Hemorrhoid Treatments vary considerably—from simple home remedies to invasive surgery, including a Hemorrhoidectomy. The complexity of hemorrhoid treatment depends on the state of the hemorrhoid tissue. This article will cover several different types of treatment options for hemorrhoids. But first, let’s find out what a hemorrhoid is.
Before hemorrhoid treatment is discussed, just what are hemorrhoids? They are simply dilated and congested veins at the lower end of the anal canal, and are very similar to varicose veins. They are highly vascular “cushions" or “pads" consisting of separate masses of thick sub mucosa containing blood vessels, smooth muscle, as well as elastic and connective tissues. These cushions in the anal canal are present in everyone but when they become enlarged and inflamed they become “hemorrhoids" with symptoms ranging from discomfort to substantial pain and need treatment.
To further understand the hemorrhoid treatment landscape, the rest of the environment needs clarification. The rectum is the 10-15 cm of the lower colon above the dentate line (a line dividing the upper 2/3s and lower 1/3 of the anal canal). In the rectal ampulla, in a space above the dentate line, there are three vascular hemorrhoidal cushions which help muscles maintain continence (preventing involuntary bowel movements). There are 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 (a transitional zone between the skin of the anal canal and the perianal skin). The nerves here help maintain continence and discriminate between gas, fluid and solid waste, helping to avoid embarrassing solid and liquid discharges. 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. The outer aspect of a hemorrhoid is covered with skin but the inner side is mucosa
By age 50, over half the population will have some occurrence of hemorrhoid symptoms requiring treatment, with the incidence peaking between 45 and 65. Men and women are 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 treatment each year. Consumers spend over 250 million dollars each year on over-the-counter hemorrhoid treatment products while 1.5 million use prescription medications for the treatment of hemorrhoids. 1.5 million patients undergo Colonoscopies annually as well as more than 120,000 surgical hemorrhoidectomies. Most are unnecessary.
One of the main causes of developing hemorrhoids is not enough soluble fiber in your diet. Other factors that cause hemorrhoids are insufficient hydration, straining, and sitting longer than 2 minutes on the toilet (also resulting in the prolapse of anal cushions). Tendencies for hemorrhoids may be inherited, if only through behavior lifestyle and diet habits passed along from parent to offspring. Other influences include increased abdominal pressure through pregnancy, obesity, pelvic tumors, spinal cord injuries, heavy lifting, prolonged sitting, smoking, coughing, constipation, diarrhea, anal intercourse, anal fissures and aging. Hemorrhoids can be exacerbated by excessive cleaning, rubbing, steroids and overuse of hemorrhoid creams. Further enlargement results from weakened supporting tissue that drags hemorrhoids downward, which most definitely requires treatment. Dietary factors play an extremely important role as well, including erratic eating habits (mostly failure to eat breakfast), spicy foods, excessive consumption of fats and alcohol, inadequate hydration and any number of other dietary lifestyle issues. These are the most common factors that increase the need for treatment, especially among those between the ages of 30 to 65.
Hemorrhoid Grades for Treatment Options:
The severity is graded by the degree of prolapse
- Grade 1 hemorrhoid – no prolapse and painless bleeding.
- Grade 2 hemorrhoid – prolapse on defecation, but tissues return spontaneously. Seen on straining.
- Grade 3 hemorrhoid – prolapse requiring physical reinsertion resulting in bleeding and aching pain.
- Grade 4 hemorrhoid – unable to reinsert prolapsed hemorrhoid, leading to mucous discharge, bleeding, pain and necrosis.
Typical Hemorrhoid Symptoms Requiring Treatment:
- Chronic intermittent bright red bleeding with bowel movements, on tissue, in commode or streaked on stool surface.
- Feeling of fullness, swelling, extra tissue and incomplete bowel movement.
- Irritation or itching from seepage of mucus, fecal soiling or dermatitis from hemorrhoid creams causing rash.
- Pain may occur with prolapse, associated external hemorrhoids or anal fissure.
- Bulge of tissue on anal skin
- Blood on toilet tissue.
- Thrombosis of external hemorrhoids leading to a hard painful lump.
- Skin tags left over after dilated external hemorrhoids, hemorrhoidectomy, or resolved thrombosis (blood clot). Tags can trap stool, causing dermatitis and itching.
Diagnostics for the Treatment of Hemorrhoids:
- History and physical exam including peril-anal inspection and digital rectal exam, usually done in left lateral position with side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis (inflammation) or abscess.
