Hemorrhoids and what to do about them
and what to do about them
A few simple strategies
can help ease the pain and trouble associated
with these bothersome bulging blood vessels.
Many women have a passing encounter
with hemorrhoids during pregnancy. But by midlife,
hemorrhoids often become an ongoing complaint.
By age 50, about half the population has experienced
one or more of the classic symptoms, which include
rectal pain, itching, bleeding, and possibly
prolapse (hemorrhoids that protrude through the
anal canal). Although hemorrhoids are rarely
dangerous, they can be a recurrent and painful
intrusion. Fortunately, there’s a lot we
can do about them.
Anatomy of hemorrhoids
Hemorrhoids are distended
blood vessels that form either externally
(around the anus) or internally (in
the lower rectum).
What are hemorrhoids?
In one sense, everyone has hemorrhoids,
the pillow-like clusters of veins that lie just
beneath the mucous membranes lining the lowest
part of the rectum and the anus. The condition
most of us call hemorrhoids (or piles) develops
when those veins become swollen and distended,
like varicose veins in the legs. Because the
blood vessels involved must continually battle
gravity to get blood back up to the heart, some
people believe hemorrhoids are part of the price
we pay for being upright creatures.
There are two kinds of hemorrhoids:
internal ones, which occur in the lower rectum,
and external hemorrhoids, which develop under
the skin around the anus. External hemorrhoids
are the most uncomfortable, because the overlying
skin becomes irritated and erodes. If a blood
clot forms inside an external hemorrhoid, the
pain can be sudden and severe. You might feel
or see a lump around the anus. The clot usually
dissolves, leaving excess skin (a skin tag),
which may itch or become irritated.
Internal hemorrhoids are typically
painless, even when they produce bleeding. You
might, for example, see bright red blood on the
toilet paper or dripping into the toilet bowl.
Internal hemorrhoids may also prolapse, or extend
beyond the anus, causing several potential problems.
When a hemorrhoid protrudes, it can collect small
amounts of mucus and microscopic stool particles
that may cause an irritation called pruritus
ani. Wiping constantly to try to relieve the
itching can worsen the problem.
What causes hemorrhoids?
Experts are divided on exactly
what causes hemorrhoids, but probably several
mechanisms are at work. Traditionally, hemorrhoids
are associated with chronic constipation, straining
during bowel movements, and prolonged sitting
on the toilet — all of which interfere
with blood flow to and from the area, causing
it to pool and enlarge the vessels. This also
explains why hemorrhoids are common during pregnancy,
when the enlarging uterus presses on the veins.
More recent studies show that
patients with hemorrhoids tend to have a higher
resting anal canal tone — that is, the
smooth muscle of the anal canal tends to be tighter
than average (even when not straining). Constipation
adds to these troubles, because straining during
a bowel movement increases pressure in the anal
canal and pushes the hemorrhoids against the
sphincter muscle. Finally, the connective tissues
that support and hold hemorrhoids in place can
weaken with age, causing hemorrhoids to bulge
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Hemorrhoids can usually be diagnosed
from a simple medical history and physical exam.
External hemorrhoids are generally apparent,
especially if a blood clot has formed. Your clinician
may perform a digital rectal exam to check for
blood in the stool. She or he may also examine
the anal canal with an anoscope, a short plastic
tube inserted into the rectum with illumination.
If there’s evidence of rectal bleeding
or microscopic blood in the stool, flexible sigmoidoscopy
or colonoscopy may be performed to rule out other
causes of bleeding, such as colorectal polyps
or cancer, especially in women over age 50.
Most hemorrhoid symptoms improve
dramatically with simple, at-home measures. To
avoid occasional flare-ups, try the following.
Get more fiber. Add
more fiber to your diet from food, a fiber supplement
(such as Metamucil, Citrucel, or Fiber Con),
or both. Along with adequate fluid, fiber softens
stools and makes them easier to pass, reducing
pressure on hemorrhoids. High-fiber foods include
broccoli, beans, wheat and oat bran, whole-grain
foods, and fresh fruit. Fiber supplements help
decrease hemorrhoidal bleeding, inflammation,
and enlargement. They may also reduce irritation
from small bits of stool that are trapped around
the blood vessels. Some women find that boosting
fiber causes bloating or gas. Start slowly, and
gradually increase your intake to 25–30
grams of fiber per day. Also, increase your fluid
aerobic exercise, such as brisk walking 20–30
minutes a day, can help stimulate bowel function.
