Hemorrhoids

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Almost everyone will get hemorrhoids at some point in their life. Most of the time, symptoms go away on their own, after a few days, even without treatment. On occasion, your hemorrhoid condition is complex and needs a doctor's attention. That's where we can help.

Hemorrhoids are enlarged or swollen veins in the bottom of the rectum or the anus. They do not usually cause serious health problems. But they can be annoying and uncomfortable.

Hemorrhoids are common, occurring in both men and women. They are more common in people:

Pelvic tumors
Pregnancy, both during or after
Sendenaty people, or those who sit for prolonged periods of time
Those who have diarrhea or constipation
Who are older

Treatment consists of dietary changes and having regular bowel habits. If your hemorrhoids are large, do not go away on their own or you have many hemorrhoids, you may need surgery.

Causes of hemorrhoids

In general the cause of hemorrhoids is increased pressure on the veins in the pelvis and rectal area. The cause of this can be:

Excessive straining found with chronic constipation
Excessive straining found with chronic diarrhea
Pregnancy, due to pressure in the pelvis from the baby in the uterus
Obesity
Prolonged daily sitting like with truck drivers or other sedentary professions

Symptoms of hemorrhoids

The most common symptoms of hemorrhoids include the following:

Painless rectal bleeding, usually is a small amount
Anal itching or pain, due to irritation of the skin surrounding the anus
Tissue bulging around the anus, some people can see or feel hemorrhoids on the outside of the anus
Leakage of feces or difficulty cleaning after a bowel movement

Rectal bleeding

Many people with hemorrhoids notice bright red blood on the stool, in the toilet or on the tissue after a BM. The amount of blood is usually small. Yet even a small amount of blood can cause the water to appear bright red. This can be frightening.

Less common is heavy bleeding.

While hemorrhoids are one of the most common reasons for rectal bleeding, there are other, more serious causes. It is not possible to know what is causing rectal bleeding unless you have an examination. You should seek medical attention if you see bleeding after a bowel movement.

Rectal pain

Hemorrhoids can become painful. If you develop severe pain, call your healthcare provider immediately. This may be a sign of a serious problem.

Testing for hemorrhoids

Often your doctor can determine if you have hemorrhoids by asking about your symptoms and doing a physical examination.

Your doctor will do a digitial rectal examination, an exam using a gloved finger inside your rectum. You may need to do an anoscopy. This is where your doctor inserts a short, lighted scope into your anus and exams the inside of your anal canal. You may need to have a Colonoscopy or sigmoidoscopy for further testing.

Hemorrhoids hidden inside the rectum are “internal” hemorrhoids. You cannot see them, but they can cause symptoms.

Hemorrhoids that you can see or feel are “external” hemorrhoids.

Reproduced with permission from: Patient Information: Hemorrhoids (The Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA 2012. Copyright © 2012 UpToDate, Inc. For more information visit www.uptodate.com.

Hemorrhoid types

hemorrhoidexternal

External hemorrhoids are visible on the outside of the anus and originate in the lower part of the anus. These can become inflammed and the blood inside the veins can become clotted. This is a thrombosed, or clotted, hemorrhoid.

hemorrhoidspicture

Internal Hemorrhoids are generally not visible on the outside. This is because they originate higher up in the anal canal. Internal hemorrhoids more commonly cause bleeding after a bowel movement.

If internal hemorrhoids become large and severe, they can push out through the anus, becoming visible. This can be very painful. This is especially true if the hemorrhoid becomes trapped in the anal muscle and cannot go back inside.

Classification of Internal Hemorrhoids:

Grade 1 (minor) - A hemorrhoid is present but only visualized by a doctor with ansocopy or colonoscopy. The hemorrhoid does not extend out the anus.
Grade 2 - The hemorrhoid(s) extends out of the anus with a bowel movement or with straining. After your BM, the hemorrhoid goes back inside on its own.
Grade 3 - The hemorrhoid(s) extends out of the anus with a bowel movement or with straining. You have to manually push the hemorrhoid back inside the anus. If you have this, you should seek medical attention, but it is not urgent.
Grade 4 (severe) - A hemorrhoid(s) extends outside the anus and are not able to be manually pushed back inside. If you have this seek medical attention immediately. There are significant potential complications.

Hemorrhoid treatment

Most of the time, hemorrhoid symptoms go away after a few days even without treatment. If not, treatment focuses on relieving the pain.

Nonsurgical treatment for hemorrhoids

One of the most important steps in treating hemorrhoids is to avoid constipation. Hard stools can lead to rectal bleeding and/or a tear in the anus, called an anal fissure. Besides pushing and straining to move your bowels can worsen existing hemorrhoids. It also increases your risk of developing new hemorrhoids.

