Help for hemorrhoids

A scourge of midlife, hemorrhoids are unquestionably a pain. Many women have a passing encounter with hemorrhoids during pregnancy. By age 50, about half the population has experienced one or more of the classic symptoms, which include rectal pain, itchiness, bleeding, and possibly prolapse (hemorrhoids that protrude through the anal canal). Although hemorrhoids are rarely dangerous, they can be a recurrent and painful intrusion. Fortunately, there’s a lot we can do about them.

What Are Hemorrhoids?

In one sense, everyone has hemorrhoids, the pillow-like clusters of veins that lie just beneath the mucus membranes lining the lowest part of the rectum and the anus. The condition most of us call hemorrhoids (or piles) develops when those veins become swollen and distended, like varicose veins in the legs (please see illustration).

There are two kinds of hemorrhoids: internal ones, which occur in the lower rectum, and external hemorrhoids, which develop under the skin around the anus. External hemorrhoids are the most uncomfortable, because the overlying skin becomes irritated and erodes. If a blood clot forms inside an external hemorrhoid, the pain can be sudden and severe. You might feel or see a lump around the anus. The clot usually dissolves, leaving excess skin (a skin tag), which may itch or become irritated.

Internal hemorrhoids are typically painless, even when they produce bleeding. You might, for example, see bright red blood on the toilet paper or dripping into the toilet bowl. Internal hemorrhoids may also prolapse, or extend beyond the anus, causing several potential problems. When a hemorrhoid protrudes, it can collect a small amount of mucus and microscopic stool particles that may cause an irritation called pruritus ani. Wiping constantly to try to relieve the itching can worsen the problem.

What Causes Hemorrhoids?

Experts are divided on exactly what causes hemorrhoids but probably several mechanisms are at work. Traditionally, hemorrhoids are associated with constipation, straining during bowel movements, and prolonged sitting on the toilet – all of which interfere with blood flow to and from the area, causing it to pool and enlarge the vessels. This also explains why hemorrhoids are common during pregnancy, when the enlarging uterus presses on the veins.

Most recent studies show that patients with hemorrhoids tend to have a higher resting anal tone – that is, the smooth muscle of the anal canal tends to be tighter than average (even when not straining). Constipation adds to those troubles, because straining during a bowel movement increases pressure in the anal canal and pushes the hemorrhoids against the sphincter muscle. Finally, the connective tissues that support and hold hemorrhoids in place weaken with age, causing hemorrhoids to budge and prolapse.

How Do You Diagnose Hemorrhoids?

Hemorrhoids can usually be diagnosed from a simple medical history and physical exam. External hemorrhoids are generally apparent, especially if a blood clot has formed. Your doctor may perform a digital rectal exam (DRE) to check for blood in the stool. She/he may also examine the anal canal with an anoscope, a short plastic tube inserted into the rectum, with illumination. If there’s evidence of rectal bleeding or microscopic blood in the stool, flexible sigmoidoscopy or colonoscopy may be performed to rule out other causes of bleeding, such as colorectal polyps, especially in women over the age of 50.

What Home Treatments Can We Do?

Most hemorrhoid symptoms improve dramatically with simple home measures. To avoid occasional flare-ups, try the following:

• Get more fiber. Add more fibers to your diet from food, a fiber supplement (such as Metamucil, Fibrosine, or Psyllium), or both. Along with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids. High-fiber foods include broccoli, beans, wheat and oat bran, whole-grain foods, and fresh fruits. Fiber supplements help decrease hemorrhoidal bleeding, inflammation, and enlargement. They may also reduce irritation from small bits of stool that are trapped around the blood vessels. Some women find that boosting fiber causes bloating or gas. Start slowly, and gradually increase your intake to 25-30 grams of fiber per day. Also, increase your fluid intake.

• Exercise. Moderate aerobic exercise, such as brisk walking 20-30 minutes a day, can help stimulate bowel function.

