What are hemorrhoids?
Hemorrhoids are enlarged veins that develop in the anal canal. Although uncomfortable at times, this common condition rarely poses a serious problem.
Normally, tissue surrounding the inside of the anus, sometimes called "anal cushions," fills with blood to help control bowel movements. Hemorrhoids develop when excessive pressure or other factors cause the veins within these cushions to swell and stretch.
Nearly everyone has hemorrhoids at some time. They can develop at any age, but the incidence increases after age 30. About 50% of people older than 50 have had hemorrhoids at some time in their life.
Rectum, anus and anal sphincter
The rectum is a muscular tube about 5 in.(12.7 cm) long that is at the end of the large intestine (colon). The rectum connects the colon to the anus, which is the opening where stool exits the body through the anal sphincter.
The anal sphincter is a ring of muscles at the opening of the anus. The sphincter keeps the anus closed as stool collects in the rectum. Eventually the pressure on the rectum wall causes the anal sphincter to relax, allowing stool to pass out of the body through the anus.
Bleeding during bowel movements, itching, and rectal pain are the most common hemorrhoid symptoms.
Rectal pain occurs mainly with external hemorrhoids. You might also notice streaks of bright red blood on the toilet paper after straining to pass a stool.
In rare cases, a vein inside an external hemorrhoid breaks. Blood may pool under the skin, forming a hard, painful lump. This is called a thrombosed, or clotted, hemorrhoid.
A sudden sharp or burning pain during a bowel movement, along with a small spot of blood on toilet tissue, is more likely to be an anal fissure than a hemorrhoid.
The most common symptom of internal hemorrhoids is rectal bleeding. You may find bright red streaks of blood on the toilet paper or bright red blood in the toilet bowl after having a normal bowel movement. Blood also may be visible on the surface of the stool.
Other symptoms of internal hemorrhoids may include:
- Itching. This is a frequent complaint, because internal hemorrhoids often seep mucus, which can cause itching.
- Skin irritation. Large hemorrhoids that bulge from the anus may secrete mucus, causing mild irritation.
- Discomfort. You may still feel the urge to pass stool right after having a bowel movement. This uncomfortable feeling is caused by the bulging of the hemorrhoid in the end portion of the large intestine (anal canal). In general, the larger the hemorrhoid, the greater the discomfort.
- Pain. Most internal hemorrhoids are not painful. However, large hemorrhoids that bulge from the anus may become painful if they swell and are squeezed by the muscles that control the anus. Severe pain may be a sign that the blood supply to the hemorrhoid is being cut off (strangulated hemorrhoid). Emergency treatment is needed.
Exams and Tests
A health professional can evaluate symptoms of hemorrhoids to rule out other, more serious problems. A number of conditions that affect the anus and colon (large intestine) can cause bleeding, mucus drainage, itching, and discomfort. Most people who have these symptoms think they have hemorrhoids, but that is often not the case.
If hemorrhoids are present, the health professional will evaluate their location and size and develop a treatment plan based on the hemorrhoids' degree of severity.
Internal hemorrhoids: First- to fourth-degree
A first-degree internal hemorrhoid bulges into the anal canal during bowel movements.
A second-degree internal hemorrhoid bulges from the anus during bowel movements, then goes back into place by itself.
A third-degree hemorrhoid bulges from the anus during bowel movements and must be pushed back in with a finger.
A fourth-degree hemorrhoid protrudes from the anus all the time.
The diagnosis of hemorrhoids is based:
1- Medical history:
Your health professional will ask questions about diet or bowel habits that may contribute to hemorrhoids. Factors that may cause hemorrhoids or make them worse include:
- Eating a low-fiber diet.
- Drinking fewer than 8 glasses of water, fruit juice, or other noncaffeinated liquids each day.
- Drinking too much alcohol.
- Prolonged sitting, straining, or holding your breath during bowel movements.
- Sitting or standing for long periods of time.
- Frequent heavy lifting or holding your breath when lifting heavy objects.
Medical conditions that make you prone to hemorrhoids include:
- Personal or family history of hemorrhoids
- Being overweight.
- Pregnancy and being postpartum.
- Long-term diarrhea.
