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.

What do Hemorrhoids look like? It all depends on the type of hemorrhoid. What hemorrhoids look like also depends largely on the current stage your hemorrhoids are in.  Hemorrhoids are swollen blood vessels that populate in and around the anus. These blood vessels can stretch under pressure. They are similar to varicose veins in the legs. Common factors that can cause hemorrhoids are, straining to move a bowel, sitting too long on the toilet, diet, lack of exercise and very little fresh air. Hemorrhoids are either inside the anus (internal hemorrhoid) or under the skin around the anus (external hemorrhoid).

Although many people have hemorrhoids not all experience symptoms. The most common symptoms of internal hemorrhoids is bright red blood covering the stool or inside the toilet or blood on the toilet paper after wiping.

However, an internal hemorrhoid may protrude through the anus outside the body making it more irritated and painful. This is known as a protruding hemorrhoid.

Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid. 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 of mucus may also be the cause of additional itching.

Hemorrhoids are very common in both men and woman. More than half of the adult population will have hemorrhoids by age 50. Hemorrhoids are also common with pregnant woman when the pressure of the fetus is on the abdomen, as well as hormonal changes that  cause  hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most woman, however, hemorrhoids caused by pregnancy are a temporary problem.  Please refer to some of the other articles on H.I.C. if you wish to view more images of what hemorrhoids look like.

written by,

David Gilbert

© 2009 Hemorrhoid Information Center

The symptoms of a Prolapsed hemorrhoids are as follows: a second degree Prolapsed Hemorrhoid retracts of its own accord, a third degree Prolapsed Hemorrhoid is one that can be manually reinserted, while a fourth degree Prolapsed Hemorrhoid is one that remains externalized and cannot be reinserted.  In the most extreme cases, a fourth degree Prolapsed Hemorrhoid becomes either Strangulated or Thrombosed, in addition to its resistance to being manually reinserted into the anus, after which it spontaneously remerges.

Prolapsed Hemorrhoid Symptoms may include mild itching or burning, slight to temperate bleeding, or in more extreme cases, produce severe pain by virtue of its becoming an inflamed mass of externalized tissue.  Other common prolapsed hemorrhoid symptoms include either red blood in the stool or residual red blood on toilet paper, or an inability to complete a bowel movement.  It should be noted that blackened stool or actual pain caused by the act of defecating is not typically symptomatic of a hemorrhoidal condition.  In the presence of these last two symptoms, a doctor should examine the individual suffering the symptoms forthwith.  Essentially, all masses of tissue that are externalized outside of the anus are regarded as external hemorrhoids, with the exception being the prolapsed hemorrhoid, which originate as an internal condition but extend outside of the rectum as they progress.  Prolapsed Hemorrhoids have a variety of causes.  Straining during bowel movements (caused by either diarrhea or constipation) is a typical culprit, as is hypertension, obesity pregnancy, and cigarette smoking.   Each of the foregoing causes has specific explanations, which are as follows:

Straining during a bowel movement places pressure on the walls of the anus, thereby weakening the rectal tissue of the anus and making it susceptible to a hemorrhoidal breach.

Constipation during pregnancy is often the result of water retention, which can induce strenuous bowel movements and thus weaken the walls of the anus, in addition to causing hypertension, which is not an uncommon condition during pregnancy.

Obesity can be a factor in causing Hemorrhoids due to an increase in the amount of pressure exerted on rectal veins, in addition to attending symptoms such as reduced muscle tone and poor posture, all of which also put additional stress on rectal veins.

Cigarette smoking during bowel movements have been linked to not only an increased risk in producing Hemorrhoids, but are also believed to be responsible for causing severe bleeding of the veins in the anus and the rectal area.

Causes and Prevention of Prolapsed Hemorrhoids

Prolapsed Hemorrhoids are caused by a myriad of reasons, and thus their prevention varies.  However, there are standard preventative measures that are typically suggested as a means for either reducing the risk of developing them, or treating them should they occur.  These measures include consuming more fluids and dietary fiber (fruits, vegetables, cereals or muffins that are high in fiber, in addition to taking fiber supplements).  The consumption of fiber and fluids reduces the strain that occurs during bowel movements, which in turn act as agitating factors that can either cause or prolong the condition.  Reducing the time and duration of a bowel movement is also a means of reducing the risk of developing Prolapsed Hemorrhoids, and is a practice that can also assist in the healing process.  Elsewhere it has been suggested by doctors, and reported by patients, that tight undergarments can be a contributing factor to irritating the condition, as can the presence of weak muscle tone in the anal region.  Additionally, women frequently report an increase in the development of Hemorrhoids, or Hemorrhoidal irritation during periods of menstruation, which may be alleviated by washing the affected area with cool or warm soapy water, which can also assist in reducing itching and irritation, and possibly stave off a general worsening of symptoms.

Prolapsed Hemorrhoid Treatment

Prolapsed Hemorrhoids, which are distinguished by an external lump of inflamed tissue protruding from the anus, can be treated with a variety of interventions, depending on their severity.  Inflammation can be reduced by bathing in warm water, which assists the blood vessels in the rectal area to relax.  Steady use of medicated ointments and creams during the initial onset of symptoms can also achieve some relief, and may be a deterrent against increased inflammation or a worsening of the condition.

Prolapsed Hemorrhoid Treatment is typically handled surgically because of the inherent severity of the condition and the nature of its symptoms. In such cases, where the hemorrhoid has externalized, a Hemorroidectomy may be performed.  The procedure consists of surgically excising, or removing, the hemorrhoid, and is noted for the long duration of its recovery time and the severity of pain that accompanies it.  The hemorroidectomy is only recommended for grade IV Hemorrhoids, and has been linked with cases of incontinence later in life.  A Stapled Hemorrhoidectomy is a procedure whose objective is to resect the tissue that is in proximity to what is referred to as the dentate line (the dentate line is the region in the anal canal  that resides above the area where an individual experiences pain).  The Stapled Hemorrhoidectomy works by reducing blood flow to the inflamed tissue, thereby starving the hemorrhoid.  It is a less painful procedure than a Hemorrhoidectomy, and is favored treatment by doctors and patients because of the shorter recovery time that is necessary to otherwise treat a Prolapsed Hemorrhoid.

Alternative Treatments for Prolapsed Hemorrhoids

Prolapsed Hemorrhoids can also be treated with a variety of alternative remedies, which include both preventative practices (usually dietary), as well as medicinally holistic treatment measures.  For example, consuming bulk fiber products like psyllium seed husk and plantain is believed to produce softer stool, which is easier to pass and thus less likely to induce new Hemorrhoids or inflame preexisting ones.  Adopting a squatting position when making a bowel movement is thought to ease stress to the anal walls and aid in easier defecation.  For Individuals whose poor circulation is the cause of their hemorrhoids, doctors sometimes recommend using a pillow to raise the legs while sleeping to assist in eliminating altogether the presence of external hemorrhoids. The use of soothing compounds and substances such as Witch hazel, Cranesbill, Aloe Vera and honey are advocated and favored by some patients because they are regarded as natural or more organic than compounds such as Preparation H, and provide relief for some of the symptoms associated with the condition.  Prolapsed Hemorrhoids have also been reported to respond to certain dietary interventions, such as Butcher’s Broom, Horse-Chestnut, as well as bioflavanoids.  Because compounds such as Butcher’s Broom contain naturally occurring anti-inflammatory agents such as ruscogenins, they are often sought out by patients who wish to try an organic approach to addressing the symptoms that attend Prolapsed Hemorrhoids.

Written by, David Gilbert

© 2009 Hemorrhoid Information Center

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