What Are Hemorrhoids?
Hemorrhoids are spongy tissues that line the anus and contain blood and blood vessels. When you have a bowel movement, the hemorrhoids act like cushions to protect the anus from the stool passing through it. When you're done with your bowel movement, the hemorrhoidal tissue helps to seal the anus.
Because the American diet contains many refined foods, we often don't get enough fiber. As a result, people tend to have small hard bowel movements, strain and spend too much time on the toilet. Over time, the hemorrhoidal tissue enlarges and slips out the anus. When the hemorrhoidal tissue becomes large enough, it causes problems such as bleeding or discomfort. Part of the confusion about hemorrhoids from patients and some physician's results from terminology (how we define our terms.) A small amount of hemorrhoidal tissue is normal and is present at birth. When this tissue becomes excessively large or causes symptoms, people call this "hemorrhoids." People are conditioned from advertising and discussions with friends and family that any anal complaint is caused by "hemorrhoids." This is why patients who come to the doctor with an anal problem almost always complain of "hemorrhoids." Enlarged hemorrhoidal tissue mainly causes bleeding or discomfort. Anal itching, severe pain or discharge is usually caused by other anal conditions.
What Are The Two Different Types Of Hemorrhoids?
The anal canal contains the muscles that keep your anus closed and allow it to open for bowel movements. Two types of lining cover these muscles and the different type of lining explains the symptoms patients experience. The lower part is lined by skin from the outside. The upper part of the anal canal is covered by intestinal lining that grew down from the rectum. These two linings meet in the middle of the anal canal. There is hemorrhoidal tissue on both sides of this line. The tissue covered by intestinal lining (upper part of the anus) is not painful and mainly causes bleeding or protrusion out of the anus. These hemorrhoids are called internal. The lower hemorrhoids are called external and are lined by skin. Enlarged internal hemorrhoids most commonly result in bleeding. The blood is bright red and painless. Often patients will see this red blood on their toilet paper or dripping into the toilet with bowel movements. Fortunately most internal hemorrhoids can be treated painlessly in the office. External hemorrhoids can become clotted or thrombosed after a small vessel is torn by straining or heavy lifting. The blood clots cause swelling and pain. If the pain is severe and seen early (first one or two days) the physician can remove them with a local anesthetic in the office. If not treated, the external hemorrhoids will heal themselves in a week or two.
Do Hemorrhoids Lead To Later Problems?
Almost no one has ever died of hemorrhoids, but a few patients bleed enough to require a blood transfusion. Mostly, there are symptoms of more serious problems that overlap with hemorrhoids. For example, rectal cancer causes bleeding. You would hate for someone to not seek medical attention for rectal bleeding because they thought it was only from hemorrhoids. People do seek medical care for hemorrhoids, but they often delay. This is partially explained by the intermittent symptoms of hemorrhoids. They bleed for a couple of days, then stop and then bleed again. This also explains why large amounts of over-the-counter preparations continue to be purchased. Unfortunately, few of them produce any true benefit. Other reasons for delay are fear of pain or embarrassment.
What Over-The-Counter Medications Do You Recommend?
Eating a healthy diet is the best approach, and small changes can make significant differences. The typical American diet is low in fiber. So if you have a choice between a whole wheat muffin or a blueberry muffin, take the whole wheat. In addition to fiber, you need an adequate amount of water. Unfortunately, many of us have very busy lifestyles. The alternative to watching your diet is to add a fiber supplement such as Metamucil, Citrucel or Fibercon. This extra fiber and water produces a stool that is soft, deformable, and easy to pass, something like thick cottage cheese. This tends to resolve the cause of hemorrhoids and in most people, eliminates or reduces hemorrhoidal symptoms. Creams with low concentrations of steroids (1 to 2.5% hydrocortisone) or a mild pain reliever may help to temporarily reduce symptoms but don't treat the cause. Also, there are problems that occur with long term steroid use. Suppositories are not recommended because they don't go where you want them to. They tend to pop up into the rectum, and other than lubricating the canal before a bowel movement, they don't do much good.
What Treatments Do You Recommend For Hemorrhoids?
If the dietary approach doesn't take care of the problem, many patients can be helped with rubber band ligation. In the office, we place a small scope into the anus and through this scope; we insert a suction device, which places a small rubber band around the hemorrhoid. This small rubber band cuts off the blood supply to the hemorrhoid. It dies and the tissue comes off with a bowel movement in about 5 to 7 days. The area where the hemorrhoid was then heals in as a small scar. This results in removal of excess tissue and fixation of the remaining tissue to prevent it from slipping out of the anus. For about 75% of patients, one treatment will take care of their symptoms. The remainder requires additional treatments, and a few may need an operation to completely eliminate their symptoms. Another office based treatment is infrared coagulation. This device uses light energy to treat the internal hemorrhoids similar to rubber band ligation. Sclerotherapy, which uses medication injected into the hemorrhoid to destroy it, is also an option. For the few patients who fail the therapies described above or those with significant external hemorrhoidal disease, an operation may be required. A hemorrhoidectomy is a surgical procedure that removes the hemorrhoidal tissue. The operation is very effective, but patients have significant anal pain while the incisions heal (usually 2-3 weeks). Lasers are not used in this surgery. Several studies have shown that they provide no advantage over the usual operative techniques and are excessively expensive.
Do Patients Ask You About Alternative Therapy For Hemorrhoids?
Yes. People will often use a variety of herbs or creams. The difficulty we have is that many of these products are not accurately labeled. We often have trouble knowing what is in the products. Some contain bowel stimulants like senna. These are OK short term, but may lead to problems if used chronically. However, organic sources of fiber are usually very good.
Are Many People Too Embarrassed To Seek Treatment For Hemorrhoids?
Yes for several reasons. First they have a fear of being hurt. Your anus is very sensitive, but almost all exams and office treatment can be accomplished in a painless manner. We spend a lot of time teaching out younger physicians on the proper way to examine patients. If patients are inappropriately hurt, they will be hesitant to return for further treatment or diagnostic tests. A good, well trained physician shouldn't hurt you. Second, many people feel this is not a topic suitable for "polite society" and talking about this area may be embarrassing. There is also a lot of misinformation from friends, family, and advertising. Finally, many physicians have inadequate knowledge of the anus. This subject is often neglected in medical school and few physicians have a lot of anorectal experience in their subsequent training. Also, some of the patient's problems will get better in spite of the therapy offered. Colon and Rectal surgeons have a special interest in diseases of the anus and rectum. Their training, experience, and ongoing research allow them to be experts in this important area.
What Forms Of Prevention Do You Recommend For Hemorrhoids?
The anus works best when it is clean and dry. So you should clean yourself gently with toilet paper after bowel movements and dry the area. Cleansing pads should be avoided as the cloth allows you to "scrub" too hard which may damage the skin and they often contain alcohol, which can also damage the skin. Ointments that may irritate the skin or keep it wet should also be avoided. Regular physical activity is good for keeping your bowel movements regular. However, if you have problems with hemorrhoids, you might want to avoid exercises like deep squats with heavy weights on your shoulders. These types of exercises might cause your hemorrhoids to pop out. It is difficult to get patients to make lifestyle changes. Some of it is motivation; some of it is a time factor. Most patients will make changes if their hemorrhoids cause enough problems, however, they will often revert back to their former habits when their hemorrhoids get better.