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What to do about hemorrhoids

By midlife, many more of us have had one or more of the classic symptoms of hemorrhoids, which include rectal pain, itching, bleeding, and possibly prolapse (protrusion of hemorrhoids into the anal canal). Leakage of feces may also occur. Although hemorrhoids are rarely dangerous, they can be a painful recurrent bother. Fortunately, there’s a lot we can do about them.

What are hemorrhoids?

In one sense, everyone has hemorrhoids — pillow-like clusters of veins that lie just beneath the mucous membranes lining the lowest part of the rectum and the anus. Trouble develops when these veins become swollen and distended, like varicose veins in the legs. There are two kinds of hemorrhoids: internal ones, which occur in the lower rectum, and external ones, which develop under the skin around the anus. External hemorrhoids are the most uncomfortable, because they irritate and erode the overlying skin. Internal hemorrhoids are usually painless, but they often result in bleeding, which may show up bright red on toilet paper or dripping into the toilet bowl. An internal hemorrhoid may also prolapse and extend beyond the anus, causing potential problems such as anal itching.

What causes hemorrhoids?

Large, prolapsing hemorrhoids are associated with chronic constipation, straining during bowel movements, and prolonged sitting on the toilet — all of which can cause blood to pool and enlarge the vessels. Inadequate fiber intake may also contribute.

Conservative treatment

Most hemorrhoid symptoms improve dramatically with simple measures. Here are some things to try:

Add fiber. Boost the fiber in your diet with either high-fiber foods or a fiber supplement or both. When taken with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids and the resulting risk of bleeding, inflammation, and swelling.

Exercise. You can stimulate bowel function with moderate aerobic exercise, such as brisk walking 20 to 30 minutes a day.

Establish a regular bowel habit. When you feel the urge, go to the bathroom immediately; don’t wait for a more convenient time. Stool can back up, leading to increased pressure and straining. Also, schedule a time each day — perhaps just after a meal — to sit on the toilet for a few minutes.

Sit in a sitz. You can often relieve itching, irritation, and spasm of the sphincter muscle with a warm water bath for the buttocks (sitz bath). Sit in a regular bathtub with a few inches of warm water, or go to a pharmacy and buy a small plastic tub that fits over a toilet seat.

Try something topical. Over-the-counter analgesic creams can temporarily soothe pain, irritation, and itching. Creams and suppositories containing hydrocortisone are also effective. Witch hazel wipes (Tucks) are soothing. A small ice pack placed against the anal area for a few minutes may also help. Finally, sitting on cushions rather than hard surfaces can help reduce swelling.

Procedures to treat hemorrhoids

Some hemorrhoids can’t be managed with conservative treatments alone. These hemorrhoids are usually candidates for one of several minimally invasive outpatient procedures. If symptoms continue despite these measures, surgery may be required. Here are the options:

Rubber band ligation. Rubber band ligation is the most widely used procedure for treating internal hemorrhoids. The technique is easy to perform, requires no anesthesia, and succeeds 70% to 80% of the time. The surgeon introduces a small elastic band into the anal canal on a ring called a ligator and places it around the base of a hemorrhoid. The band causes the hemorrhoid to shrink and the surrounding tissue to scar as it heals, holding the hemorrhoid in place. The hemorrhoid is eliminated after two to four procedures, done six to eight weeks apart. Serious complications are rare.

Laser, infrared, and bipolar coagulation. These methods involve the use of light or heat to shrink the hemorrhoid and form scar tissue. They cause less pain than rubber band ligation, but are less likely to guarantee that symptoms won’t return.

Hemorrhoidectomy. In a traditional hemorrhoidectomy, the surgeon makes an incision around both external and internal hemorrhoid tissue, removes the affected blood vessels, and closes the incision with a continuous absorbable suture. This procedure cures 95% of cases and has a low complication rate — apart from a well-deserved reputation for being painful. General or spinal anesthesia is necessary, and most people need pain medications afterward.

Stapled hemorrhoidectomy. This alternative to traditional hemorrhoidectomy is often recommended after rubber band ligation has failed. The surgeon uses a stapling device to anchor the hemorrhoids in their normal position. The procedure is performed under general anesthesia, but it’s less painful than traditional hemorrhoidectomy.

July 2008 update

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