-Connie Pennington, MD
All people have hemorrhoidal tissue as part of their normal anatomy. Hemorrhoidal tissue lies within the anal canal and perianal area and consists of blood vessels, connective tissue, and a small amount of muscle. Their purpose is to aid in continence, or prevent leakage of stool through the anal canal. Hemorrhoids can swell and small blood vessels can rupture causing a thrombosis, or a blood clot under the mucosa or skin. This happens with constipation, straining, heavy lifting, or pregnancy. There are two main types of hemorrhoids: internal and external. Internal hemorrhoids are covered with a lining called mucosa, and reside within the body. External hemorrhoids are covered by skin that is very sensitive and are found outside the body. When problems develop, these two types of hemorrhoids can have very different symptoms and treatments. Symptoms can be caused by either internal or external hemorrhoids or both. The majority of patients with anal symptoms mistakenly think they have a hemorrhoid, when in fact they actually suffer from a different diagnosis, such as an anal fissure, pruritus ani, or even anal cancer. Because a careful history and examination often reveals a different diagnosis, it is important to have a evaluation by a healthcare professional knowledgeable in diseases of the anus.
Symptomatic external hemorrhoids often present as a bluish colored painful lump just outside the anus. External hemorrhoids tend to occur spontaneously and may have been preceded by straining during a bowel movement, or heavy lifting. The skin overlying the outside of the anus is usually firmly attached to the underlying tissues. If a blood vessel ruptures a clot or thrombosis develops in this tightly held area, and the pressure goes up rapidly causing pain. The pain is usually constant and can be severe. Occasionally the elevated pressure in the thrombosed external hemorrhoid results in breakdown of the overlying skin and the clotted blood begins leaking out. External hemorrhoids can also swell and cause pain without a blood clot present.
Anal Skin Tags
An anal skin tag is a painless, soft tissue mass felt on the outside of the anus. These can be the residual effect of a previous problem with an external hemorrhoid. The blood clot stretches out the overlying skin acting as a tissue expander. The skin then remains stretched out after the blood clot is absorbed by the body, and leaves a skin tag. Other times, skin tags can develop without an obvious preceding event. Skin tags will occasionally be bothersome and can interfere with the ability to clean the anus following a bowel movement.
Internal hemorrhoids typically cause painless bleeding, unless they become large and protrude outside of the anus when they can bleed and cause pain. Bleeding attributed to internal hemorrhoids is usually bright red and can be quite brisk. It may be found when wiping, dripping into the toilet bowl, or streaked on the bowel movement itself. Not all symptomatic internal hemorrhoids will have significant bleeding. Instead, prolapse may be the main or only symptom. Prolapsing tissue may result in significant irritation and itching around the anus. There may also be a mucus discharge, difficulty with cleaning after a bowel movement, or a sense that the stool is blocked at the anus when trying to defecate.
Internal hemorrhoids are classified by their degree of prolapse, which helps determine management:
Grade I: No prolapse
Grade II: Prolapse that goes back in on its own
Grade III: Prolapse that must be pushed back in by the patient
Grade IV: Prolapse that cannot be pushed back in by the patient (often very painful)
Grade I hemorrhoids can be seen externally after deep straining and sitting on a toilet to long when vascular engorgement has caused bulging outside of the anal canal. This happens with inappropriate straining and spending to much time of the toilet. One should never read while on the toilet. Treatment recommendations focus on increasing fiber and water consumption to soften the stool and eliminate constipation. Grade I hemorrhoids can be managed conservatively and usually do not require surgery.
Grade II hemorrhoids can be internal and or external hemorrhoids that are engorged and full with the internal component prolapsed to the outside. Generally after straining is over the engorgement will go down and the internal component will return to the inside on its own. In most cases correcting underlying constipation and improving bowel habits will suffice. Sometimes internal hemorrhoid can be ligated with a rubber band in an office setting.
Grade III hemorrhoids have become so large that they easily come out with bowel movements and will not go back unless they are manually reduced, or pushed back in. When prolapsed they can cause pain, and easily succumb to trauma and bleed. Conservative measures will help in bowel movement ease, and steroid suppositories may be of use to assist with the acute inflammation. Sometimes conservative measures fail and surgical removal is necessary.
