What Are Hemorrhoids?
The term hemorrhoids is composed of two parts: “hemo” meaning blood and “rhoids” meaning flow. So, hemorrhoids mean veins that are likely to bleed. Hemorrhoids are sometimes also called piles. A common misspelling of the term “hemorrhoids” is “hemroids”.
Hemorrhoid is a painful swelling of the anorectal veins caused by weakness of their walls and excessive pressure in their lumen. The anorectal veins are composed of two sets of veins: internal veins and external veins. So, hemorrhoids are classified into two types:
- Internal hemorrhoids occur due to swelling of internal veins and they cannot be seen or felt unless severe.
- External hemorrhoids are due to swelling of external veins and they can be seen and felt around the anus.
How Common Are Hemorrhoids?
Hemorrhoids are a common condition, affecting more than 50% of the people aged 50 and over. Also, 75% of the population will get hemorrhoids at some point in their lives. Although hemorrhoids are common in all people, they occur more frequently in pregnant women, old people, obese individuals, people with liver cirrhosis, constipation and in people who strain during bowel movements.
Two main factors are responsible - acting together - for the development of hemorrhoids:
A) Weakness of the walls of the anorectal veins. Weakness is usually hereditary, but it may be also caused by hormonal changes, e.g. during pregnancy.
B) Increased pressure inside the anorectal veins. Increased pressure is caused mainly by excessive straining such as due to constipation, lifting heavy objects, due to increased pressure on the pelvic veins by the pregnant uterus, straining to pass the baby during delivery and liver diseases causing portal hypertension.
Genetic predisposition: some individuals are born with genetic weakness of the anorectal veins, which remain healthy until they are exposed to a precipitating factor such as excessive straining when hemorrhoids suddenly develop.
Age: hemorrhoids are more common in older people due to loss of tissue elasticity.
Obesity: hemorrhoids are more common in obese individuals.
Dietary factors: low-fiber diet, insufficient fluid consumption and vitamin E deficiency. These factors increase the risk of hemorrhoids by causing constipation. Also, excessive caffeine and alcohol consumption can lead to development of hemorrhoids by depleting the body of water.
Toilet habits. These include holding stools, reading papers in the toilet and excessive straining in the toilet. The modern toilet design is associated with the increased incidence of hemorrhoids in developed countries because it is less physiological with the process of defecation and causes retention of stools in our bodies. Squatting is more physiological because it allows for better emptying of the rectum with less straining.
Pregnancy is associated with increased risk of hemorrhoids due to hormonal changes leading to weakness of the venous walls. Also, straining during delivery worsens the hemorrhoids.
Liver disease and portal hypertension causing increased pressure in the portal circulation leading to opening of various portosystemic anastomoses, including anorectal veins.
Modern lifestyle: hemorrhoids are more common in industrially developed countries due to a combination of the above factors related to dietary habits and lifestyle.
As mentioned earlier, the anorectal veins are grouped into two sets of veins called internal and external hemorrhoidal veins. Hence, hemorrhoids are classified into two types according to which group of veins is affected as internal hemorrhoids and external hemorrhoids.
Internal hemorrhoids occur due to increased pressure in the internal hemorrhoidal veins, causing their swelling. Internal hemorrhoids usually only have one sign - rectal bleeding with bowel movements which is bright red in color. Pain is usually absent or minimal, unless thrombosis or infection occurs.
External hemorrhoids occur due to increased pressure in the external hemorrhoidal veins, leading to their swelling. Rectal bleeding from straining or rubbing and itching from irritation by mucus are the main symptoms. Rectal pain is also common and becomes severe if thrombosis occurs. Another symptom of external hemorrhoids includes feeling of a hard mass outside the anus, especially when thrombosis occurs.
Hemorrhoid symptoms are not present in every case of hemroid, i.e. many cases are asymptomatic. When they do occur, the most common symptoms of hemorrhoids are rectal bleeding with bowel movements, rectal itching and sometimes also rectal pain. However, symptoms differ according to the type of hemorrhoids - internal or external.
Symptoms of External Hemorrhoids
The most common symptom of external hemorrhoids is rectal pain. Also, blood may collect under the skin forming a hard, tender and painful mass.
Symptoms of Internal Hemorrhoids
Rectal bleeding during or after a bowel movement is the most common symptom of internal hemorrhoids. It should be noted that the blood resulting from hemorrhoids is always bright red in color. Dark red or black blood is never due to hemorrhoids and is usually caused by a more serious problem.
Rectal itching and skin irritation. It is caused by irritation of the anal skin by mucus secreted from internal hemorrhoids.
