Hemorrhoid is the normal anatomical structure composed by veins within the part of the rectum and anus. The hemorrhoids can be affected by a condition with the same name characterized by local inflammation and swelling of the veins. Hemorrhoids may significantly impact the normal function of the person suffering from it. It is classified as internal (inside) or external (outside), depending on the location of the inflammation. While internal hemorrhoids are normally painless, external hemorrhoids can be extremely painful. The condition is also referred to as rectal lump or piles.
Both men and women can experience hemorrhoids and it commonly occurs in about 50% of the population with more people older than 50 years. Hemorrhoids is also a temporary condition affecting most pregnant women.
Although the exact pathophysiological mechanism of hemorrhoids is unknown, inadequate intake of fiber and prolonged constipation and straining during defecation are the major risk factors of hemorrhoids in the general population. It may also be due to prolonged sitting and anal infections. Some cases of hemorrhoids are associated with other conditions like liver cirrhosis and cancers in the pelvis.
Pregnancy is also one major factor due to the pressure in the abdomen as a result of a growing fetus.
Symptoms related to internal hemorrhoids are:
- Bright red blood in the stool – most common symptom
- Itching and irritation in the anal region
- Protrusion that can be pushed back inside the anus
- Usually no pain during defecation
Symptoms related to external hemorrhoids are:
- Thrombosis – blood clot inside the blood vessels
- Painful defecation
Like every other assessment, a medical interview and physical examination is the first mode of diagnosis to test for hemorrhoids. Medical history plays a very important part for the diagnosis. Initially, digital rectal examination is performed by placing the patient in a dorsal recumbent position, while the doctor examines any abnormality using a gloved finger.
For thorough evaluation of the internal part of the anus and rectum, anoscopy is made by inserting a tiny tube in the lower part of the rectum in order to visualize its structures and search for hemorrhoids. For cases when the bleeding originates from sources other than the rectum, sigmoidoscopy or colonoscopy is conducted. The complete blood count (CBC) of the patient may also be determined if there has been any significant bleeding.
Doctors regularly use a grading system to guide diagnosis and treatment. This scale consists of the following degrees, with the higher degrees being the more serious types of hemorrhoids:
- First-degree hemorrhoids: bleeding without prolapse.
- Second-degree hemorrhoids: prolapse occurs followed by self-retraction. (bleeding may or may not be present)
- Third-degree hemorrhoids: prolapse occurs, but retraction is only possible with external pressure. (ie. by pushing with a finger)
- Fourth-degree hemorrhoids: prolapse occurs, but hemorrhoids do not retract (even with external pressure). Hemorrhoids that contain blood clots (thrombosis) or that pull the internal part of the rectum through the anus are also included in this degree.
Some cases of hemorrhoids are relieved after a few days or once treatment has been instituted. There are many over the counter medication categories for this condition, including (always consult with your physician before applying these drugs):
- Topical medications (lidocaine and preparation-H) are usually given to relieve pain. Local anesthetics promote pain relief, burning, and itching by numbing the nerve endings.
- Vasoconstrictors to reduce the size of blood vessels.
- Protectants to prevent contact and irritation of the area surrounding the anus.
- Astringents to promote dry skin and avoid pain and irritation.
- Antiseptics to prevent bacterial growth and infection.
- Keratolytics to destroy the surface of the skin and enable access to the affected region of other medications applied topically.
- Analgesics to reduce pain.
- Corticosteroids to reduce inflammation and itching.
For those cases where traditional healing methods and treatment do not provide any relief for hemorrhoids, a gastroenterologist or surgeon may use the infrared coagulation technique, which is an alternative to a painful surgical operation on the area. The treatment works by applying heat to shrink internal hemorrhoids. Rubber band ligation is another commonly used non-operative treatment. During this procedure the doctor encircles the base of the hemorrhoidal anal cushion with a tight rubber band. Sclerotherapy is also frequently used for treatment, but is associated with earlier recurrence compared to infrared coagulation and rubber band ligation.
Hemorrhoidectomy (including rubber band ligation) is the surgical operation of choice for those cases with chronic pains and severe bleeding (regularly with hemorrhoids of third to fourth degrees). This surgical operation can be really painful because there are several blood vessels within the area. Alternatively, stapled hemorrhoidectomy, consisting of the removal of the tissue supporting the hemorrhoids, may be performed as a treatment of hemorrhoids.
Iron deficiency anemia may also occur if large quantities of blood were lost in the stool and treatment for this or any other possible complication should be considered.
Patients suffering from pain are initially instructed to have a warm sitz bath where the patient sits on lukewarm water for 10 minutes several times a day. The type of treatment is very helpful in promoting vasoconstriction, thereby making the veins shrink and relieve swelling or inflammation. To relieve itching, application of hazel cream in the area may have good results.
Hemorrhoid is one of the conditions with very good prognosis because it is not life threatening. In fact, most symptoms normally go away within a few days although some may require medications or other treatments. It is important to continue a high fiber diet and drinking as much water to prevent the recurrence of hemorrhoids.
If the condition occurs as a result of underlying problems, such as colorectal cancer, the prognosis heavily depends on the stage of the tumor.
To prevent constipation that causes straining on defecation, the patient is advised to ingest foods with high fiber content and to drink plenty of water in order to soften the stool. Avoid foods and beverages that make symptoms worse such as spicy foods, coffee, alcohol, and nuts.
Patients already suffering from hemorrhoids are also instructed to avoid further irritation by restricting them from scratching the anal area and avoid using scented and colored tissues to wipe the region. They are also advised to use cotton underwear. Exercise regularly and avoid prolonged sitting or standing; be careful lifting heavy objects. Practice healthy bowel movements, avoid reading while sitting on toilet, and go to the bathroom as soon as an urge appears.
Some hemorrhoids can be very painful that it can affect the normal physiological functioning of the person. In this case, the main goal of treatment is to reduce pain and relieve the symptoms while preventing further occurrences of hemorrhoids.
New surgical techniques and treatments such as the Doppler-guided artery ligation and LigaSure hemorrhoidectomy are under clinical evaluation for hemorrhoid patients. Improving management of this condition during pregnancy is also a current research objective.