Written By:David B. Rosenfeld, M.D., F.A.C.S., F.A.S.C.R.S. 341 South Moorpark Road Thousand Oaks, CA 91361 Office: 805-230-BUTZ (2889) Fax: 866-518-0359
HEMORRHOID ANATOMY AND PHYSIOLOGY:
Hemorrhoids are venous cushions. They are a part of our anatomy just like our eyes, nose, ears, toes, etc. We are born with at least 6 hemorrhoids, three within the anus (internal hemorrhoids) and three outside the anal opening (external hemorrhoids). External hemorrhoids are abundant in nerve endings. The internal hemorrhoids lack pain fibers. These 2 types of hemorrhoids are like apples and oranges. Although they are both venous cushions, their symptoms and treatment are completely different. Though we have theories as to the function of hemorrhoids, there is no real scientific evidence of their purpose. It is proposed that the function of hemorrhoids is to aide in keeping stool from leaking out of the anus.
MYTHS ABOUT HEMORRHOIDS:
- All bumps around the anus which cause pain and bleeding are hemorrhoids.
- Laser hemorrhoidectomy hurts less than cold scalpel hemorrhoidectomy
- Hemorrhoids are hereditary (don’t forget we are all born with hemorrhoids)
- All hemorrhoids require surgery to treat the problem.
Internal hemorrhoid symptoms:
- Painless bleeding
- Prolapse (protrusion outside of the anus)
- Urgency (feeling of having to have a bowel movement)
- Mucous discharge
External hemorrhoid symptoms:
- Thrombosis (clot within the hemorrhoid) causing pain, itching and sometimes bleeding with clots. A painful swollen lump that looks like a purple grape is a thrombosed hemorrhoid.
CAUSES OF HEMORRHOID SYMPTOMS:
- Straining to have a bowel movement
- Reading on the toilet for long periods of time
- Time – like all tissues, hemorrhoids sag as we get older which increase the chances of hemorrhoid symptoms.
DIFFERENTIAL DIAGNOSIS (CONDITIONS THAT CAUSE THE SAME SYMPTOMS):
- Inflammatory bowel disease (Crohn’s and Ulcerative Colitis)
- Polyps (bleeding)
- Colon cancer (bleeding)
- Rectal cancer (bleeding)
- Anal Cancer -Squamous Cell Carcinoma or Anal Melanoma- (pain and or bleeding)
- Rectal prolapse (the whole rectal lining protrudes from the anus)
- Anal fissure – a tear of the skin around the anus (pain and bleeding)
HEMORRHOIDS IN PREGNANCY:
Return of blood from hemorrhoids passes through the inferior vena cava, which is a large vein that carries blood to the heart. As the fetus grows within the uterus, the uterus becomes larger and heavier. The uterus begins to put pressure on the inferior vena cava making it more difficult for the blood from the legs and pelvic area to drain back into the heart. Since the blood from the hemorrhoids does not drain as well, the hemorrhoids swell causing pain, bleeding, or both. Furthermore, constipation is a precipitating factor to symptomatic hemorrhoids. Many pregnant women become constipated for various reasons. In pregnancy, the treatment of hemorrhoids is most often conservative. Surgery is rarely indicated because of the risks to the mother and the fetus. Conservative therapy consists of steroid creams, warm baths, topical anesthetics and avoidance of constipation.
A statement from a journal article on hemorrhoids in pregnancy states that “the prevailing mindset among physicians and patients has been that anorectal complaints are common and expected and, like other ‘normal’ changes of pregnancy, are to be tolerated and endured.” 1 I feel that this statement is unacceptable as the new treatments available work very well to help relieve the symptoms. As a patient you should not feel that anal problems are something that should be tolerated and will go away in time.
TREATMENT OF HEMORRHOIDS
- Dietary Measures
- Fiber is a complex carbohydrate, which binds with water in the colon creating larger, softer, stool. Contrary to logical thinking, a larger bowel movement is more advantageous than a smaller or looser bowel movement. Larger, softer, stools stretch and relax the sphincter muscles helping the blood to flow. Large, soft, stools also require little pressure to pass. The less one has to bear down to have a bowel movement the less blood is engorged into the hemorrhoids. Personally, the bulking agent I recommend the most is Konsyl. It contains 6 grams of psyllium fiber, more than any other product. I use Konsyl every morning. When shaken with about 4-5 oz. of orange juice it goes down smooth (no I do not own stock in the company). It is important to drink enough water during the day in order for the fiber to work. Eating fiber without enough water can lead to constipation. It is recommended to eat 30-35 grams of fiber per day. The average daily American diet contains only 6-10 grams of fiber! It is also wise to eat foods lower in fat and cholesterol.
