September 13, 2011

Hemorrhoids, or enlarged veins in the anal area, represent one of the most common problems for which people seek medical advice. The actual incidence is unknown, but 10-25% of the adult population is thought to be affected. There appears to be a peak in middle age with a decline in the incidence after the age of 65.

Development of hemorrhoids is not completely understood, but seems to be more common in conditions such as chronic constipation, prostate enlargement, chronic cough, and pregnancy. All these conditions cause increased straining and increased intra-abdominal pressure. Contrary to popular belief, there is no evidence that prolonged sitting causes hemorrhoids.

Individuals can develop internal hemorrhoids, external hemorrhoids, or both types. Internal hemorrhoids can bleed or prolapse (protrusion of small tissue), but rarely cause pain. Bleeding is usually bright red in color, associated with defecation, and blood is seen on the outside of the stool, on the toilet paper, or dripping into the toilet bowl. Prolapse is recognized as a soft protrusion from the anus after defecation, which may resolve spontaneously or may require manual reinsertion into the anus. Prolapsed hemorrhoids that cannot be pushed back into the anus can become gangrenous and require emergency surgical intervention.

External hemorrhoids are usually seen as perianal skin tags, the result of thrombosed external hemorrhoids. Individuals can experience pain when external hemorrhoids thrombose, however there is usually no associated bleeding. Contrary to popular belief, hemorrhoids rarely cause itching. The itching can be attributed to poor hygiene, as the anal area may be more difficult to clean after defecation when hemorrhoids are present, or seepage of stool due to a prolapsed hemorrhoid.

Patients presenting with symptoms suggestive of hemorrhoids need a complete evaluation to be done before making the diagnosis of hemorrhoids, as other conditions can cause rectal bleeding and pain. After a thorough history has been completed, a physical exam including external anal inspection, digital rectal examination, and anoscopy (a small lighted scope inserted into the anus) should be done. For patients older than 40 years, evaluation with either flexible sigmoidoscopy or colonoscopy is indicated.

Most internal hemorrhoids can be treated successfully in the outpatient setting by primary care physicians. For patients with minor or infrequent symptoms, treatment begins with dietary modification and bulk laxatives. A high-fiber diet with plenty of raw fruits and vegetables, commercial fiber supplements, and increased fluid intake keep stools soft and decrease straining and irritation of existing hemorrhoids. The use of topical hydrocortisone creams is common, although there is little evidence of benefit in the scientific literature. Hydrocortisone creams may help decrease perianal itching, however, improved anal hygiene should be stressed. Hydrocortisone creams should not be used on a long-term basis as they may cause thinning of the perianal tissues.

If symptoms persist despite these measures, there are procedures that can be done in the doctor’s office. The most common techniques employed are injection sclerotherapy and rubber band ligation. Using sclerotherapy a solution is injected into the hemorrhoid and causes scarring and obliteration of the vessel. Rubber band ligation, or placement of a very small rubber band around the base of the hemorrhoid, will cut off the blood supply to the tissue and cause the hemorrhoid to eventually slough off. Both procedures involve very little risk or discomfort to the patient. Patients may require more than one session for complete eradication of hemorrhoids. Other techniques include cryosurgery, laser hemorrhoidectomy, and various coagulation modalities, all of which may require repeat treatments for eradication of hemorrhoids.

Surgical excision of internal hemorrhoids is reserved for patients for whom the previously described procedures have not worked, or who have persistently prolapsing or nonreducible prolapsed hemorrhoids. This procedure is generally performed as same-day surgery and requires some form of anesthesia. Complications tend to be rare and recurrence of hemorrhoids is low.

Therapy for thrombosed external hemorrhoids varies depending on the severity of the patient’s pain. If the pain is mild, a regimen of frequent sitz baths, stool softeners, and pain medications is followed, as the pain is generally self-limited and lasts for 7 days or so. If the pain persists beyond 7-10 days, despite these measures, excision of the external hemorrhoid can be performed. This procedure can be performed in the doctor’s office, using injection of a local anesthetic and removal of the vein with a scalpel.

Patients with perianal skin tags from old thrombosed external hemorrhoids usually seek treatment because of problems associated with maintaining adequate anal hygiene. Unfortunately, excision of anal skin tags does not relieve the underlying problem of anal hygiene.

SEE ALSO: Constipation, Pregnancy

Suggested Reading

  • Hulme-Moir, M., & Bartolo, D. C. (2001). Disorders of the anorectum. Gastroenterology Clinics of North America, 30, 183-197.
  • Hussain, J. N. (1999). Office management of common anorectal problems: Hemorrhoids. Primary Care, 26, 35-51.
  • Pfenninger, J. L., & Zainea, G. G. (2001). Common anorectal conditions: Part II. American Family Physician, 64, 77-88.


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