- Sigmoidoscopy to rule out tumors of lower colon
- A manometry/endorectal ultrasound-incontinence study
- Colonoscopy for persistent bleeding
Prevention Treatment of Hemorrhoids:
- Eat foods high in fibers especially fresh fruits, leafy vegetables, and whole-grain breads and cereals. Take additional over-the-counter fiber supplements. Drink plenty of water and fluids—at least 6-8 glasses of water daily is a vital element in the prevention treatment cycle. Altering your eating and drinking habits help, especially consuming smaller portions more frequently to avoid constipation, enhancing the passage of stool.
- 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 exacerbates hemorrhoid development.
- Observe proper anal hygiene. Keep the area clean and dry at all times. Avoid scrubbing, as this further aggravates hemorrhoids and irritates the anus. When wiping, use a gentle and slow motion.
- Using water to clean the area is the best, but if this is not possible, use moist toilet paper or baby wipes.
- Reduce your weight. Losing weight significantly decreases pressure on the lower part of your body, specifically the rectum. Maintain a healthy height to weight ratio to decrease hemorrhoids.
- Avoid lifting heavy objects and other forms of activity resulting in excessive straining. Ask for help.
- Refrain from prolonged sitting for extended periods of time. This limits pressure being exerted on your backside.
- When work requires you to be seated most of the time, take a break every now and then and walk around for few minutes
Home Remedy Treatment of Hemorrhoids:
Apply an ice pack to the affected area. It provides a quick relief from the pain and swelling by shrinking the veins. Do not to insert 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 swelling and alleviate the pain associated with hemorrhoids. Make sure to use clean water free of any bath products.
Anorectal preparations may temporarily help relieve anal itching or irritation, but will not cure rectal bleeding and prolapse. Patients prefer creams over suppositories.
Medical Treatment of Hemorrhoids:
Cauterizing methods can be effective for hemorrhoids through electrocautery, infrared radiation, laser, or cryosurgery.
Sclerotherapy hemorrhoid treatment involves the injecting of an agent, such as phenol, into the hemorrhoid, collapsing the vein walls causing the hemorrhoid to shrivel up. The success rate four years after treatment is 70%.
Doppler guided transanal hemorrhoidal dearterialization is minimally invasive, has fewer complications than the hemorrhoidectomy. It utilizes ultrasound technology to locate arteries supplying blood to the hemorrhoid, which is then “tied off.”
Hemorrhoidectomy is the surgical removal of the hemorrhoid used only in severe cases with significant post operative pain, requiring 2–4 weeks for recovery.
In the stapled hemorrhoidectomy soft tissue is resectioned, disrupting the blood flow to the hemorrhoids. It is less painful than the hemorrhoidectomy and heals faster.
Rubber Band Ligation Treatment of Hemorrhoids:
Rubber band ligation is an outpatient treatment for second-degree internal hemorrhoids. In this procedure, a small band is applied at the base of the hemorrhoid, stopping blood supply to the hemorrhoidal mass, causing hemorrhoids to shrink and completely disappear within 2 to 7 days. The band then falls off during normal bowel movements. Rubber band ligation is a viable alternative to a hemorrhoidectomy at this stage, as it involves less pain with a shorter recovery period. Its success rate is between 60 and 80%. Some important RBL developments:
- 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.
Post-RBL Treatment Protocol – Who Can Be Banded?
- Patients may resume normal activities after the banding but should avoid strenuous activities until the next day.
- There may be a feeling of heaviness or fullness for 1-2 days.
- Avoid constipation. Continue with fiber and fluids.
- Bleeding may occur which may be from associated fissures or other hemorrhoids. Lie down on side, drink fluids, apply ice to anal area and if condition persists call physician.
- Call physician for urinary retention, fever, myalgia, flu-like symptoms.
- The band will fall off and pass in 1-7 days.
Disadvantages to Hemorrhoid Banding Treatment:
- Anticoagulants such as Coumadin, Plavix, or aspirin are a relative contraindication to hemorrhoid treatment and if possible it is best to discontinue use for 5 days before and after banding.
- In portal hypertension the rectal varices are treated by treating the portal hypertension.
- In pregnancy try to stay away from 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, to reduce itching and swelling.
- Over-the-counter products containing hydrocortisone are not FDA approved for internal anorectal use.
- Prolonged use can weaken tissue, promote infection, and cause allergic reaction
Options to Surgical Treatment:
- Prevention is the best line of treatment
- Conservative treatment offers symptomatic relief but does not treat the cause.
- Rubber band ligation is a non-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.