Rectal discomfort. It is a feeling of urge to pass stools after bowel motion. This is caused by bulging of the hemorrhoids through the anal canal. The larger the mass, the greater the discomfort.
Rectal pain. In contrast to external hemorrhoids, internal hemorrhoids are usually painless, unless the mass is huge in size. If pain is present in internal hemorrhoids, it is usually mild to moderate. Severe pain is usually a result of strangulated hemorrhoids due to interruption of the blood supply. This is a medical emergency.
Anal leakage. If internal hemorrhoids become prolapsed, they may cause anal leakage and soiling.
Differential Diagnosis of Hemorrhoids Symptoms
Hemorrhoids are the most common cause of rectal pain and/or rectal bleeding. Other possible causes of rectal bleeding include anal fissure, anal fistula, pruritis ani and perianal abscess. In addition, after the age of 50 the most frequent cause of rectal bleeding is anorectal cancer, especially if there is a family history of anorectal cancer. Hence, a physician should examine these possibilities to exclude other possible causes of rectal bleeding.
Medical history is taken including current symptoms and a history of possible causes, such as constipation or diarrhea. The aim of the clinical examination is to check the anus for signs of hemorrhoids whereas the goal of rectal (PR) examination is to confirm the diagnosis and to clinically exclude other possible causes of rectal bleeding. Investigations are conducted, if symptoms are not confirmed by clinical examination to be due to hemorrhoids, in order to exclude more serious causes. Investigations include anoscopy, proctoscopy or colonoscopy.
Since some hemorrhoids are inherited and others are acquired, some are related to lifestyle (bowel habits) and others to dietary habits, any effective treatment will, in addition to treating the symptoms, need to address the causes of hemorrhoids. In principle, there are two main lines of treatment of hemorrhoids, i.e. conservative and surgical methods:
A) The conservative methods of hemorrhoids treatment include the following:
(1) Dietary modifications in the form of increasing the intake of dietary fiber and drinking sufficient amounts of fluids. This is beneficial in preventing constipation. Constipation causes hemorrhoids by traumatizing the bowel mucosa and straining the bowel muscles. Other dietary modifications include avoiding foods proven to contribute to hemorrhoids such as nuts, spicy food, alcohol and coffee as well as other foods that are known to worsen symptoms in your individual case.
(2) Toilet re-training. Avoid holding stools, go to toilet once you feel the urge to pass stools. Also, avoid reading papers in the toilet and sitting in the toilet for too long. Modify the method of sitting on the toilet. Flex your thighs on your abdomen and press your elbows on your knees. This position resembles squatting which allows for better emptying of the colon with less straining.
(3) Behavioral modifications. Avoid sitting or standing in the same position for a long time. Move around to relieve pressure on the anorectal veins. Exercise regularly. This will help smooth bowel movements and prevent constipation. Avoid lifting heavy objects.
(4) Non-invasive treatment of hemorrhoids:
- Apply ice on hemorrhoids for 10 minutes, followed by hot fomentations for 20 minutes.
- Do not rub or wipe the affected area after a bowel movement. Use baby wipes instead.
- If you experience severe pain, bed rest may be beneficial in providing relaxation to the bowel muscles which should help ease the pain.
- Take a sitz bath several times a day in which the affected area is soaked with warm water for 15 minutes.
- Use soaps and bath washes that contain less chemicals.
- Use cotton undergarments that absorb moisture including sweat which aggravates the hemorrhoids symptoms.
- Use topical over-the-counter zinc preparations. They protect the anal skin and prevent itching.
- Suppositories such as H formula will temporarily relieve the symptoms, but they have side effects with prolonged use as they may damage the anal skin. So, do not use them for more than seven to ten days at a stretch.
- Local hydrocortisone creams are beneficial in reducing the inflammation and preventing itching. Weak concentrations are available over the counter. If not effective, your doctor can prescribe stronger concentrations for you.
- Local analgesic sprays that can relieve the pain or inflammation are available over the counter.
B) Surgical treatment of hemorrhoids
Surgery, known as hemorrhoidectomy, removes the hemorrhoids and thus solves the problem. However, the post-operative pain may be intolerable and other complications may occur too. In addition, surgery does not address the causes of hemorrhoids. So, as long as the cause is still present, hemorrhoids are likely to recur. Surgical techniques used to remove hemorrhoids include Milligan-Morgan surgical method, Ferguson surgical method, procedure for prolapse and hemorrhoids (PPH) and laser hemorrhoids surgery.