Hemorrhoids are the swelling and inflammation of veins in the rectum
Hemorrhoids are very common. It is estimated that approximately half
of all Americans have this condition by the age of 50. However, only a
small number seek medical treatment. Annually, only about 500,000 people
are medically treated for hemorrhoids, with 10 to 20% of them requiring
Causes and risk factors
Some people are more prone to developing hemorrhoids due to inherent
problems with their bodies' collagen and elastic fibers due to a genetic
predisposition. This leads to weak rectal vein walls or week venous
valves. These people may have other related defects such as 'flat feet',
herniae. Others develop hemorrhoids due to problems in their intestinal
The causes of hemorrhoids include genetic predisposition (weak rectal
vein walls and/or valves, excessive time (over 1 minute daily) and
straining during bowel movements, and chronic bowel straining or
pressure due to poor posture or muscle tone. Constipation, bouts of
diarrhea, poor bathroom habits (reading on the toilet or multiple
cleaning attempts), pregnancy, excessive coughing, constant sitting and fiber-deprived Western diet can all
foster the conditions that cause hemorrhoids.
Hemorrhoids is particularly common among pregnant women. The pressure
of the fetus in the abdomen, as well as hormonal changes, cause the
hemorrhoidal vessels to enlarge. These vessels are also placed under
severe pressure during childbirth. For most women, however, hemorrhoids
caused by pregnancy are a temporary problem.
Types of hemorrhoids
Hemorrhoids can present as internal or external hemorrhoids or both.
External hemorrhoids are those that occur outside of the anal opening.
Internal hemorrhoids are those that occur inside the rectum.
External hemorrhoids are asymptomatic except when secondary
thrombosis occurs. However, some patients with non-thrombosed
hemorrhoids may complain of pruritus ani or itching, swelling, and
burning sensation. In addition, excessive straining, rubbing, or
cleaning around the anus may cause irritation with bleeding and/or
itching, which may produce a vicious cycle of symptoms. Draining mucus
may also cause itching.
If the vein ruptures and a blood clot develops, the hemorrhoids
become a thrombosed
hemorrhoid. Thrombosis may result from defecatory straining or extreme
physical activity, or it may be a random event. Patients often report
feeling the sensation of sitting on a tender marble. Physical
examination identifies the external thrombosis as a purple mass at the
If infected this can lead to inguinal lymph node enlargement. The
inguinal lymph nodes are situated in the crease between the leg and
pelvis (more on the outside of that crease, ie, laterally). They drain
the penis, scrotum, vulva, vagina, perineum, gluteal region, lower
abdominal wall, lower anal canal.
area lack sensitive nerve endings, internal hemorrhoids are usually not
painful and most people are not aware that they have them. Internal
hemorrhoids, however, may bleed when irritated. The most common symptom
of internal hemorrhoids is bright red blood covering the stool, on
toilet paper, or in the toilet bowl.
Untreated internal hemorrhoids can lead to two severe forms of
hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed
hemorrhoid is an internal hemorrhoid that are so distended that it is
pushed outside of the anus. If the anal sphincter muscle goes into spasm
and trap the prolapsed hemorrhoid outside of the anal opening, the
supply of blood is cut off, and the hemorrhoids become a strangulated
Many anorectal problems, including fissures, fistulae, abscesses, or
irritation and itching (pruritus ani), have similar symptoms. The
differential diagnosis of anal mass includes many benign diseases.
hemorrhoids, rectal prolapse, perianal haematomas, anal tags, polyps,
warts or condylomas, anal abscesses can all present as an anal mass.
Non-proctological lumps can also be present from time to time. These
include sebaceous cysts and lipomas. On the other hand, a palpable mass
and/or bleeding is the presenting symptom in 50% of patients that are
later found to have anal cancer. Other potential causes include inflammatory bowel disease or bowel infection.
A thorough evaluation and proper diagnosis are important any time
bleeding from the rectum or blood in the stool occurs. Bleeding may also
be a symptom of other digestive diseases, including colorectal cancer.
Examination of the anus and rectum to includes inspection to look for
swollen blood vessels that indicate hemorrhoids and a digital rectal
exam with a gloved, lubricated finger to feel for abnormalities. Closer
evaluation of the rectum for hemorrhoids requires an exam with an
anoscope, a hollow, lighted tube useful for viewing internal
hemorrhoids, or a proctoscope, useful for more completely examining the
To rule out other causes of gastrointestinal bleeding, examination of
the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire
colon with colonoscopy may be necessary. Sigmoidoscopy and colonoscopy
are diagnostic procedures that also involve the use of lighted, flexible
tubes inserted through the rectum.
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Prevention of hemorrhoids includes drinking more fluids, eating more
fiber, exercising, practicing better posture, and reducing bowel
movement strain and time. Hemorrhoid sufferers should avoid using
laxatives and should strictly limit time straining at stool to well
under 1 minute (ideally 10 seconds) daily.
For many people, hemorrhoids are temporary conditions that are healed
either serendipitously or by the same measures recommended for
prevention. In these cases, warm sitz bath, cold compress, or topical
analgesic (such as Preparation H), is sufficient to provide temporary
The first step is to eliminate the factors causing hemorrhoids. After eliminating the risk factors and possible causes
the goal is to achieve symptomatic relief as well as shrinkage of the hemorrhoids.
This can be accomplished by Sitz baths as well as pain meds.
Treatment of chronic or complicated hemorrhoids
Chronic hemorrhoids or those that flare up from time to time can
be medically treated by:
- dilation: stretching of the anal sphincter muscle. Although no
longer popular, this treatment can be successfully applied to select
cases of strangulated hemorrhoids.
- rubber band ligation: elastic bands are applied onto an internal
hemorrhoid to cut off its blood supply. Within several weeks, withered
hemorrhoid is sloughed off during normal bowel movement.
- sclerotherapy (injection therapy): sclerosant or hardening agent
is injected into hemorrhoids. This causes the vein walls to collapse
and the hemorrhoids to shrivel up.
- cryosurgery: a frozen tip of a cryoprobe is used to destroy
- laser, infared or BICAP coagulation: laser, infrared beam, or
electricity is used to cauterize the affected tissues.
- hemorrhoidectomy: a true surgical procedure to excise and remove
For severe cases of hemorrhoids, such as prolapsed, thrombosed, or
strangulated hemorrhoids, surgery may be the only treatment option. The
pain in thrombosed external hemorrhoid, which is better known as a
perianal haematoma, is usually severe and instantly relieved by incision
and evacuation of the clot.
General measures to decrease flare ups and aggravation are increase
dietary fiber found in fruits, vegetables, grains and cereals. A fiber
supplement may also be used. Increase water intake. These measure may
soften the bowel movements and prevent straining and trauma.
Natural astringents and soothing agents, such as witch hazel,
cranesbill and aloe vera, may also be used topically. Lastly, fiber-rich
bulking agents such as plantain and psyllium can be used to help create
soft stool that is easy to pass to lessen the irritation of existing
hemorrhoids or to achieve the daily limit of well under 1 minute
(ideally 10 seconds) straining at stool.
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