Hemorrhoids are dilated and congested vascular complex at the lower end of the anal canal, Think of them as varicose veins. They are highly vascular “cushions” or “pads” consisting of discrete masses of thick sub mucosa which contain blood vessels, smooth muscle, and elastic and connective tissues. Such cushions are present in everyone and the term “hemorrhoids” is confined to situations in which these cushions are enlarged, inflamed and cause symptoms.

The Rectum is the 10-15 cm of the lower colon above the dentate line. In the rectal ampulla, a space above the dentate line, there are three vascular hemorrhoidal cushions which help the muscles to maintain continence. No pain fibers here. The dentate line separates the zone of internal hemorrhoids above from the zone of external hemorrhoids below.  The anal canal is the 3-4 cm between the dentate line and anal verge. The nerves in this area help us with continence to discriminate between gas, fluid and solid waste.  Anus or anal verge is the outlet covered by true skin rich in nerve endings.  Internal hemorrhoids are above the dentate line and covered with insensitive mucosa while externals are below the dentate line and covered by sensitive skin-like cells.  If the outer aspect of a hemorrhoid is covered with skin but the inner side is mucosa

Over half the population will have some occurrence of hemorrhoid symptoms by age 50 and the incidence peaks between 45 and 65. Men and women affected equally, but men are more likely to seek treatment.  Ten to twenty million Americans have active hemorrhoids and as many as 5 million seek medical help each year. We spend over 250 million dollars each year on hemorrhoid products. 1.5 million Prescriptions.  More than 120,000 surgical hemorrhoidectomies are done each year.  Most are unnecessary. 1.5 million Colonoscopies are done each year.

The causes of hemorrhoids is a lack of soluble fiber and enough water in the diet, straining, and sitting longer than 2 minutes on the toilet which promotes prolapse of the anal cushions. Hemorrhoids may be inherited, but it may only be the behaviors and diet habits that are passed along. Increase in abdominal pressure e.g. pregnancy, obesity, pelvic tumors, lifting, sitting, coughing, constipation, diarrhea, anal intercourse and aging are among the causes of developing hemorrhoids. Hemorrhoids can be exacerbated by excessive cleaning, rubbing, steroids, and hemorrhoid creams. Enlargement comes from the dragging of the hemorrhoids downward, weakened supporting tissue.

There are many risk factors that promote hemorrhoids, from these factors; Past history of hemorrhoid symptoms or anal fissure,  Age 30-65, heavy lifting, prolonged sitting, constipation/Diarrhea, pregnancy, failure to eat breakfast, spicy food, fats, alcohol, smoking, low water intake, obesity and spinal cord injuries.

Hemorrhoid Grades:

The severity is graded by the degree of prolapse

• Grade 1 hemorrhoid -no prolapse and cause painless bleeding.
• Grade 2 hemorrhoid – prolapse on defecation, go back spontaneously. Seen on straining.
• Grade 3 hemorrhoid – prolapse and have to be pushed back leading to bleeding and aching pain.
• Grade 4 hemorrhoid – Can’t be pushed back leading to mucous discharge, bleeding, pain and necrosis.

Typical Hemorrhoids Symptoms:

1. Chronic intermittent bright red bleeding with bowel movements, on tissue, in commode, or streaked on stool surface.
2. Feeling of fullness, swelling, extra tissue and incomplete BM.
3. Irritation or itching from seepage of mucus, fecal soiling or dermatitis from hemorrhoid creams causes rash.
4. Pain may occur with prolapse, associated external hemorrhoids or anal fissure.
5. Bulge of tissue on anal skin
6. Blood on toilet tissue.
7. Thrombosis of external hemorrhoids leading to a hard painful lump.
8. Skin tags left over after dilated external hemorrhoids, hemorrhoidectomy, or resolved thrombosis. Can trap stool and cause dermatitis and itching.

Diagnosis of Hemorrhoids:

1. History and physical exam including peril- anal inspection and digital rectal exam. Done in left lateral position. Side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis or abscess.