Grade IV hemorrhoids are swollen and prolapsed to the point that they cannot be reduced. They can be painful, bleed, and cause a mucus like discharge. Although not life-threatening, they are usually managed with surgical removal.
Some acutely prolapsing grade four hemorrhoids can cause the tissue to become strangulated and necrotic necessitating urgent surgical removal. A full thickness rectal prolapse is often confused with prolapsing internal hemorrhoids. With a rectal prolapse the entire rectum turns inside-out protruding through the anus. This can lead to bowel ischemia and necrosis. If a prolapse is encountered it should be manually reduced immediately. Rectal prolapse usually requires surgical correction.
Treatment of an Acute Hemorrhoid
An inflamed, swollen, or bleeding hemorrhoid usually responds to sitting in a warm tub of water, or a Sitz bath. The warm water relaxes the anal sphincter muscles and helps decrease swelling. The topical application of hemorrhoid preparations may be of benefit.
A Guide to Over the Counter Products
Over the counter products can be used to relieve hemorrhoidal symptoms. The following is a guide to the most useful product for various conditions, and how the product generally works. Many products contain combinations of ingredients. Many products are expensive, overused, and simply do not work. Use caution when investing in over the counter products and invest wisely.
Local Anesthetics: Look for the ingredients benzocaine, benzyl alcohol, dibucaine, dyclonine, lidocaine, pramoxine, and tetracaine. Local anesthetics temporarily relieve pain, burning, and itching by numbing the nerve endings. They can be useful for painful external or prolapsed internal hemorrhoids. They should be used externally only. Local anesthetics are generally short acting but can provide good temporary relief, particularly right after a bowel movement, until vascular engorgement subsides.
Antiseptics: Look for the ingredients Boric acid, Hydrastis, Phenol, Benzalkonium chloride, and Resorcinol. Local antiseptics assist in inhibiting the growth of bacteria and other organisms. If you smell a foul odor, or suspect a bacterial infection there may be an abscess and you need to be evaluated by a medical professional.
Vasoconstrictors: Look for the ingredients ephedrine sulfate, epinephrine, and phenylephrine. Vasoconstrictors help to make the blood vessels become smaller, reducing swelling. They are good for situations where hemorrhoids are engorged and bleeding, but other serious causes of bleeding may need to be ruled out by a medical specialist.
Astringents: Look for the ingredients calamine, zinc oxide, and witch hazel. These products promote dryness of the skin, which helps relieve burning, itching, and pain. These are excellent skin barriers and soothe hemorrhoidal pain while protecting the skin from mucus discharge and chapping.
Skin protectants: Look for the ingredients aluminum hydroxide gel, cocoa butter, glycerin, kaolin, lanolin, mineral oil, white petroleum, starch, zinc oxide (calamine), and cod liver oil. These products help form a physical barrier on the skin around the anus and prevent liquid stool and mucus from causing skin damage. These are excellent products to soothe hemorrhoidal pain without harsh ingredients.
Corticosteroids: Look on the label for HC, or hydrocortisone listed in the ingredients. Topical steroids reduce inflammation, relieve itching, and decrease swelling of acutely inflamed hemorrhoids. Topical steroids should not be used more than 7-8 days at a time. Long term use can cause anal itching and permanent skin damage around the anus. For more information on steroids, please refer to a complete description found under "anal itching" in the navigation menu.
Treatment of Hemorrhoids
The cornerstone of therapy, regardless of whether surgery is needed or not, is dietary and lifestyle changes. The most important things are increasing dietary fiber, drinking plenty of water, and exercising. This is all designed to regulate bowel movements. The goal is to avoid both very hard stools and diarrhea, while achieving a soft, bulky, easily cleared type of stool. It is usually recommended to consume at least 20-35 grams of fiber per day, by including plenty of fruits and vegetables. Fiber supplements can be useful. These supplements are available in powder, chewable, and capsule or tablet forms. Fiber can cause constipation if water is not consumed along with the supplement, and 8-10 glasses of filtered water is recommended daily. Sitting on a toilet causes vascular engorgement of hemorrhoidal tissue, therefore time on the toilet should be limited. No reading on the toilet! If symptomatic hemorrhoids fail to respond to dietary changes alone, or if symptoms are severe enough, there are a number of office-based and surgical procedures available.