Here are some treatment options:

Fiber supplements — Increasing fiber in your diet is one of the best ways to soften your stools. You can find fiber in fruits and vegetables. The recommended amount of dietary fiber is 20 to 35 grams per day. Several fiber supplements are available, including psyllium (Konsyl®; Metamucil®; Perdiem®), methylcellulose (Citrucel®), calcium polycarbophil (FiberCon®; Fiber-Lax®; Mitrolan®), and wheat dextrin (Benefiber®). Start with a small amount and increase slowly to avoid side effects.
Laxatives — The next step up is for you to try a laxative. Many people worry about taking laxatives regularly. They fear that, if they stop the laxative, they will not be able to have a bowel movement naturally. Laxatives are not "addictive." In fact, using laxatives does not increase your risk of constipation in the future. Instead, they may actually prevent long-term problems with constipation.
Warm sitz baths — During a sitz bath, you soak the rectal area in warm water for 10 to 15 minutes two to three times daily. Sitz bath tubs are available in most drugstores. It is also possible to use a bathtub and sit in 2 to 3 inches of warm water. Do not add soap, bubble bath, or other additives in the water. Sitz baths work by improving blood flow and relaxing the muscle around the anus.
Topical treatments — Various creams and suppositories are available to treat hemorrhoids. Many are available over-the-counter, without a prescription. Creams and rectal suppositories may help, temporarily, relieve pain, inflammation and itching. You should not use hemorrhoid creams and suppositories, particularly hydrocortisone, for longer than one week. If you need to use it longer, speak to your healthcare provider and get their approval.

It is important to see your doctor if you notice bleeding from your rectum. You need to make sure the cause is hemorrhoids and not some other problem.

Minimally invasive treatment options

If you have bothersome hemorrhoids after using conservative measures, you may want to consider a minimally invasive procedure.

The following procedures are treatment options for internal hemorrhoids.

Rubber band ligation

Rubber band ligation is the most widely used procedure to treat hemorrhoids. It is successful in approximately 70 to 80 percent of patients.\

Your doctor will place rubber bands or rings around the base of an internal hemorrhoid. This restricts the blood supply to the hemorrhoid. It shrinks and degenerates over several days. Many patients report a sense of "tightness" after the procedure. You can use a warm sitx bath to improve comfort.

We encourage patients to use fiber supplements immediately to avoid constipation.

Delayed bleeding may occur when the rubber band falls off. This usually occurs two to four days after the procedure. In some cases, a raw and sore area develops one to five to days later. Other less common complications of rubber band ligation include:

Severe pain
Thrombosis of other hemorrhoids
Localized infection or pus formation (abscess)

While these might happen, rubber band ligation rarely causes serious complications.

Laser, infrared, or bipolar coagulation

These methods of treatment involve the use of laser or infrared light or heat to destroy your internal hemorrhoids.

We perform most procedures as a day surgery or outpatient surgery.

Sclerotherapy

During sclerotherapy, we inject a chemical solution into hemorrhoidal tissue. This causes the tissue to break down and form a scar. Sclerotherapy may be less effective than rubber band ligation.

Surgical treatment of hemorrhoids

If you continue to have hemorrhoids, despite conservative or minimally invasive therapies, you may need surgical removal of hemorrhoids. We call this hemorrhoidectomy. Surgery is the treatment of choice for patients with large internal hemorrhoids.

Hemorrhoidectomy involves surgically removing excess hemorrhoidal tissue. We can do this in various ways, but it is generally done under general anesthesia with the patient asleep. It is successful in 95 percent of patients.

Risks of Hemorrhoid Surgery include (but not limited to):

Bleeding may be immediate or delayed several days after the surgery.
Constipation, due to pain in rectal area and due to narcotic pain medication.
Injury to the anal sphincter, which could result in anal incontinence.
Anal stricture (narrowing of the anus due to scar tissue).

After hemorrhoid surgery

This is generally a same-day surgery. Most people are able to return to work and other activities in about 1-2 weeks. You may have a small amount of bleeding on the dressing or after having a bowel movement. This can last for a couple weeks. You should contact your doctor if the bleeding is more than a few Tablespoons per day.

You may resume your usual diet immediately after surgery.

It is very important to not allow yourself to become constipated after surgery. To avoid constipation, we recommend:

Starting a diet of high fiber the morning after surgery. Bran cereal, wheat or rye bread, fresh fruits, and vegetables are ideal.
Mixing one tablespoon of Metamucil with eight ounces of water twice a day. You should start this on the morning after surgery.
Taking Dulcolax stool softener (100mg) twice daily. This starts on the day before your surgery, and until you are no longer taking pain medication.
If you go 48 hours without a bowel movement (BM), take two tablespoons of Milk of Magnesia. Continue taking every 6 hours until your first BM, and then stop.
Call the office if you go more than 2 days without a BM or if you are having abdominal pain or abdominal distension.
Drink plenty of water and juice and eat fresh fruits and vegetables.