HEMORRHOID ANATOMY AND PHYSIOLOGY
Hemorrhoids are venous cushions. They are a part of our anatomy just like 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. Hemorrhoids swell with blood and it is felt that the 3 internal hemorrhoids, when swollen, aide in keeping stool from leaking out of the anus.
CAUSES OF HEMORRHOID SYMPTOMS
•Constipation
•Diarrhea
•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.
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.
INTERNALHEMORRHOID SYMPTOMS
•Pain
•Itching
•Painless bleeding
•Pressure
•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.
***If you develop these or other symptoms do not assume that you have hemorrhoids . Other conditions can cause the same symptoms. See your doctor to get a full
evaluation and a referral to a colorectal specialist for a proper examination.
DIFFERENTIAL DIAGNOSIS (CONDITIONS THAT CAUSE THE SAME SYMPTOMS)
•Inflammatory bowel disease (Crohns 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.
HEMORRHOID TREATMENT
- NON-SURGICAL
•Dietary Measures
o Fiber and either topical creams or suppositories work best for symptoms of mild bleeding, itching or discomfort due to internal hemorrhoids. A stool softener may be
necessary if the stools are hard. The primary goal is to bulk the stools. Fiber, such as Konsyl, is a complex carbohydrate, which binds with water in the colon
enlarging the stool. Contrary to logical thinking, a larger bowel movement is more advantageous than a smaller or looser bowel movement. Larger stools stretch
and relax the sphincter muscles helping the blood to flow through the hemorrhoids. 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. It is
important to drink 4-6 glasses of 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.
•Ointments and Suppositories
o Preparation-H: A topical hemorrhoid 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
o Steroids: Steroids are known to decrease hemorrhoid swelling and inflammation. It can be used as ointments or suppositories. Typically I prescribe a 2.5%
hydrocortisone cream 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 hemorrhoids I prescribe a steroid cream.
o Pramasone: An anti-itch ointment. Anal Pram is an ointment which combines Pramasone with a steroid. This treatment offers relief of anal itching and swelling.
•Office Hemorrhoid Therapy
o 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. This hemorrhoid treatment usually lasts up to about 6 months. Repeat
hemorrhoidtreatments are usually necessary.
o 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. Very useful for hemorrhoid bleeding or protruding hemorrhoids.
o 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
- SURGICAL THERAPY
•Excisional hemorrhoidectomy: 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 surgery 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.
•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), rectovaginal fistula formation, and anal 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 emorrhoids. 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 beginning stitch at the top of the hemorrhoid lifting the
enlarged hemorrhoid upward. 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. The surgery is painless with only a dull ache for about 3-5 days. Patients are very satisfied with the
results. If t 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.
**It is important to remember that other serious diseases produce the same symptoms. Therefore, if you have symptoms such as an anal lump, bleeding, discharge, pain, prolapse, or itching, it is important to see your doctor for an evaluation. 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 hemorrhoid treatment
1. Medich, David, Fazio, Victor: Hemorrhoids, Anal Fissure, and Carcinoma of the colon, Rectum, and Anus During Pregnancy. Surgical Clinics of North America 75:1 77-88, 1995.