Office Treatment of External Hemorrhoids
This involves the injection of a local anesthetic (numbing medicine) and excising the hemorrhoidal tissue. The pain associated with a symptomatic, thrombosed external hemorrhoid often peaks about 48-72 hours after its onset and will begin to resolve after roughly four-five days. Pain with or without rupture and bleeding are the indications for surgical treatment. If you are not in pain or experiencing symptoms then non-operative measures are used (warm baths, pain-relieving creams and fiber therapy described above). Removing a small to medium sized external hemorrhoid can be done in the office setting. Excision involves the injection of a local anesthetic and excising the hemorrhoidal tissue. It is important to note that the entire hemorrhoid must be removed and not simply lanced and drained, as that can be associated with recurrence and the development of skin tags.
Office-Based Therapies For Internal Hemorrhoids
The most commonly used office procedure for internal hemorrhoids is rubber band ligation. This can be done for internal hemorrhoids only and do not apply to external hemorrhoids.
Rubber Band Ligation
Rubber band ligation can be used for Grades 1, 2, and some Grade 3 internal hemorrhoids. It is performed by first placing an anoscope into the anal canal, and then placing a device through the anoscope, which can pull up the redundant internal hemorrhoidal tissue and place a rubber band at its base. The band acts to cut off the hemorrhoid's blood supply and it falls off (with the band) at roughly 5-7 days, at which time you may notice a small amount of bleeding. If you are taking blood thinners such as Coumadin, Heparin, or Plavix you may not be a candidate for this procedure. One or two rubber bands can be placed per visit and this may require several short visits to achieve relief of your symptoms, but is not associated with any significant recovery time for most people. Rubber band ligation can be associated with a dull ache or feeling of pressure lasting 1-3 days that is usually well-treated with Ibuprofen or Tylenol. Upon completion of your banding session(s), you likely will not need further treatment, provided you continue the previously described dietary and lifestyle changes. If your symptoms return, repeat banding certainly can be considered. Hemorrhoidectomy is always an option if significant progress is not made with banding. Complications are very uncommon, but may include bleeding, pain, urinary retention, or infection.
Surgical Excision of Hemorrhoids
Fewer than 10% of all patients evaluated with symptomatic hemorrhoids will require surgical management. Most patients respond to non-operative treatment and do not require a surgical procedure. Hemorrhoidectomy, or surgical removal of the hemorrhoidal tissue, may be considered with symptomatic large external hemorrhoids, combined internal and external hemorrhoids, and or grade 3-4 prolapse. Hemorrhoidectomy is highly effective in achieving relief of symptoms and it is uncommon to have any significant recurrence. However, it also causes much more pain and disability than office procedures and can be associated with complications including bleeding and urinary retention.
Hemorrhoidectomy is performed in an operating room and is done while you are completely asleep (general anesthesia). After the hemorrhoids are excised a numbing anesthetic will be injected so that pain is minimal when you wake up in the recovery room. You can expect to have pain following hemorrhoid surgery. The goal is to make it manageable, but it may be up to 2-4 weeks before you are able to resume your full level of activities. You will be discharged with a pain medication. It is important to know that pain medications are constipating, so it is advisable to keep the bowel movements soft by consuming a high fiber diet, drinking plenty of water, and using stool softeners, milk of magnesia, or Miralax post-operatively until pain with bowel movements subside. Sitting in a warm bath 2-3 times daily for 10-15 minutes per time may make you more comfortable. Occasionally, patients will have difficulty urinating after anorectal surgery. If you are unable to void, try urinating in the tub during a sitz bath. If that does not work, proceed to an emergency department for placement of a catheter in your bladder. It can be removed in 2-3 days when the swelling has subsided.
Hemorrhoids are the most commonly misdiagnosed disease of the anus. See a trained medical professional to make sure hemorrhoids are responsible for your symptoms.
Eat a diet high in fiber (25-30 grams a day)
Drink plenty of water
Do not spend more than 3-4 minutes on the toilet and do not read on the toilet (causes vascular engorgement and promotes inflammation and bleeding)
Do not strain excessively
Do not suffer. See a medical specialist for help!