Hemorrhoids: Diagnosis And Treatment Options
TIMOTHY MOTT, MD, Naval Hospital Pensacola, Pensacola, Florida
KELLY LATIMER, MD, MPH, U.S. Naval Hospital Sigonella, Catania, Italy
CHAD EDWARDS, MD, Hamilton Medical Center, Dalton, Georgia
Am Fam Physician. 2018 Feb 1 97:172-179.
Patient information: A handout on hemorrhoids is available.
Hemorrhoids develop when the venous drainage of the anus is altered, causing the venous plexus and connecting tissue to dilate, creating an outgrowth of anal mucosa from the rectal wall. However, the exact pathophysiology is unknown. Hemorrhoids occur above or below the dentate line where the proximal columnar transitions to the distal squamous epithelium . The anus is approximately 4 cm long in adults, with the dentate line located roughly at the midpoint.2 Hemorrhoids developing above the dentate line are internal. They are painless because they are viscerally innervated. External hemorrhoids develop below the dentate line and can become painful when swollen. The extent of prolapse of internal hemorrhoids can be graded on a scale from I to IV, which guides effective treatment . This grading system is incomplete, however, because it focuses exclusively on the extent of prolapse and does not consider other clinical factors, such as size and number of hemorrhoids, amount of pain and bleeding, and patient comorbidities and preferences.3
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Increasing fiber intake is an effective first-line, non-surgical treatment for hemorrhoids.
FIGURE 1.
What Causes Prolapsed Hemorrhoids
When internal hemorrhoids become more severe, they may prolapse. Hemorrhoids are caused when the rectal veins in the anal canal become swollen. In general, the most common causes of hemorrhoids include:
- Pregnancy
- Poor diet without much fiber
- Straining during bowel movements
- Sitting or standing for too long
- Physical labor, particularly labor that causing straining
- Chronic diarrhea
- Strain or exertion from sneezing, coughing, or vomitting
When internal hemorrhoids become significantly enlarged, they can become prolapsed. Once internal hemorrhoids swell to the point that they protrude out of the rectum, they are prolapsed.
When Do I Need To See A Health Care Provider For Hemorrhoids
You should see your health care provider if you:
- Still have symptoms after 1 week of at-home treatment
- Have bleeding from your rectum. Hemorrhoids are a common cause of bleeding, but other conditions can also cause bleeding. They include Crohn’s disease, ulcerative colitis, colorectal cancer, and anal cancer. So it’s important to see your provider to find the cause of the bleeding.
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How Are Hemorrhoids Diagnosed
Your healthcare provider diagnoses hemorrhoids based on symptoms and a physical exam. You may also have:
- Digital rectal exam: Your provider inserts a gloved, lubricated finger into the rectum to feel for swollen veins.
- Anoscopy: Your provider uses an anoscope to view the lining of the anus and rectum.
- Sigmoidoscopy: Your provider uses a sigmoidoscope to view inside the lower part of the colon and rectum. Procedure types include flexible sigmoidoscopy and rigid sigmoidoscopy .
These tests may be uncomfortable but arent painful. They typically take place in a doctors office or outpatient center without anesthesia. You go home the same day.
Your provider may perform a colonoscopy to confirm findings from other tests or check for signs of colon cancer. This outpatient procedure requires anesthesia.
When Should You See The Doctor For Hemorrhoids
Before assuming that your condition is hemorrhoids, its a good idea to see your doctor for an examination. After all, its difficult to take a look for yourself. And please, no selfies!
If there is any bleeding, severe pain or fecal incontinence , you should definitely see your doctor. A large amount of bleeding or the sudden onset of severe pain means you should seek medical treatment immediately.
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How Do Doctors Treat Hemorrhoids
Doctors treat hemorrhoids with procedures during an office visit or in an outpatient center or a hospital.
