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.

Hemorrhoids Causes

Hemorrhoids are usually caused by increased pressure on the veins in the pelvic and rectal area. As pressure increases, blood pools in veins and causes them to swell. Eventually, the swollen veins stretch the surrounding tissue, and hemorrhoids develop. Bowel habits that can cause increased pressure and lead to the development of hemorrhoids include:

• Rushing to complete a bowel movement. Hurrying can lead to excessive straining and increase pressure on rectal veins.
• Persistent diarrhea or constipation, which may cause straining and increase pressure on veins in the anal canal.

Other factors that can lead to the development of hemorrhoids include:

• A family history of hemorrhoids. You may inherit the tendency to develop them.
• Being overweight. Excess weight, especially in the abdomen and pelvis, may increase pressure on pelvic veins.
• Pregnancy and labor. Hormonal changes during pregnancy increase blood flow to the pelvis and relax supportive tissues while the growing fetus causes increased pressure on blood vessels. During labor, hemorrhoids may develop because of the intense pressure on the anal area while pushing to deliver the baby.
• Being age 50 or older. Half of people who are older than 50 seek treatment for hemorrhoids.
• Infection in the anal canal.
• Medical conditions. For example, long-term heart and liver disease may cause blood to pool in the abdomen and pelvic area, enlarging the veins.
• Tumors in the pelvic area. These occur very rarely.

Factors that may make hemorrhoids worse.

• Prolonged sitting or standing. This may cause blood to pool in the anal area and increase pressure on the veins.
• Frequent heavy lifting or holding your breath when lifting heavy objects. This can cause a sudden increase of pressure in blood vessels.

Hemorrhoids Symptoms

Bleeding during bowel movements, itching, and rectal pain are the most common hemorrhoid symptoms.

External hemorrhoids

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.

Internal hemorrhoids

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.

When To Call a Doctor

Common symptoms of hemorrhoids may indicate other serious health problems. Colon or rectal cancer and other conditions have many of the same symptoms as hemorrhoids. You should call your health professional if:

• Rectal bleeding occurs that is not associated with trying to pass stools.
• Stools become more narrow than usual (may be no wider than a pencil)
• You cannot pass stools, or you have diarrhea with abdominal bloating.
• Stools are black or tarry.
• Any unusual material seeps from the anus.
• Fever accompanies bloody stools or what you think may be hemorrhoids.
• A lump or bulge that is not tender and does not go away develops at the anal opening.

If you have hemorrhoids, call your health professional if:

• Moderate rectal pain lasts longer than 1 week after home treatment.
• Pain or swelling is severe.
• Tissue from inside the body bulges from the anus and does not return to normal after 3 to 7 days of home treatment.
• A lump inside the anus becomes bigger or more painful.

Hemorrhoids 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.

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.

Hemorrhoids Risks

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.

Results

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

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.

B-Anoscopy

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.

Hemorrhoids Prevention
You can help prevent the irritating and painful symptoms of hemorrhoids.

Avoid constipation

• Make sure you are drinking enough fluids.
  • Drink 2 to 4 extra glasses of water per day, especially in the morning
  • Drink 1.5 qt(1.4 L) to 2 qt(2 L) of water and other fluids, such as fruit juice or noncaffeinated beverages, every day.
•  Add high-fiber foods to your diet. Health professionals recommend that you eat 20 to 30 grams of fiber every day. Packaged foods and fiber supplements include the amount of fiber content in the nutrition information. You should increase the amount of fiber in your diet slowly so that your stomach can adjust to the change. Adding too much fiber too quickly may cause stomach upset and gas.
  • Eat at least 2 servings of fruit, such as apricots, peaches, pears, raisins, figs, prunes, dates, and other dried fruits, each day.
  • Eat at least 3 servings of vegetables, such as cooked dried beans or peas (legumes), broccoli, or cauliflower, each day.
•  Increase whole-grain foods, such as bran flakes, bran muffins, graham crackers, oatmeal, brown rice, and whole wheat bread. Eat brown rice, bulgur, or millet instead of white rice. Eat 6 to 11 servings of grains (breads, cereals, rice, pasta) each day. For example, a serving is 1 slice of bread, half of a bagel, or ½ cup pasta or rice
  • Use whole wheat bread instead of white bread. Choose whole-grain breads and cereals; buy bread that lists whole wheat, stone-ground wheat, or cracked wheat in the ingredients.
  • Eat a bowl of bran cereal with 2 tsp(10 mL) of bran per serving.
  • Snack on unbuttered, unsalted popcorn
  • Add 2 Tbsp(30 mL) of wheat bran to cereal or soup. If you do this, start slowly with 1 tsp(5 mL) a day. Gradually increase the amount to 2 Tbsp(30 mL) a day.
  • Mix 2 Tbsp(30 mL) of psyllium (found in Metamucil and other bulk-forming agents) with a liquid, and drink it.
•  Avoid foods that are high in fat and sugar.
• Avoid alcoholic beverages and caffeine, which can increase dehydration.
• Exercise more. A walking program would be a good start.
• Set aside relaxing times for having bowel movements. Urges usually occur sometime after meals. Establishing a daily routine for bowel movements, such as after breakfast, may help.
• Go when you feel the urge. Your bowels send signals when a stool needs to pass. If you ignore the signal, the urge will go away, and the stool will eventually become dry and difficult to pass.
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Avoid making hemorrhoids worse

• Blot the anus gently with white toilet paper moistened with water or a cleansing agent (such as Balneol) after bowel movements. Baby wipes or other premoistened towels (such as Tucks) are also useful for this purpose.
• Avoid rubbing the anal area. You can rinse off in the shower or on a bidet instead of wiping yourself with toilet paper. After cleansing, gently pat the anal area dry with a soft, absorbent towel or cloth.
• Use soaps that contain no perfumes or dyes.

Hemorrhoids Treatments

• Laser Treatment
• Doppler Treatment (THD)
• Rubber Treatment Ligation
• Stapler Treatment