2. Sigmoidoscopy to rule out tumors of lower colon

3. Manometry/endorectal ultrasound-incontinence study

4. Colonoscopy for persistent bleeding

Prevention of Hemorrhoids:

1-      Eat foods high in fibers such as fresh fruits, leafy vegetables, and whole-grain breads and cereals. Eat additional fiber supplement available over the counter. Drink plenty of water and fluids, at least 6-8 glasses of water daily. Changing your eating and drinking lifestyle, avoid constipation and helps in passing the stool out easily.

2-      Avoid sitting on the toilet for long periods of time. Use the toilet only whenever you feel the urge to have bowel movement. Prolonged sitting on the toilet as well as forcing out the stool causes the hemorrhoids to get worse.

3-      Observe proper anal hygiene. Keep the area clean and dry at all times. Avoid scrubbing the area, for this further aggravates the hemorrhoids and causes irritation. When wiping, use a gentle and slow motion.

4-      Using water to clean the area is the best, but if this is not possible, use a moist toilet paper or baby wipes.

5-      Reduce your weight. Losing weight significantly decreases the pressure on the lower part of your body specifically the rectum area. Maintain a healthy weight for your height to get rid of hemorrhoids.

6-      Avoid lifting heavy objects or other form of activity where you do excessive straining. Ask someone else to help you out.

7-      Refrain from prolonged sitting for extended periods of time. This will limit the pressure being exerted on your bottom.

8-      When your work requires you to be seated most of the time, take a break every now and then and walk around for few minutes

Medical treatment of hemorrhoids:

Apply ice pack to the affected area. It will give a quick relief from the pain and swelling by shrinking the veins. Be careful not to insert the ice directly into the rectum because it will burn your skin

Soak yourself in a warm tub or sitz bath several times a day for about 10 minutes. The warm water will ease the swelling and alleviate the pain associated with hemorrhoids. Make sure to use clean water free from any bath products.

Anorectal preparations may temporarily help relieve anal itching or irritation, but will not cure the problem of rectal bleeding and prolapse. Patients prefer creams over suppositories.

None surgical RBL of hemorrhoids:

1999- Dr. Patrick O’Regan develops a disposable ligation system featuring gentle suction instead of metal grasper.

2006- 2008 Centers for Colo Rectal Health opened in Chicago, Atlanta, Las Vegas, San Francisco, Los Angeles, Denver and New Orleans.

Ligator has now been proven safe and reliable in over 15,000 applications.

Banding normalized the size of hemorrhoidal cushions.

Inflammation reattaches tissue to surrounding muscles.

External disease improves but skin tags may be left behind.

Banding may be done via side viewing anoscope. Band is placed 1.5 to 2 cm above dentate line to decrease pain. After band is applied it is digitally checked for position and comfort.

Who can be banded?

1. Patients may resume normal activities after the banding but should avoid strenuous activities until next day.
2. There may be a feeling of heaviness or fullness for 1-2 days.
3. Avoid constipation. Continue with fiber and fluids.
4. Bleeding may occur which may be from associated fissure or other hemorrhoids. Lie down on side, drink fluids, apply ice to anal area, and if persists call physician.
5. Call physician for urinary retention, fever, myalgia, flu like symptoms.
6. The band will fall off and pass in 1-7 days.

Contraindication to banding:

Anticoagulants such as Coumadin, Plavix, or aspirin are a relative contraindication to hemorrhoid treatment and if possible it is best to stop them for 5 days before and after banding.

In portal hypertension the rectal varices are treated by treating the portal hypertension.

In pregnancy try to avoid rectal procedures to avoid the rare complication of pelvic sepsis or the liability of abortion. Anal fissures may be treated with Nitroglycerin.

Not capable of tolerating office procedure

Large external hemorrhoid disease?

Grade IV hemorrhoidal disease not responding to banding?

Other hemorrhoid treatment modalities:

Anti-inflammatory Cortisone preparation, reduce itching and swelling.

OTC products containing hydrocortisone are not FDA approved for internal anorectal use.

Prolonged use can weaken tissue, promote infection, and cause allergic reaction

Surgical treatment:

Prevention is the best line of treatment

Conservative treatment offer symptomatic relief but does not treat the cause

Rubber band ligation is a none surgical, safe, and painless, in – office treatment. This is the most recommended and effective first choice treatment

Surgical procedures are reserved for large external hemorrhoids and for internal hemorrhoids not responding to rubber band ligation.