Office treatments include the following:
- Rubber band ligation. Rubber band ligation is a procedure that doctors use to treat bleeding or prolapsing internal hemorrhoids. A doctor places a special rubber band around the base of the hemorrhoid. The band cuts off the blood supply. The banded part of the hemorrhoid shrivels and falls off, most often within a week. Scar tissue forms in the remaining part of the hemorrhoid, often shrinking the hemorrhoid. Only a doctor should perform this procedureyou should never try this treatment yourself.
- Sclerotherapy. A doctor injects a solution into an internal hemorrhoid, which causes scar tissue to form. The scar tissue cuts off the blood supply, often shrinking the hemorrhoid.
- Infrared photocoagulation. A doctor uses a tool that directs infrared light at an internal hemorrhoid. Heat created by the infrared light causes scar tissue to form, which cuts off the blood supply, often shrinking the hemorrhoid.
- Electrocoagulation. A doctor uses a tool that sends an electric current into an internal hemorrhoid. The electric current causes scar tissue to form, which cuts off the blood supply, often shrinking the hemorrhoid.
Outpatient center or hospital treatments include the following:
Sometimes complications of hemorrhoids also require treatment.
Why Do Hemorrhoids Occur
Sometimes hemorrhoids develop for no reason, but often they are associated with chronic constipation or diarrhea, straining during bowel movements, and prolonged sitting on the toilet. You can reduce your risk by following these three easy steps:
- Get enough fiber in your diet
- Stay well hydrated
- Exercise regularly .
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Hemorrhoids By The Numbers
- Around 20 million people in the United States suffer from hemorrhoids .
- In 2004, the National Institutes of Health noted that the diagnosis of hemorrhoids was associated with 3.2 million ambulatory care visits, 306,000 hospitalizations and 2 million prescriptions in the United States.
- The peak incidence of hemorrhoids is between the ages of 4565. Development of hemorrhoids before the age of 20 is unusual.
- The risk of developing hemorrhoids is higher in white adults than in black adults, higher in women than in men and higher for women who are pregnant.
What Are Internal Hemorrhoids
Hemorrhoids are vascular structures in your rectum.Specifically, the final portion of the large intestine that your body uses to store and pass stool. These veins are cushioned by muscle and connective tissue.
Everyone has internal hemorrhoids, but we only notice them once they become a problem.
When we refer to hemorrhoids or piles, we are typically referring to hemorrhoids that have become inflamed. About half of adults over 50 experience this issue.
Internal hemorrhoids form near the end of the rectum, but you likely wont see or feel anything unusual, even when a hemorrhoid swells, because they are still far inside the body.
You only see or feel an internal hemorrhoid if they prolapse. Internal hemorrhoids do not cause pain because they are located in an area without any nerve endings. If you are experiencing pain, it may be from a different condition, such as external hemorrhoids, anal fissures or spasms.
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What Are The Signs And Symptoms Of An External Or Thrombosed Hemorrhoid
Thrombosed external hemorrhoids are a painful condition. These occurs when a blood clot develops in a hemorrhoidal blood vessel causing swelling and inflammation.
- When a blood clot occurs in a hemorrhoid, the hemorrhoid will become even more swollen. This swelling leads to increased pain.
- The pain is usually worse with bowel movements and may increase with sitting.
A thrombosed external hemorrhoid may resolve on its own however, this condition often needs medical care. Bleeding with a bowel movement is never normal and should prompt a visit to a health-care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons for bleeding including inflammatory bowel disease, infection, and tumors.
Hemorrhoids are not arteries or veins, but instead are normal blood vessels called sinusoids that are located in the walls that surround the rectum and anus. When the venous pressure within these blood vessels increases, the hemorrhoids swell and dilate, because it is more difficult for blood to empty from them. This leads to the most common symptoms of bleeding and swelling.
Common situations that increase pressure within the hemorrhoidal blood vessels and lead to abnormalities include the following.
- Straining to have a bowel movement. This may be due to constipation or diarrhea.
