Symptoms . Diagnosis . Management . Outlook
Hemorrhoids, also called piles, are enlarged or varicose veins of the anus and rectum. They are a common health ailment, particularly in developed countries, affecting nearly 5% of the population. There are two types of hemorrhoids, external and internal, which can occur separately or in combination. A person could have a single hemorrhoid, or have several at the same time. Hemorrhoids affect up to 38% of women in the third trimester of pregnancy.
External hemorrhoids develop under the skin just outside the opening of the anus. They are usually painful if they develop a clot (thrombose), in which case they appear as very tender, circular, purplish bulges around the anal opening.
Internal hemorrhoids are often present without causing any discomfort or even awareness of their existence. This is because around internal hemorrhoids there is rectal lining (mucous membrane), rather than nerve-rich skin. You might experience a feeling of fullness in the rectum, as if you need to have a bowel movement. You may not even know you have them unless they thrombose or bleed, resulting in passing bright red blood during and/or following a bowel movement. However, if a hemorrhoid loses its blood supply (strangulates) it can become very painful. Sometimes an internal hemorrhoid pushes down or stretches until it bulges outside of the anus (prolapse). This could manifest as a pinching sensation in the anal area, or you may notice a painless lump when you wipe after a bowel movement.
The extra bumps and crevasses of hemorrhoids could lead to improper cleaning of the area, resulting in anal itching.
Hemorrhoids may have a number of predisposing causes but, in most cases, increased pressure in the abdomen plays a key role. Some of the most common underlying factors for developing hemorrhoids include constipation and straining during bowel movements, repeated lifting of heavy objects, frequent diarrhea, prolonged sitting or standing, obesity, and pregnancy. Excessive abdominal pressure can cause the small veins around the anus and rectum to stretch. As the veins lose their elasticity, they become distended with blood and more likely to thrombose and become more fragile. Pregnant women are particularly prone to hemorrhoids, partially because the uterus sits directly on the blood vessels that drain the hemorrhoidal veins.
Your physician may diagnose hemorrhoids following a physical examination of the anus and rectum. This can include a rectal exam performed with a gloved, lubricated finger, or with a small instrument that will allow your physician to visualize the rectum more closely.
Rectal bleeding may be a symptom of other, potentially more serious, conditions. One source of bleeding could be anal fissures, which are tears in the lining of the anus causing pain when passing a bowel movement. Some types of inflammatory bowel disease can also cause rectal bleeding, as can tumours of the rectum and colon. If you pass blood from the anus, then you should consult with your physician to determine if further testing is required.
It is very important to avoid straining while having a bowel movement, as this puts extra pressure on the anal area. The management of hemorrhoids typically involves a number of moderate dietary and lifestyle changes to ensure soft and formed stools, which help to avoid straining.
Recommendations for ongoing dietary management include consuming well-balanced meals and snacks, and ensuring high-fibre content and adequate fluid intake, as outlined in Canada’s Food Guide. Fibre and fluid help soften stool, allowing it to move more quickly and easily through the colon, rectum, and anus, which reduces strain.
Aim for 20-35g of fibre daily, consumed evenly throughout the day. To help monitor your fibre intake, check the nutrient content on the labels of packaged foods. Make gradual changes while increasing fibre intake, as this approach could help you to avoid the bloating, gas, and general abdominal discomfort that can occur as your body adapts to the dietary modifications.
There are also some commercial fibre supplements available. These include psyllium husk (Metamucil®), methylcellulose (Prodiem® powder), inulin, which is soluble vegetable fibre (FibreSure™, Benefibre™ powder), and calcium polycarbophil (Prodiem® caplets).
Most hemorrhoid sufferers will find good results with the use of a basic fibre supplement; however, if constipation continues to remain a problem, then products containing the herb senna could offer additional relief. Be sure to check the labels as some of these products contain different substances depending on their format (e.g., powders are different from caplets). Also note that those products marked ‘plus’ could contain additional unwanted substances that increase their laxative effect.
Resist the Urge to Scratch
The area around your hemorrhoid might feel itchy. Don’t scratch, as you could damage delicate vein walls.
It is extremely important to clean yourself properly and gently following a bowel movement. Use only non-perfumed, non-coloured toilet paper and try dampening it under the faucet before each wipe. Some varieties of toilet paper are softer than others and some facial tissues contain moisturizing cream, which you may find to be more soothing. Using pre-moistened flushable wipes might also increase cleaning comfort.
Have a Sitz bath
This is a type of therapeutic bath, where you sit in very warm water with your knees raised. The warm water helps lessen the pain while increasing blood flow to the area. This helps to shrink the swollen veins and promote healing. You may even try adding Epsom salts to the bath water.
Push it Back Inside
If your hemorrhoid protrudes from the anal canal, try pushing it back inside. A hemorrhoid left hanging out of the anus is at a greater risk to develop clots or strangulate.
Hemorrhoids During Pregnancy
To help prevent or manage hemorrhoids if you are pregnant, try lying on your left side for about 20 minutes every 4-6 hours, as this decreases pressure on the main vein draining the lower half of the body.
Ointments and Creams
Hemorrhoidal symptoms often subside within a few days, even with no specific treatment. Topical hemorrhoid treatments usually contain one or more active ingredients including a local anesthetic, mild anti-inflammatory compounds, or astringents.
Local anaesthetics temporarily relieve pain, burning, and itching by numbing the nerve endings (e.g., benzocaine 5-20% and lidocaine 2-5%). Analgesic products, like anesthetic products, relieve pain, itching, and burning by depressing receptors on pain nerves (e.g., menthol 0.1-1%; do not use products containing greater than 1% menthol).
Witch hazel is a widely used plant-based astringent; when applied to the rectum with a cotton ball, this product can offer relief. Several other products have stronger ingredients that focus on reducing inflammation and these may require a prescription.
If significant hemorrhoidal symptoms persist despite conservative measures, a number of minor surgical options are available and a physician may perform many of these in the office. Treatment for internal hemorrhoids includes application of rubber bands (ligation), injection of a material that blocks the vein (sclerosant), stapling, cryosurgery, laser, or electro-coagulation techniques. More extensive surgical excision may be required for large, permanently prolapsed hemorrhoids or strangulated hemorrhoids. Thrombosed external hemorrhoids generally respond promptly to surgical incision and clot removal.
Some people can have a single hemorrhoid while others have ongoing hemorrhoids throughout life. Most hemorrhoids completely resolve within a week or so. Maintaining adequate intake of dietary fibre, drinking plenty of water, avoiding abdominal strain, and getting regular moderate exercise may help to prevent the recurrence of hemorrhoids.