Hemorrhoids

Often described as "varicose veins of the anus and rectum,” hemorrhoids are enlarged, bulging blood vessels in and around the anus and lower rectum. The rectum is the bottom section of your colon (large intestine). The tissues supporting the vessels stretch. As a result, the vessels expand, the walls thin and bleeding occurs. When the stretching and pressure continue, the weakened vessels protrude. The two types of hemorrhoids, external and internal, refer to their location. 

External (outside) hemorrhoids form near the anus and are covered by sensitive skin. They are usually painless unless a blood clot (thrombosis) forms or they become very swollen. 

Thrombosed external hemorrhoids are blood clots that form in an outer hemorrhoid in the anal skin. If the clots are large, they can cause significant pain. A painful anal mass may appear suddenly and get worse during the first 48 hours. The pain generally lessens over the next few days. You may notice bleeding if the skin on top opens. 

Internal (inside) hemorrhoids form within the anus beneath the lining. Painless bleeding and protrusion during bowel movements are the most common symptoms. However, an internal hemorrhoid can cause severe pain if it is completely prolapsed. This means it has slid out of the anal opening and cannot be pushed back inside. 

HEMMORRHOIDS FACTS AND STATS 

• Hemorrhoids are one of the most common ailments.
• Millions of Americans currently suffer from hemorrhoids.
• The average person suffers for a long time before seeking treatment for hemorrhoids.
• Advances in treatment methods means some types of hemorrhoids can be treated with far less painful methods than before.

CAUSES

The exact cause of hemorrhoids is unknown. A lot of pressure is put on human rectal veins due to our upright posture, which can potentially cause bulging. Other contributing factors include:

• Aging
• Chronic constipation or diarrhea
• Pregnancy
• Heredity
• Straining during bowel movements
• Faulty bowel function due to overuse of laxatives or enemas
• Spending long periods of time on the toilet (e.g., reading)

SYMPTOMS

Any of the following may be a sign of hemorrhoids:

• Bleeding during bowel movements
• Protrusion of skin during bowel movements
• Itching in the anal area
• Pain in the anal area
• Sensitive lump(s)

NONSURGICAL TREATMENT

It is important that symptoms are checked by a colon and rectal surgeon first before you try self-treatments. They will perform a thorough examination and recommend treatment. Mild symptoms can be relieved frequently without surgery. With nonsurgical treatment, pain and swelling usually decrease in two to seven days. The firm lump should recede within four to six weeks.

Treatment includes:

• Eating a high-fiber diet and taking over-the-counter fiber supplements (25-35 grams of fiber/day) to make stools soft, formed and bulky.
• Avoiding excessive straining to reduce the pressure on hemorrhoids and help prevent protrusion.
• Shortening time on the toilet to only 1 to 2 minutes to help prevent protrusion
• Drinking more water to help prevent hard stools and aid in healing.
• Taking warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day to help the healing process.

SURGICAL TREATMENT

If pain from a thrombosed hemorrhoid is severe, your physician may decide to remove the hemorrhoid and/or clot with a small incision. These procedures can be done at your physician’s office or at the hospital under local anesthesia.

Rubber Band Ligation: This treatment works well on internal hemorrhoids that protrude during bowel movements. A small rubber band is placed over the hemorrhoid, cutting off its blood supply. The hemorrhoid and the band fall off in a few days. The wound usually heals in one to two weeks. Mild discomfort and bleeding may occur. This treatment needs to be repeated for complete treatment of the hemorrhoids depending on the size or if they return.
 

RUBBER BAND LIGATION OF INTERNAL HEMORRHOIDS:

• Bulging, bleeding, internal hemorrhoid
• Rubber band applied at the base of the hemorrhoid
• About seven days later, the banded hemorrhoid has fallen off, leaving a small scar at its base 

Injection and Coagulation: This method can be used on internal hemorrhoids that do not protrude. Both methods are fairly painless and cause the hemorrhoid to shrivel. Several treatments may be needed. This cannot be used for external hemorrhoids.

Hemorrhoids stapled and sutured: These methods can shrink internal tissue but cannot be used for external hemorrhoids. These procedures are generally more painful than rubber band ligation but less painful than hemorrhoidectomy.

Hemorrhoidectomy: This is the most complete surgical method for removing extra tissue that causes bleeding and protrusion. It is done for both internal and external hemorrhoids under anesthesia using sutures. Depending on the case, hospitalization and a period of rest may be required.

Hemorrhoidectomy is considered when:

1. Clots repeatedly form in external hemorrhoids
2. Ligation is not effective in treating internal hemorrhoids
3. The protruding hemorrhoid cannot be reduced
4. There is chronic bleeding

DO HEMORRHOIDS LEAD TO COLORECTAL CANCER?

Hemorrhoids do not increase the risk of colorectal cancer nor cause it. However, more serious conditions can cause similar symptoms. Even when a hemorrhoid has healed completely, your colon and rectal surgeon may request other tests. A colonoscopy may be done to rule out other causes of rectal bleeding. Every person age 45* and older should undergo a colonoscopy to screen for colorectal cancer.  

*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45.  

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.