- Infection in the anal canal.
- Liver or heart disease, which results in a backflow of blood that increases pressure on blood vessels in the abdomen and pelvic area.
2- Physical exam:
A digital rectal exam and an anoscopy are the only tests needed for an initial evaluation if the health professional thinks that hemorrhoids are the obvious cause of rectal bleeding and you are younger than age 50 and have minimal risk factors for colon cancer.
A-digital rectal exam:
A digital (finger) rectal examination is done to check for abnormalities of organs or other structures in the pelvis and lower abdomen. During the examination, a health professional inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area.
A digital rectal exam is routinely done for men as part of a complete physical examination to check the prostate gland. It is routinely done for women as part of a regular gynecological examination to check the uterus and ovaries. Other organs, such as the bladder, can sometimes also be felt (palpated) during a digital rectal exam.
Why It Is Done
A digital rectal exam (DRE) is done to:
- Detect growths in or enlargement of the prostate gland in men. A tumor in the prostate can often be felt as a hard lump. This may be done as part of a regularly scheduled examination or to investigate symptoms (such as difficulty urinating or a decrease in force of the urine stream) that may indicate a problem with the prostate gland. However, the digital rectal exam is not a foolproof method of detecting prostate cancer because not all abnormalities in the prostate can be felt through the rectum.
- Detect abnormalities of a woman's reproductive organs, such as the uterus and ovaries. It is usually done during a regularly scheduled pelvic examination and Pap test. It may also be done to investigate symptoms (such as pelvic pain or abnormal vaginal bleeding) that can indicate a problem with a woman's reproductive organs.
- Help find the cause of symptoms such as rectal bleeding (blood in the stool), abdominal or pelvic pain, difficulty in urinating, or a change in bowel habits.
- Collect a stool sample to test for blood in the stool.
- Check for hemorrhoids or growths (such as cancer) in the rectum. Although a DRE is often included as part of a routine physical examination to screen for abnormal growths in the rectum, DRE alone is not used to diagnose colorectal cancer. Also, a DRE may not detect internal hemorrhoids because they are soft and difficult to feel; a sigmoidoscopy may be needed to diagnose internal hemorrhoids.
How To Prepare
No special preparation is required before having this test. If you have hemorrhoids, tell your health professional before the examination begins. Your health professional will try to avoid irritating your hemorrhoids.
How It Is Done
For a digital rectal exam, you will be instructed to take off your clothes below the waist and drape a paper or cloth covering around your waist.
A man is often examined while he stands, bending forward at the waist. A man can also be examined while lying on his left side, with his knees bent toward his chest.
A woman is often examined while lying on her back on an examination table, with her feet raised and supported by stirrups. A rectovaginal exam is often done for women so that organs in the pelvic area can be evaluated.
Your health professional then inserts a gloved, lubricated finger into the rectum. Pressure may be applied with the other hand on the lower abdomen or pelvic area to feel for tenderness or abnormalities (such as enlargement, hardness, or growths) of the organs and related tissues.
How It Feels
Men usually feel some discomfort or pain during a digital rectal exam (DRE). Your health professional must press firmly on the prostate to feel for abnormalities. This pressure may be uncomfortable and make you feel the need to urinate. The prostate gland examination may be painful if the prostate is swollen or irritated.
Most women do not find a DRE painful. You may feel some pressure or discomfort when your health professional presses on your abdomen to feel the internal organs.
People with hemorrhoids, breaks in the skin around the anus (called anal fissures), or other anal sores may find a DRE more painful than people without these conditions.
Slight bleeding from the rectum may occur after an examination, especially if hemorrhoids or a breaks in the skin around the anus (anal fissures) are present.
On rare occasions, you may experience a loss of consciousness (called vasovagal syncope) because of fear or pain when your health professional inserts a finger into the rectum. This is more common if you are standing up.
During a digital rectal examination, your health professional checks for abnormalities of organs or other structures in the pelvis and lower abdominal area by inserting a lubricated, gloved finger of one hand into the rectum.
Digital rectal Exam
No abnormalities, such as organ enlargements, tissue hardening, or growths, are felt (palpated) during the examination.
