Hemorrhoids

You may be surprised to learn that hemorrhoids are a normal part of our anatomy. We have both internal and external hemorrhoids, located inside the anal canal and around the anal opening, respectively. The internal hemorrhoids are a part of the blood supply to the anus and are made up of small arterial branches. In addition, internal hemorrhoids”also known as anal cushions”normally help us maintain continence (hold our gas and stool) and also distinguish gas from stool before we pass gas. The external hemorrhoids are veins.

When they are in their normal state, we are not aware of our hemorrhoids: they cause no symptoms. But, sometimes we can develop problems because of our internal hemorrhoids. This is known as internal hemorrhoidal disease. Such symptoms can occur occasionally (flare ups) or may be chronic (long-term).

When our external hemorrhoids cause symptoms, it is because a blood clot suddenly forms in one of these veins at the opening of the anus. This is known as a thrombosed external hemorrhoid. This blood clot results in a firm external lump that is associated with anal pain and, at times, bleeding between bowel movements.

Hemorrhoidal problems”both internal and external”are common. There are treatment options for you.

What are the symptoms of internal hemorrhoidal disease?

The symptoms of internal hemorrhoidal disease include the following:

• Rectal bleeding, usually bright red, during and occasionally between bowel movements
• Anal pain, especially during or after bowel movements
• Anal itching or burning
• Difficult cleansing
• Protrusion (prolapse) of the internal hemorrhoids during bowel movements. The hemorrhoids may go back in on their own or can be pushed back inside the anus by hand.
• Drainage

Various factors can lead to the development of hemorrhoid problems:

• Straining during bowel movements
• Hard or watery bowel movements
• Sitting on the toilet for a long time (for example, while reading or playing video games)
• A low-fiber diet
• Pregnancy and vaginal deliveries
• Aging

Thrombosed external hemorrhoids can occur after straining, either during bowel movements or heavy lifting or vigorous activity. Hard or watery bowel movements can also produce a thrombosed external hemorrhoid.

How are hemorrhoids diagnosed?

A diagnosis of a hemorrhoidal problem begins with a visit to your doctor. The doctor will ask about your symptoms and perform a physical examination, including an evaluation of the anal area.

During an anal examination, the doctor will:

• Look at the perianal skin;
• Do a digital rectal examination, in which a lubricated finger is gently inserted into the anus; and,
• Check the inside of the anal canal”where the internal hemorrhoids are located”using a short lighted probe called an anoscope.

In some cases, you may need an additional study such as a flexible sigmoidoscopy or a colonoscopy to ensure that your symptoms are not due to any disease in your colon or rectum.

How is internal hemorrhoidal disease treated?

Various treatments are available for internal hemorrhoidal disease. Not all people will require an office or a surgical procedure.

For milder or occasional symptoms, the following treatments can help:

• Keep stool soft and regular by increasing fiber intake to 30 grams/day and, if needed, by starting a fiber supplement.
• Establish good toilet habits, such as not straining or sitting on the toilet for a long period of time. For people who are constipated, a stool softener or laxative may be added after discussion with your doctor.
• Take a warm tub or sitz bath to relieve more acute pain associated with bowel movements.

For more severe or chronic symptoms, other options may be discussed, including office and surgical procedures. The best procedure for you depends on the size of the internal hemorrhoids and how severe your symptoms are.

Techniques for treating internal hemorrhoidal disease include:

• Rubber band ligation: Usually performed in the office without sedation, rubber band ligation involves placing rubber bands at the base of the internal hemorrhoid, cutting off its blood supply and allowing it to slough off.
• Sclerotherapy: In an office setting, a sclerosing (chemical) agent is injected into the internal hemorrhoid to create scar tissue to fix it in place.
• Doppler-guided hemorrhoidal artery ligation: This surgical procedure, done in the operating room under general anesthesia, uses a special anal probe equipped with a Doppler device, which allows the blood vessels leading to the internal hemorrhoids to be identified and then tied off (ligated) with suture, causing them to shrink. The internal hemorrhoids can also be fixed in place with suture.
• Stapled hemorrhoidopexy (PPH, Procedure for Prolapse and Hemorrhoids): Also performed in the operating room, this technique employs a special stapling device that removes a donut of the rectal lining, which then pulls the prolapsing internal hemorrhoids back into the anus.
• Excisional hemorrhoidectomy: The internal and, if appropriate, external hemorrhoids are removed by cutting them out.

In most cases, a thrombosed external hemorrhoid does not require surgery. As the blood clot dissolves, the thrombosed external hemorrhoid shrinks. If appropriate, within the first three days of the appearance of the thrombosed external hemorrhoid, the clot can be removed or the thrombosed external hemorrhoid completely excised (cut out). This is a minor procedure that can usually be done in the office.

How can I prevent internal hemorrhoidal disease?

Here are some ways to prevent internal hemorrhoidal disease:

• Try to keep your stool soft and regular. Make sure you have a good intake of fiber, about 30 grams/day, by eating fruits, vegetables, and whole grains. A fiber supplement may help you reach your fiber goal. Your doctor may suggest a stool softener or laxative.
• Exercise regularly to help prevent constipation.
• Maintain good toilet habits. Don't strain or sit too long on the toilet.
• Do not delay bowel movements. Instead, heed the call to go to the toilet when you feel the urge.