- Micronized Diosmin – Diosmin is the active ingredient in orange peels. It is felt that Diosmin increases the venous and lymphatic vascular tone which has been shown to improve both varicose vein and hemorrhoid symptoms. The brand I use is called “European Leg Solution” and can be found on line. Other brands exist which can also be found on line. As Diosmin is a flavenoid or plant metabolite and not a medicine it is safe to use on a daily basis.
- Water is very important as it is soaked up by the fiber making the stools bulky and soft. At least four 8 ounce glasses are necessary per day. Caffeine and liquor are diuretics which increase urination causing dehydration. Stool becomes harder as the colon is used to reabsorb more water during times of dehydration. Water is a natural lubricant and is important for good bowel regularity. Therefore, coffee, tea, caffeinated sodas, and liquor do not count as water. Drinking water with each meal will add 3 glasses of water a day.
- Sitz Baths
- A sitz bath can be done using your bath tub or by purchasing a sitz tub. A sitz bath is a warm to hot tub of water. The warm/hot water helps to relax the anal muscles. This treatment is very effective when you are in the water. Unfortunately, once the sitz bath is over the symptoms usually return. I recommend sitz baths after each bowel movement for up to 2 weeks. If the pain with defecation is extremely severe, and unbearable than I recommend having the bowel movement in the sitz tub. Just put the tub on the toilet and fill it with warm to hot water (not so hot as to scald yourself) and sit in the tub when you have to have a bowel movement. Crap in the tub and then turn it over into the toilet and flush. Then wash out the sitz tub. Sitting in the hot water while having a bowel movement keeps your muscles relaxed. This method is very effective in decreasing or even preventing pain with bowel movements.
- Ointments and Suppositories
- Preparation-H: A topical ointment which sooths the outside of the anus. Though it is believed that Preparation-H will shrink the tissue, there is no scientific evidence (that I am aware of) proving this phenomenon. I believe it is the soothing nature of the ointment that helps the symptoms
- Steroids: Steroids are known to decrease inflammation and therefore shrink the swelling. It can be used as ointments or suppositories. Typically I prescribe a 2.5% hydrocortisone cream with Pramoxine HCL or suppositories for internal hemorrhoid symptoms. Steroid suppositories melt within the anal canal and the steroid coats the internal hemorrhoids decreasing their swelling.
- For external thrombosed hemorrhoids I prescribe a steroid cream. Since 95% of all thrombosed hemorrhoids resolve without surgery conservative management including a topical steroid ointment and hot baths are the first line of therapy. If the thrombosis is not better in 4 weeks or it recurs in the same spot I suggest an excision in the office (see surgical treatment for thrombosed hemorrhoids below).
- Pramoxine HCL: An anti-itch ointment. Anal Pram is an ointment which combines Pramoxine with a steroid. This treatment offers relief of anal itching and swelling.
- Stool Softeners
- If your stool is still hard after using fiber and water an over the counter stool softener such as Colace is recommended.
- Office Procedures (internal hemorrhoids only!)
- Hemorrhoid injections (Sclerotherapy):
- The best first line therapy for symptomatic internal hemorrhoids. A substance (phenol mixed with olive oil) is injected into the internal hemorrhoids causing them to shrink. The procedure takes about 5 minutes and is painless. Symptomatic relief from itching, bleeding and discomfort begins the following day but it takes about 6 weeks for the injections to take full effect. The treatment usually lasts up to about 6 months. Repeat treatments are usually necessary.
- Rubber Band Ligation:
- Placing a rubber band on the internal hemorrhoid in the office which over 2-3 days removes the hemorrhoid. This procedure is more uncomfortable than injections but has a longer lasting effect and is comparable to surgical hemorrhoidectomy for bleeding or protruding hemorrhoids.