Dr. Mando is the Medical Director of the Center for Colorectal Health in Louisiana.

Many people suffer in silence that have hemorrhoids because they are too embarrassed to see a  doctor. Social taboos are associated with this part of our body and we are conditioned to keep any problems with bathroom habits to ourselves. The fear of being ridiculed for having hemorrhoids is enough to keep this condition in our own personal closet forever.  Yet, if you suspect that you have hemorrhoids, you do need to get a diagnosis from your doctor. Remember that doctors are not there to embarrass you, and they routinely perform these examinations all the time.  There are many other conditions that could be causing your symptoms, such as rectal cancer or anal fissures.  Your life is too valuable to gamble with, so always go to your doctor to make sure what you are dealing with is a hemorrhoid. It is one thing to be embarrassed, and quite another thing to have a different disease which could be life-threatening.

Even though you may feel uneasy, seeing a doctor is the right choice!

The doctor will be able to visually identify prolapsed and external hemorrhoids, and then, will examine the interior of the rectum. If you have  internal hemorrhoids they usually can be felt by a digital rectal exam. With this exam, the doctor will insert a gloved lubricated finger into the rectum where they can feel any abnormalities. If the doctor needs to examine the inside of  the rectum visually, they will use an anoscope. An anoscope is a hollow lighted tube useful for viewing internal hemorrhoids.

To rule out any other causes of gastro-intestinal bleeding, the doctor may have you return for a more complete examine of the rectum and colon. A sigmoidoscopy or colonoscopy are diagnostic procedures that involve the use of lighted, flexible tubes inserted through the rectum. These two exams would not be done on your first visit, unless you have gone through the pre-op care required beforehand. Your digestive system would need to be cleansed of all fecal matter for these exams. A sigmoidoscopy can exam half the colon for abnormalities, and it is usually done in the doctor’s office.  In contrast, a colonoscopy exams the whole length of the colon, and is performed in a hospital or outpatient surgical setting.

written by Joy Seeman

© Hemorrhoid Information Center 2009

Hemorrhoidolysis is a non-invasive procedure in which the hemorrhoid is shrunk using an electrical current that is manually applied to the actual site of inflammation, using a tool that is known as an electrode, or small probe.  The electrode transmits a low-grade electrical current onto the hemorrhoid itself, which in turn causes a chemical reaction in the tissue.  It is believed that the tissue at the inflamed site that undergoes this chemical reaction causes hemorrhoidal tissue to shrink, eventually alleviating both the hemorrhoids and its symptoms.  The procedure is also called Galvanic Electrotherapy, or the Ultroid method.

Hemorrhoidolysis is a relatively new modality of treatment for hemorrhoids that is most successful for resolving internal hemorrhoids.  Typically the procedure is painless and can be preformed without anesthesia in a very short period of time within a doctor’s office.  Since complications are virtually non-existent (there are rarely reported side effects such as bleeding or swelling), Hemorrhoidolysis is frequently performed on an outpatient basis, with the individual usually being be able to return to work or home the same day.

Hemorrhoidolysis is most commonly employed for the treatment of internal hemorrhoids.  The theory upon which electrotherapy is based has a long history of successful use by sports doctors and physical therapists for treating soft-tissue conditions such as muscle spasms or atrophy.  Typically the doctor is able to manually treat one hemorrhoid at a time, over what averages out to be three to four visits.  Because the procedure is non-invasive and produces so few complications, it is particularly popular amongst patients who wish to avoid the possible side-effects and recovery time associated with other remedies such as Rubber Band Ligation.  It should be noted that long-term resolution of one’s hemorrhoids and its symptoms also depends upon certain lifestyle changes that demand alterations to diet, exercise, and bowel habits.  Given the procedure’s rate of success treating milder cases of internal hemorrhoids, doctors and patients will likely continue turning to Hemorrhoidolysis.

