can build up in 2 different places. There are 2 distinct branches of veins that drain the blood from the lower rectum and anus.

The internal veins can become swollen to form internal hemorrhoids. Internal hemorrhoids, unless they are severe, cannot be seen or felt, unlike external hemorrhoids.

Similarly, the external veins can enlarge to form external hemorrhoids. External hemorrhoids can be seen around the outside of the anus and, often, can be felt.

Causes

Hemorrhoids are associated with constipation, straining at bowel movements, and pregnancy. Many physicians believe that these conditions lead to increased pressure in the hemorrhoid veins, thus causing them to swell. Hemorrhoids are very common and have been estimated to occur in up to half the general population by age 50.

Symptoms

The symptoms are fairly straightforward. The most common is painless rectal bleeding. You will see bright red blood on the outside of your bowel movement, on toilet tissue, or dripping into the toilet. The bleeding usually is self limited and does not last long.

Hemorrhoids may become prolapsed.

  • This occurs when the internal hemorrhoids swell and then protrude through the anal canal.
  • You then can feel the hemorrhoids, at your anus, from the outside.
  • Often a simple push of the hemorrhoids back into the rectum can solve the problem.
  • If the hemorrhoids cannot be reduced back into the rectum, then they will continue to inflame and can become trapped outside of the anus.
  • If your hemorrhoids become prolapsed and cannot be reduced, then you will need to see a doctor.
  • You may develop itching in your anus from prolapsed hemorrhoids. This condition is called pruritus ani.

External hemorrhoids may become quite painful when they get thrombosed.

  • This occurs when blood clot (thrombus) forms in the hemorrhoid; the hemorrhoid will become even more engorged. This swelling leads to increased discomfort or pain.
  • The pain usually worsens with straining during bowel movements or with sitting.
  • This too is a condition that may require a doctor’s examination and treatment.

When to call the doctor

If you notice recurrent bleeding between bowel movements or have a moderate amount of bleeding, you should consult with your doctor.

If you have a family history of colon cancer or are over age 40 you should see your doctor for evaluation of the recurrent rectal bleeding.

If you have prolapsed hemorrhoids that will not go back into the anus, or you have significant anal or rectal pain, you should consult your doctor.

There are numerous other medical causes of rectal bleeding that are much more serious than hemorrhoids. These will require a doctor to further evaluate he cause so that serious conditions such as colon cancer and colitis are not overlooked

When to go to the hospital

Most of the time hemorrhoids can be managed by your primary care physician. A few situations exist that may require that instead you to go to the hospital emergency department.

If you have considerable pain, bleeding, or a prolapsed hemorrhoid and are unable to get in touch with your doctor, then you should be evaluated in the emergency department.

If you have a large amount of bleeding from your rectum, become weak, or experience lightheadedness you should be evaluated in the emergency department.

Exams and Tests

The number one tool that the doctor will need is a medical history and physical exam to evaluate your hemorrhoids. Occasionally your doctor may need to evaluate your hemorrhoids by looking directly at them by performing an anoscopy.

During an anoscopy, a small, lighted scope is placed into the anus and rectum to fully view the anal canal and lower rectum. This procedure is a bit uncomfortable but is easily performed in a doctor’s office and does not require sedation, usually a local anesthetic gel is applied.

If there has been significant bleeding or symptoms of severe blood loss, then your doctor may order a simple blood test to ensure that you have notdeveloped anemia.

Hemorrhoid Treatment

Self-Care at Home

The treatment varies depending on the severity of the problem. Most of the time, conservative treatment can be performed at home.

Hot sitz baths

  • For a sitz bath, sit in a few inches of warm water in a tub. Epsom salts can also be added to the bath water.
  • A sitz bath is recommended 3 times a day and after each bowel movement for 10 to15 minutes.
  • This is the best way to reduce the inflammation and the discomfort.
  • Thorough drying of the skin around the anus after each bath is extremely important so that it doesn’t rub and become torn.

Dietary changes

  • Drinking more liquids and eating a diet rich in fiber, such as leafy green vegetables and fruits, will make the stools bulkier and softer, helping to relieve constipation.

Stool softeners

  • Stool softeners can also be advantageous.
  • If you use a laxative and it leads to watery, or runny stools, it could cause an infection in the anus and should not be avoided.

Sitting restrictions

  • Some doctors also recommend people with hemorrhoids not sit for a prolonged periods of time.
  • Some people have reported feeling more comfortable when they sit on an air doughnut.

OTC medications

  • These medications help only minimally and at times even lead to longer healing, so consult with your physician first.

Medical Treatment

Thrombosed hemorrhoids

  • If a hemorrhoid with a clot develops (thrombosed hemorrhoid), you will feel some pain.
  • If the pain is not severe and the swelling is minimal, often this can be treated with hot sitz baths and stool bulking agents.
  • If the pain is intolerable or there is a large amount of swelling present, it might be necessary to remove the blood clot. This procedure can be done in a doctor’s office or emergency department but must not be attempted at home.
  • Almost universally there is great relief of the pain after the clot is removed and any residual discomfort can be easily treated with acetaminophen (Tylenol) or ibuprofen (Advil/Motrin) for pain.

Prolapsed internal hemorrhoids

  • If you have prolapsed hemorrhoids, which you are unable to introduce through the anus, then your doctor will need to reduce them.
  • Many times the doctor is able to gently push the hemorrhoids back into place.
  • If the hemorrhoids are too swollen to be reintroduced back, then a surgical procedure to relieve the swelling may be called for.
  • If the hemorrhoids remain trapped through the anal canal and nothing is done, then the hemorrhoid will become strangulated, not receive enough blood and start to die.
  • If this occurs, the hemorrhoid will become infected, and this can lead to a more serious generalized infection in the blood.

Surgery

The surgeon can elect to inject the hemorrhoids with a medicine to shrink them or place small rubber bands around the hemorrhoids to cut off the blood supply so they will die. These procedures are usually done in the office and don’t require you to be put to sleep or admitted to a hospital.

Sometimes, it is necessary for the surgeon to actually remove the hemorrhoids. In this case you will need to be put to sleep or have a spinal anesthetic.

Follow-up

Warm sitz baths 3 times a day and after each bowel movement along with increasing the amount of dietary fiber is beneficial.

Any pain associated to the surgery can be easily managed with over-the-counter pain relievers.

Prevention

There is no scientifically proven method for avoiding the development of hemorrhoids. Eating a high-fiber diet and avoiding straining is believed to aid in preventing hemorrhoids, but there is no way to completely eliminate the risk.

Outlook

Most people with hemorrhoids have an excellent outcome. There cab be flare-ups of bleeding or slight discomfort from time to time, but they don’t last long and can be relieved with care at home, typically with sitz baths.