Definition of Hemorrhoids
Hemorrhoids or haemorrhoids, are vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed. In their physiological state, they act as a cushion composed of arterio-venous channels and connective tissue.
The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleedingwhile external hemorrhoids may produce few symptoms or if thrombosed significant pain and swelling in the area of the anus. Many people incorrectly refer to any symptom occurring around the anal-rectal area as “hemorrhoids” and serious causes of the symptoms should be ruled out. While the exact cause of hemorrhoids remains unknown, a number of factors which increase intra-abdominal pressure, in particular constipation, are believed to play a role in their development.
Initial treatment for mild to moderate disease consists of increasing fiber intake, oral fluids to maintain hydration, NSAIDs to help with the pain, and rest. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Surgery is reserved for those who fail to improve following these measures. Up to half of people may experience problems with hemorrhoids at some point in their life. Outcomes are usually good.
Cause of Hemorrhoids
The exact cause of symptomatic hemorrhoids is unknown. A number of factors are believed to play a role including: irregular bowel habits (constipation or diarrhea), a lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascitis, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging. Other factors that are believed to increase the risk include obesity, prolonged sitting, a chronic cough and pelvic floor dysfunction. Evidence for these associations, however, is poor.
During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. Delivery also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.
Signs and Symptoms of Hemorrhoids
The commonest symptom of internal hemorrhoids is bright red blood in the toilet bowl or on one’s feces or toilet paper. When hemorrhoids remain inside the anus they are almost never painful, but they can prolapse (protrude outside the anus) and become irritated and sore. Sometimes, prolapsed hemorrhoids move back into the anal canal on their own or can be pushed back in, but at other times they remain permanently outside the anus until treated by a doctor.
Small external hemorrhoids usually do not produce symptoms. Larger ones, however, can be painful and interfere with cleaning the anal area after a bowel movement. When, as sometimes happens, a blood clot forms in an external hemorrhoid (creating what is called a thrombosed hemorrhoid), the skin around the anus becomes inflamed and a very painful lump develops. On rare occasions the clot will begin to bleed after a few days and leave blood on the underwear. A thrombosed hemorrhoid will not cause an embolism.
Risk Factors for Hemorrhoids
Hemorrhoids are caused due to excessive pressure in the rectum, compelling the blood to stretch and bulge the walls of veins leading to their rupture. Some of the common causes and risk factors for hemmorhoids include:
- Constant sitting
- Not drink enough water
- Straining bowel movements due to constipation or hard stools
- Sitting on the toilet for a long time
- Low-fiber diet
- Severe coughing
- Pregnancy and Childbirth
- IBS (Irritable Bowel Syndrome)
- Heavy lifting
- Lack of erect posture
- Higher socioeconomic status
- Colon malignancy
- Hepatic disease
- Elevated anal resting pressure
- Spinal cord injury
- Loss of rectal muscle tone
- Rectal surgery
- Anal intercourse
- Faulty bowel function due to overuse of laxatives or enemas; straining during bowel movements
- Crohn’s Disease
Diagnosis of Hemorrhoids
Hemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. A rectal exam may be performed to detect possible rectal tumors, polyps, an enlargedprostate, or abscesses. This examination may not be possible without appropriate sedation due to pain, although most internal hemorrhoids are not associated with pain. Visual confirmation of internal hemorrhoids may require anoscopy, a hollow tube device with a light attached at one end. There are two types of hemorrhoids: external and internal. These are differentiated by their position with respect to the dentate line. Some persons may concurrently have symptomatic versions of both. If pain is present the condition is more likely to be an anal fissure or an external hemorrhoid rather than an internal hemorrhoid.
Internal hemorrhoids are those that originate above the dentate line. They are covered by columnar epithelium which lacks pain receptors. They were classified in 1985 into four grades based on the degree of prolapse.
- Grade I: No prolapse. Just prominent blood vessels.
- Grade II: Prolapse upon bearing down but spontaneously reduce.
- Grade III: Prolapse upon bearing down and requires manual reduction.
- Grade IV: Prolapsed and cannot be manually reduced.
External hemorrhoids are those that occur below the dentate or pectinate line. They are covered proximately by anoderm and distally by skin, both of which are sensitive to pain and temperature.
Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices and itching have similar symptoms and may be incorrectly referred to as hemorrhoids. Rectal bleeding may also occur due to colorectal cancer, colitis includinginflammatory bowel disease, diverticular disease, and angiodysplasia. If anemia is present, other potential causes should be considered.
Other conditions that produce an anal mass include: skin tags, anal warts, rectal prolapse, polyps and enlarged anal papillae. Anorectal varices due to increased portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition.
Prevention from Hemorrhoids
A number of preventative measures are recommended including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high fiber diet and drinking plenty of fluid or taking fiber supplements, and getting sufficient exercise. Spending less time attempting to defecate, avoiding reading while on the toilet, as well as losing weight for overweight persons and avoiding heavy lifting are also recommended.
Treatment of Hemorrhoids
Conservative treatment typically consists of nutrition rich in dietary fiber, uptake of oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest. Increased fiber intake has been shown to improve outcomes, and may be achieved by dietary alterations or the consumption of fiber supplements. Evidence for benefits from sitz baths during any point in treatment however is lacking. If they are used they should be limited to 15 minutes at a time.
While many topical agents and suppositories are available for the treatment of hemorrhoids, there is little evidence to support their use. Steroid containing agents should not be used for more than 14 days as they may cause thinning of the skin. Most agents include a combination of active ingredients. These may include: a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine. Flavonoids are of questionable benefit with potential side effects. Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.
A number of office based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur.
- Rubber band ligation is typically recommended as the first line treatment in those with grade 1 to 3 disease. It is a procedure in which elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the dentate line, intense pain results immediately afterwards. Cure rate has been found to be about 87% with a complication rate of up to 3%.
- Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is ~70% which is higher than that with rubber band ligation.
- A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually only used when other methods fail. This procedure can be done using electrocautery,infrared radiation, laser surgery, or cryosurgery. Infrared cauterization may be an option for grade 1 or 2 disease. In those with grade 3 or 4 disease re-occurrence rates are high.
A number of surgical techniques may be used if conservative management and simple procedures fail. All surgical treatments are associated with some degree of complications including bleeding, infection, anal strictures and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder. There may also be a small risk of fecal incontinence, particularly of liquid, with rates reported between 0% and 28%. Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse.
- Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases. It is associated with significant post-operative pain and usually requires 2–4 weeks for recovery. However, there is greater long term benefit in those with grade 3 hemorrhoids as compared to rubber band ligation. It is the recommended treatment in those with athrombosed external hemorrhoid if carried out within 24–72 hours. Glyceryl trinitrate ointment post procedure, helps both with pain and healing.
- Doppler-guided, transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound doppler to accurately locate the arterial blood inflow. These arteries are then “tied off” and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate, but fewer complications compared to a hemorrhoidectomy.
- Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, is a procedure that involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids. However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorroidectomy and thus it is typically only recommended for grade 2 or 3 disease.