• Take time. When you feel the urge to defecate, go to the bathroom immediately; don’t wait until a convenient time. Stools can back up, leading to increased pressure and straining. Also, schedule a set time each day, such as after a meal, to sit on the toilet for a few minutes. This can help you establish a regular bowel habit.

• Sitz. A sitz bath is a warm water bath for the buttocks and hips (the name comes from the German word sitzen, meaning "to sit"). It can relieve itchiness, irritation, and spasms of the sphincter muscle. Medical supply stores sell small plastic tubs that fit over the toilet seat, or you can sit in a regular bathtub with a few inches of warm water. Most experts recommend a 20-minute sitz bath after each bowel movement and two to three times a day in addition. Take care to gently pat the anal area dry afterward; do not rub or wipe hard. You can also use a hair dryer to dry the area.

• Seek topical relief. Over-the-counter hemorrhoid creams containing a local anesthetic can temporarily soothe pain. Creams and suppositories containing hydrocortisone are also effective, but don’t use them for more than a week at a time, because they can cause the skin to atrophy. Witz hazel wipes (Tucks) are soothing and have no harmful effect. A small ice pack placed against the anal area for a few minutes can also help reduce pain and swelling. Finally, sitting on a cushion rather than a hard surface helps reduce the swelling of existing hemorrhoids and prevents the formation of new ones.

• Treat the clot. When an external hemorrhoid forms a blood clot, the pain can be excruciating. If the clot has been present for longer than two days, apply home treatments for the symptoms while waiting for it to go away on its own. If the clot is more recent, the hemorrhoids can be surgically removed or the clot withdrawn from the vein in a minor office procedure performed by a surgeon.

What Procedures Are Used For Treatment?

Some hemorrhoids can’t be managed with conservative treatments alone, either because symptoms persist or because an internal hemorrhoid has prolapsed. Fortunately, a number of minimally invasive treatments are available that are less painful than traditional hemorrhoid removal (hemorrhoidectomy) and allow a quicker recovery. These procedures are generally performed in a surgeon’s office or as out-patient surgery in a hospital.

• Band it. The most commonly used hemorrhoid procedure in the United States is rubber band ligation, in which the band causes the hemorrhoid to shrink and the surrounding tissue to scar as it heals, holding the hemorrhoid in place. It takes two to four procedures, done six to eight weeks apart, to completely eliminate the hemorrhoid. Complications, which are rare, include mild pain or tightness (usually relieved with a sitz bath), bleeding, and infection. Other office procedures include laser or infrared coagulation, sclerotherapy, and cryosurgery. They all work on the same principle as rubber band ligation, but are not quite as effective in preventing recurrence. Side effects and recurrence vary with the procedure, so consult your physician about what’s best for your situation.

• Hemorrhoidectomy. You may need surgery if you have large protruding hemorrhoids, persistently symptomatic external hemorrhoids, or internal hemorrhoids that return despite rubber band ligation. In a traditional hemorrhoidectomy, a narrow incision is made around both external and internal hemorrhoidal tissue and the offending blood vessels are removed. This procedure cures 95 percent of cases and has a low complication rate – plus a well-deserved reputation for being painful. The procedure requires general anesthesia and most patients need narcotic analgesics afterward. Patients can usually return to work after seven to 10 day. Despite the drawbacks, many people are pleased to have a definitive solution to their hemorrhoids.

• Staples. A newer alternative to traditional hemorrhoidectomy is called stapled hemorrhoidopexy. This procedure treats bleeding or prolapsed internal hemorrhoids. The surgeon uses a stapling device to anchor the hemorrhoids in their normal position. Like traditional hemorrhoid removal, stapled hemorrhoidopexy is performed under general anesthesia as day surgery, but it’s less painful and recovery is quicker. It’s more painful than rubber band ligation and has more minor side effects, but it only needs to be done once; the hemorrhoids are also much less likely to return.

Yes, a few simple strategies can help ease the pain and trouble associated with these bothersome, bulging blood vessels.