- Infrared Coagulation:
- An office procedure where a focused infrared beam is used to burn the internal hemorrhoids. The burning causes a scarring reaction, which shrinks the hemorrhoids. This procedure is uncomfortable but not painful. It has a longer lasting effect than injections
- Excisional hemorrhoidectomy:
- The old fashioned surgical excision of hemorrhoids. The surgery is done as an outpatient at a same day surgery center or hospital. It is an extremely painful operation. The immediate pain from the surgery lasts up to 2-4 days; however, intense pain will last up to 2 weeks. The treatment lasts up to 10-15 years, as the hemorrhoids will grow back. This therapy is reserved for patients who have failed conservative therapy or whose hemorrhoids prolapse (protrude) so much that they will not go back inside. Risks are small and include; severe bleeding, severe infection, and stenosis.
- Doppler Guided Hemorrhoid Artery Ligation and Rectoanal Repair (DGHAL/RAR):
- This is a procedure first developed in Europe in 1995. This surgery uses a Doppler guided anoscope to identify the feeding arteries to the hemorrhoids. Once identified the arteries are sutured to cut off the blood supply to the hemorrhoids. There are usually 6 arteries. Once performed the hemorrhoids begin to decrease in size. To perform the internal hemorrhoidopexy (hemorrhoid lift), the anoscope identifies the enlarged hemorrhoid and a stitch is placed at the top of the hemorrhoid. Using a baseball (running) stitch, the tissue is sutured all the way down to the bottom of the hemorrhoid stopping at an area before the nerve endings begin. The final stitch at the bottom is tied to the begging stitch at the top of the hemorrhoid lifting the enlarged hemorrhoid upward (hemorrhoidopexy). Since the internal and external hemorrhoids lay along the same plane of tissue, this procedure also pulls the external hemorrhoids up which can markedly reduce the symptoms of external hemorrhoids. Because the whole procedure is done above the nerve endings there is no sharp pain, just a dull ache for about 3 days. Patients are very satisfied with the results. If it fails it can be done again safely. The chance of failure in 3 years is only 12%. Risks are small and include; severe bleeding and infection.
- Stapled Hemorrhoidectomy:
- Newer literature on this procedure indicates the surgery does not work as well as originally anticipated. I favor the DGHAL/RAR. The stapled hemorrhoidectomy uses cutting and stapling to treat hemorrhoids. A special instrument is used to cut the tissue above the internal hemorrhoids. The procedure removes a rim of tissue above the internal hemorrhoids which cuts off the blood supply to these hemorrhoids making them shrink. At the same time it pulls the hemorrhoids up inside the anus holding them in their original position. This is similar in concept to a face lift. The pain after words is much less than the old fashioned hemorrhoid surgery. This procedure is not indicated for large external hemorrhoids. If the procedure fails to cure the hemorrhoids it can not be done again. The risks are small but can be severe such as; hemorrhage, severe pelvic infection (sepsis), vaginal fistula formation, and stenosis.
- For external thrombosed hemorrhoids two surgeries are available:
- For the acute phase of the swollen lump, removing the clot (enucleation) is performed if patients are having severe pain. In the office the hemorrhoid is injected with Lidocaine. A small incision is made over the lump and the clot is removed. The swelling persists for 3-4 weeks, however; the acute pain is gone.
- External hemorrhoid excision:
- If the hemorrhoid persists for longer than 5 weeks or recurs in the same spot I suggest excising the whole external hemorrhoid in the office. Lidocaine is injected in the hemorrhoid and the hemorrhoid is excised completely. The recovery is 3-5 days for most patients but may require a full week to recover.
It is important to remember that hemorrhoid symptoms when diagnosed properly are not life threatening. Other diseases, which produce the same symptoms, can be more serious. Therefore, if you have any of the above symptoms such as an anal lump, bleeding, discharge, pain, prolapse, or itching, it is important to call my office for a consultation. To help prevent hemorrhoid problems it is essential to increase the amount of fiber and water in your diet. Decreasing the amount of fat and cholesterol is also helpful. Furthermore, do not be afraid of having your hemorrhoids treated as the office procedures are quite painless and can prevent the need for a surgical hemorrhoidectomy.
- Medich D, Fazio V. Hemorrhoids, Anal Fissure, and Carcinoma of the colon, Rectum, and Anus During Pregnancy. Surgical Clinics of North America 75:1 77-88, 1995
- Faucheron J, Ganger Y: Doppler-Guided Hemorrhoidal Artery Ligation for the Treatment of Symptomatic Hemorrhoids: early and Three-Year Follow-up Results in 100 Consecutive Patients. Disease of the Colon and Rectum 51:945-949, 2008