Take time. When
you feel the urge to defecate, go to the bathroom
immediately; don’t wait until a more convenient
time. Stool can back up, leading to increased
pressure and straining. Also, schedule a set
time each day, such as after a meal, to sit on
the toilet for a few minutes. This can help you
establish a regular bowel habit.
Sitz. A sitz bath
is a warm water bath for the buttocks and hips
(the name comes from the German “sitzen,” meaning “to
sit”). It can relieve itching, irritation,
and spasms of the sphincter muscle. Pharmacies
sell small plastic tubs that fit over a toilet
seat, or you can sit in a regular bathtub with
a few inches of warm water. Most experts recommend
a 20-minute sitz bath after each bowel movement
and two or three times a day in addition. Take
care to gently pat the anal area dry afterward;
do not rub or wipe hard. You can also use a hair
dryer to dry the area.
Seek topical relief. Over-the-counter
hemorrhoid creams containing a local anesthetic
can temporarily soothe pain. Creams and suppositories
containing hydrocortisone are also effective,
but don’t use them for more than a week
at a time, because they can cause the skin to
atrophy. Witch hazel wipes (Tucks) are soothing
and have no harmfu l effects. A small ice pack
placed against the anal area for a few minutes
can also help reduce pain and swelling. Finally,
sitting on a cushion rather than a hard surface
helps reduce the swelling of existing hemorrhoids
and prevents the formation of new ones.
Treat the clot. When
an external hemorrhoid forms a blood clot, the
pain can be excruciating. If the clot has been
present for longer than two days, apply home
treatments for the symptoms while waiting for
it to go away on its own. If the clot is more
recent, the hemorrhoid can be surgically removed
or the clot withdrawn from the vein in a minor
office procedure performed by a surgeon.
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Procedures to treat hemorrhoids
Some hemorrhoids can’t
be managed with conservative treatments alone,
either because symptoms persist or because an
internal hemorrhoid has prolapsed. Fortunately,
a number of minimally invasive treatments are
available that are less painful than traditional
hemorrhoid removal (hemorrhoidectomy) and allow
a quicker recovery. These procedures are generally
performed in a surgeon’s office or as outpatient
surgery in a hospital.
Rubber band ligation
To perform a rubber
band ligation, the clinician places
a ligator over the hemorrhoid to position
a rubber band around its base.
Band it. The most
commonly used hemorrhoid procedure in the United
States is rubber band ligation, in which a small
elastic band is placed around the base of a hemorrhoid
(see bow to the right). The band causes the hemorrhoid
to shrink and the surrounding tissue to scar
as it heals, holding the hemorrhoid in place.
It takes two to four procedures, done six to
eight weeks apart, to completely eliminate the
hemorrhoid. Complications, which are rare, include
mild pain or tightness (usually relieved with
a sitz bath), bleeding, and infection. Other
office procedures include laser or infrared coagulation,
sclerotherapy, and cryosurgery. They all work
on the same principle as rubber band ligation
but are not quite as effective in preventing
recurrence. Side effects and recurrence vary
with the procedure, so consult your physician
about what’s best for your situation.
may need surgery if you have large protruding
hemorrhoids, persistently symptomatic external
hemorrhoids, or internal hemorrhoids that return
despite rubber band ligation. In a traditional
hemorrhoidectomy, a narrow incision is made around
both external and internal hemorrhoid tissue
and the offending blood vessels are removed.
This procedure cures 95% of cases and has a low
complication rate — plus a well-deserved
reputation for being painful. The procedure doesn’t
involve an overnight hospital stay, but it does
require general anesthesia, and most patients
need narcotic analgesics afterward. Patients
can usually return to work after 7–10 days.
Despite the drawbacks, many people are pleased
to have a definitive solution to their hemorrhoids.
Staples. A newer
alternative to traditional hemorrhoidectomy is
called stapled hemorrhoidopexy. This procedure
treats bleeding or prolapsed internal hemorrhoids.
The surgeon uses a stapling device to anchor
the hemorrhoids in their normal position. Like
traditional hemorrhoid removal, stapled hemorrhoidopexy
is performed under general anesthesia as day
surgery, but it’s less painful and recovery
is quicker. It’s more painful than rubber
band ligation and has more minor side effects,
but it only needs to be done once; the hemorrhoids
are also much less likely to return. Research
is now under way comparing stapled hemorrhoidopexy
with rubber band ligation and hemorrhoidectomy
as a first-line treatment for internal hemorrhoids.
(This article was first printed in the July,
2004 issue of the Harvard Women’s Health
Watch. For more information or to order, please
go to http://health.harvard.edu/women.)
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