The What, Why, and How of Hemorrhoids

What are hemorrhoids?

Hemorrhoids are normal vascular structures found in every individual. They are a collection of vessels (arteriovenous channels) that are located both within the rectum (internal hemorrhoids) and below the rectum around the anus (external hemorrhoids).  Hemorrhoids are located below the superficial layers of the mucosa (internal hemorrhoids) lining the rectum and skin around the anus (external hemorrhoids) that drain into the deeper larger vessels within the abdomen.  

Despite being present in everyone, the term “hemorrhoid” has taken on more of a pathologic or disease state e.g. when they become enlarged causing bleeding, itching, prolapse (internal hemorrhoids) or thrombosed causing pain (external hemorrhoids)

What function do hemorrhoids serve?

Classically, these veins are thought to form a cushion to aide in continence. Other than helping blood flow in the area that they don’t serve much greater purpose that we know of.

Are hemorrhoids the cause of my issues?

Many patients attribute “hemorrhoids” as a cause of any symptom of the rectum/anus they may encounter but they are not always involved. A careful history and exam can find anal fissures, inflammation of the rectum (proctitis), an STD like herpes or chlamydia, anal or rectal cancer!

What are the differences between external and internal hemorrhoids?

There are some important differences between the two main types of hemorrhoids. These differences are useful in determining what symptoms means.  Typically, external hemorrhoids do not cause bleeding as their initial symptoms. These actually can become enlarged and very painful as they are located just outside the anus. They can’t be pushed back in. They can bleed if they rupture and a clot usually can be seen when bleeding. External hemorrhoids are very painful as they are covered by skin which has nerve endings that signal pain. Internal hemorrhoids do not typically present with pain rather they present as painless rectal bleeding. When large enough they can prolapse out of the rectum and get trapped and ischemic due to pressure form the anal canal. In general though, there usually is no pain involved. Itching can be seen when fecal matter gets trapped around the anus and hygiene becomes a problem due to their presence in the anal canal. The skin around anus in contact with the prolapsed internal hemorrhoids can become inflamed from the irritation caused by trauma in the anal canal, mucous expressed by the cells of the colon that cover the internal hemorrhoid or from bacteria/feces that irritates the perianal skin.  You can see itching with external hemorrhoids form the similar reason but mostly due to inability to clean well.

What causes hemorrhoids?

Hemorrhoids exist in everyone but the reason for formation of symptomatic hemorrhoids is not entirely clear. Classic teaching suggests they form from excessive straining, during pregnancy from changes in blood flow and effect of pregnant uterus on the pelvis, prolonged sitting, heaving lifting, constipation, or even frequent bowel movements.  With external hemorrhoid the most common idea is that poor blood flow due to mechanical forces leads to slowing in blood flow and then thrombosis or clotting while changes in connective tissue in the rectum or increased pressure in the rectum due to hard stools or frequent stools leads leads to swelling of internal hemorrhoids. Interestingly, many of my patients deny straining, diarrhea or constipation. Unfortunately, we can only use careful history taking to try to ascertain clues as to why.  For a patients, it's a very uncomfortable experience but they ultimately can be treated and patients can experience relief in time.

How do you treat hemorrhoids?

External hemorrhoids are acutely painful and excision of the clot can provide immediate relief but quickly finding a surgeon or gastroenterologist (one comfortable to do this) is not easy.

In general, an osmotic laxative like Miralax can be used daily to prevent hard painful stools. Topical and systemic pain relief as well as warm water baths (sitz baths) can be helpful. I typically recommend topical lidocaine 3-4 times per day, motrin/ibuprofen, and sitz baths twice a day. Warm water baths are soothing. Eventually the clot will resorb and the pain and swelling will dissipate. Often, patients can be left with an external skin tag as a result. This is stretched anal skin overlying the hemorrhoid. This skin tag may not cause any symptoms but when it does could be removed surgically.

For internal hemorrhoids, increasing fiber intake is the mainstay of therapy for improving ease of bowel movements, avoiding prolonged sitting and straining while defecating. Very large hemorrhoids that are chronically bleeding can be treated surgically via rubber banding techniques, most commonly. Over the counter remedies like preparation H and steroid creams are not useful other than to treat itching or pain.  Steroids suppositories may help reduce size but along with topical creams should not be used longer than 2 weeks. Finally, sitz baths can help increase blood flow and relax the anal sphincter to reduce pressure and allow ease of evacuation. They also reduce itching.

What can you do to prevent hemorrhoids from coming back?

I inform all my patients to add dietary and supplemental fiber to the diet as best they can. Guidelines recommend about 25-35 g per day. Other than high fiber foods, I typically favor Citrucel (methylcellulose) and Fibercon (polycarbophil) supplements as they are in pill form and when taken with lots of water 24-32 0z can add water to stools and prevent straining by easing elimination.  Other fibers are good too like psyllium husk but these tend to cause bloating, which a lot of my patient’s have already. 

Other hemorrhoid tips and information:

Readers should always consider talking to their doctors about perianal or rectal symptoms they think are attributed to hemorrhoids before taking matters into their own hands as often times patient’s are mistaken and they may instead have an anal fissure, STD, or genital wart rather than hemorrhoids. It’s important to get an exam and the right diagnosis so that the right treatment is used.

Daniel Motola, MD is a Gastroenterologist and Hepatologist at Gotham Medical Associates