- Prolonged sitting, including on the toilet
- Lack of exercise
Conventional Treatment For Hemorrhoids
When you go to see a doctor for enlarged hemorrhoids, he or she will look at your anus to see if its inflamed and whether the hemorrhoids come out of the anus when you push or if theyre already outside. Depending on the severity of your symptoms, there are a number of examinations your doctor may choose to perform in order to make a diagnosis. Doctors typically do a digital rectal examination first, which involves gently inserting a finger into the anus with gloves and lubricant. The doctor will feel the inside of the anal canal using circular movements, which allows him to examine the sphincter muscles and the texture of the membranes lining the anus.
If your doctor believes that you do have enlarged hemorrhoids, she will most likely perform a proctoscopy next. This involves inserting a short tube with a light and lens on it that exams the membranes lining the rectum. The doctor is looking to see if there are enlarged hemorrhoids and how big they are. People tend to fear the pain and discomfort that come with these procedures, but they usually dont hurt and do help your doctor make suggestions about how to get rid of hemorrhoids.
Most of the patients suffering from hemorrhoids have their symptoms alleviated through diet therapy, fiber supplements, hemorrhoid cream and medical treatments, such as sclerotherapy, rubber band ligation and infrared coagulation.
1. Sclerotherapy
2. Rubber Band Ligation
3. Infrared Coagulation
4. Hemorrhoid Surgery
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How To Get Rid Of Hemorrhoids: Diagnosis And Treatments
Most individuals who have hemorrhoids discover them by either
- feeling the lump of an external hemorrhoid when they wipe themselves after a bowel movement,
- noting drops of blood in the toilet bowl or on the toilet paper, or
- feeling a prolapsing hemorrhoid after bowel movements.
With a history of symptoms, a physician can begin diagnosis on the basis of a careful examination of the anus and anal area. Although the physician should try his or her best to identify the hemorrhoids, it is perhaps more important to exclude other causes of hemorrhoid-like symptoms that require different treatment such as
- anal fissures,
This is true whether or not hemorrhoids are found during anoscopy.
Procedures For Hemorrhoids 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 hemorrhoid treatments are available that are less painful than traditional hemorrhoid removal and allow a quicker recovery. These procedures are generally performed in a surgeon’s office or as outpatient surgery in a hospital.
Band it. The most commonly used hemorrhoid treatment in the United States is rubber band ligation, in which a small elastic band is placed around the base of a hemorrhoid . 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 , 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.
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Who Is At Risk Of External Hemorrhoids
If your parents have had hemorrhoids, you may be more likely to have them as well. Hemorrhoids may also be more likely to happen during pregnancy.
As we age, hemorrhoids can occur due to increased pressure caused by sitting a lot. And anything that causes you to strain during bowel movements can lead to external hemorrhoids.
A healthcare professional may be able to help you determine the cause of your hemorrhoids.
Dont Make Things Worse
Bump up the fiber. It softens your stools and makes them move through your body more easily. Youll find it in beans, whole-grain breads and cereals, and fresh fruits and veggies. You may also want to try a supplement if you cant get enough from foods. Add fiber slowly to help avoid gas and bloating.
Drink lots of fluids. Stay well hydrated to keep stools soft so theyre easier to pass. Water is the best choice. Drink plenty throughout the day. Prune juice is a natural laxative and can help you go.
Exercise regularly. Even brisk walking 20-30 minutes every day can help keep you from getting stopped up.
Breathe! Keep the air moving in and out when youre working hard. Its common to hold your breath as youre pushing, pulling, or making an effort and that can lead to hemorrhoid pain and bleeding.
Use a pillow. Sit on a cushion instead of a hard surface. It will ease swelling for any hemorrhoids you have. It may also help prevent new ones from forming.
Take breaks. If you must sit for a long time, get up every hour and move around for at least 5 minutes.
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What Are The Causes
The most common causes of hemorrhoids are prolonged sitting, straining at stool, and constipation. Irritants in the diet can exacerbate hemorrhoids, including strong spices such as red pepper and mustard, and drinks such as coffee, decaffeinated coffee, and alcohol. Stress can cause hemorrhoids, as can pregnancy . Obesity, chronic diarrhea and anal intercourse can also lead to hemorrhoids.