David Gilbert received his BA from U.C.L.A. He is currently doing graduate work in psychology at California Graduate Institute, in Los Angeles, CA. Throughout his career in the mental health field he has worked clinically with several populations, and also contributed to academic works whose topics address both health and mental health issues.

© Hemorrhoid Information Center

Stapled Hemorrhoidectomy is a relatively new procedure designed to treat what are known as third and fourth degree hemorrhoids, which is a more severe hemorrhoidal scenario than a case of first or second degree external hemorrhoids, or internal hemorrhoids.  Prolapsed Hemorrhoids, for which the Stapled Hemorrhoidectomy is designed, refers specifically to variety of hemorrhoid in which hemorrhoidal tissue extends beyond the mouth of the anus.  Typically, the Prolapsed Hemorrhoid presents as a mass of red tissue that is usually accompanied by a mucosal layer that will be apparent after bowel movements either in the stool, or as a residue left on toilet paper.  In some cases, the mucosal substance will leak and soil undergarments, which is also a means of detecting the presence of this particular variety of hemorrhoid. Stapled Hemorrhoidectomies, unlike the traditional Hemorrhoidectomy, which involves completely excising the inflamed tissue, necessitate removing only a portion of the protruding, or prolapsed tissue, using a tool referred to as a Circular Anal Dilator.  The Circular Anal Dilator separates the extended tissue for removal, while making it possible for the remaining tissue to be secured with staples and set back into its initial position.  The objective of the Stapled Hemorrhoidectomy is to starve the hemorrhoid by reducing to the inflamed region the hemorrhoid’s necessary supply of blood.  Stapled Hemorrhoidectomies were introduced by an Italian physician named Dr. Antonio Longo, around 1993. Originally touted as a more efficient and favorable course of action over traditional surgery, it promised fewer complications, and a shorter and less painful recovery period.  Also known as a Procedure for Prolapsed Hemorrhoids, or PPH, this particular treatment has been reported to produce significantly fewer post-operative impediments than the more invasive and traditional Hemorrhoidectomy.

Circular Anal Dilator

Stapled Hemorrhoidectomy enjoys a high success rate for resolving both the hemorrhoidal condition itself, and also attending hemorrhoid symptoms such as bleeding, because its overall treatment objective is to effectively eliminate blood-flow to the infected region. Stapled hemorrhoidectomies are typically used in severe third or fourth degree cases, although on occasion the procedure will be performed on milder cases that have not responded to other modalities of treatment.  Because of the high success rate associated with the procedure, it is a favored option amongst surgeons and patients wishing to adopt an alternative to conventional surgery.  It is not uncommon for patients to be treated with PPH on a same day basis, and they can usually return to daily activities within a few days.  The procedure itself is a relatively short operation, requiring only minimal anesthesia.  In some cases it has been reported that post-operative complications can include what is called fecal urgency, or a severe and persistent need to defecate, in addition to prolonged and severe pain. Because of these factors and risks, as with all surgical procedures and treatment options, one should first consult with their physician to ensure they choose the best possible option that best suits their needs and their circumstances.  In this way, an informed decision can be made as to whether or not the correct course of action is to undergo the Stapled Hemorrhoidectomy.

written by, David Gilbert

[i] Racalbuto, A. et al., Hemorrhoidal stapled prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial. International Journal of Colorectal Disease.

[ii] Cited Wikipedia, http://en.wikipedia.org/wiki/Stapled_hemorrhoidectomy

[iii] Cited Wikipedia, http://en.wikipedia.org/wiki/Stapled_hemorrhoidectomy

[iv] Science Daily, (Oct. 22, 2006)

[v] Racalbuto, A. et al., Hemorrhoidal stapled prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial. International Journal of Colorectal Disease.

[vi] Cited Wikipedia, http://en.wikipedia.org/wiki/Stapled_hemorrhoidectomy

[vii] Ganio, E., Altomare, D.F., Gabrielli F., et al. Prospective randomized multicentre trial comparing stapled with open hemorrhoidectomy. British Journal of Surgery, 2001; 88: 669-674

[viii] 5. Cheetham MJ, et al. Persistent pain and faecal urgency after stapled hemorrhoidectomy. Lancet, August 26, 2000;356:730-3.