Abnormalities, such as organ enlargements, tissue hardening, or growths, are felt (palpated) during the examination.
For men, the prostate gland may be enlarged, indicating benign prostatic hypertrophy (BPH) or inflammation of the prostate gland (prostatitis), or tumors or polyps are felt.
For women, growths (such as tumors or polyps) of the cervix, uterus, or ovaries are felt.
Growths such as hemorrhoids, polyps, tumors, or abscesses may be found in the lower rectum. Internal hemorrhoids may not be able to be detected. Breaks in the skin around the anus (anal fissures) may be discovered.
Abnormalities of the bladder may also be felt.
What Affects the Test
Hemorrhoids or anal fissures may cause discomfort during a digital rectal exam.
What To Think About
- If a digital rectal exam (DRE) is being done to screen for prostate cancer, the examination may be combined with a blood test for prostate-specific antigen (PSA). The two tests are often done together to improve the odds of detecting prostate cancer.
- Certain organizations, such as the American Cancer Society, recommend annual screening with both DRE and PSA for men older than age 50. Depending on your symptoms, other tests may be done, such as a test for blood in the stool or a visual examination of the anus and rectum (anoscopy).
Transrectal ultrasound and a prostate biopsy are usually done if the DRE or prostate-specific antigen test indicates prostate cancer may be present.
- Although DRE is often included as part of a routine physical examination to screen for abnormal growths in the rectum, DRE alone is not used to diagnose colorectal cancer. If results of a DRE are abnormal, additional tests (such as a colonoscopy or barium enema) may be needed.
During an anoscopy, a short, rigid, hollow tube (anoscope) that may contain a light source is used to look at the last 2 in.(5 cm) of the colon (anal canal). Anoscopy can usually be done at any time because it does not require any special preparation (enemas or laxatives) to empty the colon.
If you are older than age 40 with a family history of colon cancer, or if anoscopy does not provide a clear diagnosis, a flexible sigmoidoscopy may be the next test needed. This test allows a health professional to look inside the anus, rectum, and lower part of the large intestine (colon) for abnormal growths or other signs of disease.
If the source of rectal bleeding isn't found by flexible sigmoidoscopy, a barium enema or a colonoscopy may be done to determine if bleeding is higher in your digestive tract. These tests are not used routinely to diagnose hemorrhoids.
Infrared photocoagulation for hemorrhoids
Infrared photocoagulation (also called coagulation therapy) is a medical procedure used to treat hemorrhoids. During the procedure, the doctor uses a device that creates an intense beam of infrared light. The light creates scar tissue, cutting off the blood supply to the hemorrhoid. The hemorrhoid dies, and a scar forms on the wall of the anal canal. The scar tissue holds nearby veins in place so they don't bulge into the anal canal. Infrared photocoagulation is done in a doctor's office. You may feel heat during the procedure. Afterward, you may have a sensation of fullness in the lower abdomen, or you may feel as if you need to have a bowel movement. Infrared Coagulation (IRC) is the most widely used office treatment for hemorrhoids and is preferred over other methods because it is fast, well tolerated by patient, and virtually problem free. Generally there are no side effects after IRC. Most patients return to normal lifestyle the same day.
Millions of patients have been treated with IRC. Experience tells us that hemorrhoids by IRC generally do not recur.
What To Expect After Treatment
Bleeding from the anus occurs 7 to 10 days after the procedure, when the hemorrhoid falls off. Bleeding is usually slight and stops by itself.
- You may use mild pain relievers and sit in a shallow tub of warm water (sitz bath) for 15 minutes at a time to relieve discomfort.
- Health professionals recommend that you take stool softeners containing fiber to ensure smooth bowel movements.
What To Think About
The success of coagulation therapy depends largely on the doctor's expertise and your ability to make changes in daily bowel habits that will make passing stools easier. Coagulation therapy is expensive, but it is less expensive than surgery that requires a hospital stay and time away from work. Not all doctors have the experience or the necessary equipment to do coagulation therapy. This may help you decide which procedure to choose. Ask your doctor which procedure he or she has done the most, how many times he or she has done the procedure, and how satisfied people have been with the outcomes.