How To Treat Hemorrhoids And When You Should See Your Doctor
Hemorrhoids are an irritating, often painful condition that occurs when the veins around the anus or lower part of the rectum become swollen and inflamed as a result of too much pressure. External hemorrhoids develop underneath the skin around the anus, while internal hemorrhoids develop in the lining of the tissues.
Hemorrhoids affect about 1 in 20 Americans, and about half of adults over age 50 have them. Age is one factor as we get older, the supporting tissues in the rectum and anus become weaker and more vulnerable to pressure.
Pregnancy also can weaken these tissues, which is why pregnant women often experience hemorrhoids. Other potential causes include chronic constipation or diarrhea, straining during bowel movements and sitting on the toilet for extended periods. Also, frequently lifting heavy objects may increase the likelihood of hemorrhoids.
What are the symptoms of hemorrhoids?
Hemorrhoid symptoms vary depending on whether the inflamed veins are external or internal.
External hemorrhoids may cause itching and pain, especially while seated. Also, you may feel one or more tender lumps around the anal area. Scratching, rubbing or excessively cleaning the area can make symptoms worse.
With internal hemorrhoids, you may notice bright red blood when you have a bowel movement. Internal hemorrhoids are not usually painful unless they fall through the anal opening, called prolapsing.
How are hemorrhoids treated at home?
When to see the doctor
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Best Prolapsed Hemorrhoid Surgery Options
There are surgical options available to treat grade IV prolapsed hemorrhoids. When prolapsed hemorrhoids cannot be manually pushed back into place, surgery is often needed.
Minimally invasive options are available to treat prolapsed hemorrhoids. These can be done at a doctors office and involve cutting off the blood supply to your hemorrhoid to rid you of the problem. The most common is the rubber band ligation.
In severe cases, surgery under anesthesia may be necessary. The most common surgery to treat prolapsed internal hemorrhoids is the hemorrhoidopexy. This is commonly referred to as stapling.
Performed in a hospital, hemorrhoidopexy is also referred to as a procedure for prolapse and hemorrhoids . During the surgery, a medical-grade stapler is used to attach the prolapsed hemorrhoidal tissue in place on your rectal wall.
The blood flow is cut off to the hemorrhoids and your anal tissue will shrink back into place. This surgical procedure has a high success rate and is less painful than other hemorrhoid surgeries, like the hemorrhoidectomy.
How To Get Rid Of Hemorrhoids Fast
Internal hemorrhoids are usually painless, while the external kind can be quite painful. Either way, there is often bleeding and you shouldnt have to suffer through that. That is why it is important to learn how to shrink hemorrhoids fast at home.
There are natural tips for how to get rid of piles without seeing a doctor. The following details how to get rid of hemorrhoids naturally with home remedies.
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Symptoms Of Thrombosed External Hemorrhoids
External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids.
External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as thrombosis. Thrombosis of such a hemorrhoid causes an anal lump that is
- very painful,
- tender, and
- often requires medical attention.
The thrombosed hemorrhoid may heal with scarring, and leave a tag of skin protruding in the anus. Occasionally, the tag is large, which can make anal hygiene difficult or irritate the anus. Even after such a hemorrhoid goes away, a residual skin tag may remain, and this may need to be surgically removed.
How To Get Rid Of Hemorrhoids
May 14, 2019
Hemorrhoids are a very common anorectal condition that affects millions of people around the world. Over half of all people will develop symptomatic hemorrhoids at some point, so its common to wonder how to get rid of hemorrhoids. Most patients are able to get rid of hemorrhoids with a high-fiber diet, herbal supplements and non-surgical medical treatments, such as my DIY Hemorrhoid Cream with Turmeric & Tea Tree Oil.
Hemorrhoids are frequently seen in primary care clinics, emergency wards, gastroenterology units and surgical clinics, but how do you know when hemorrhoids have developed and when you should see a doctor? These are common concerns among people who develop hemorrhoids and dont know how to deal with and treat the pain. Thankfully, there are natural treatments for how to get rid of hemorrhoids fast, and starting there may help relieve these literal pains in the butt.
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