WHAT ARE HEMORRHOIDS, CAUSES/RISK FACTORS, TYPES, etc

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Hemorrhoids (piles) are blood vessels in the smooth muscles of the walls of the rectum and anus of everyone. They are very common and normal part of the anatomy at the junction where small arteries merge into veins. Hemorrhoids become significant only when the hemorrhoidal clumps of vessels start to swell and itch with pain and/or bleeding. Hemorrhoid swelling occurs when variety of factors increase the pressure in the small vessels that make up the hemorrhoid causing them to inflame and engorge with blood leading to signs and symptoms of Hemorrhoids.

Hemorrhoids are common occurrence among five of six adults in their life time. At the age of 50 years, about 60% of adults experience the signs and symptoms of hemorrhoids. Hemorrhoids are present even in healthy individuals. In the global population scale, the prevalence of symptomatic hemorrhoids is estimated at 4.4%. An estimated 75% of people will experience enlarged hemorrhoids at some point. However, only about 6% will visit the hospital because of hemorrhoids. Hemorrhoids that cause health challenges equally affect men and women, and their prevalence which is age related peaks between 45 and 65 years of age. Although there is no known sex predilection, studies indicate that men are more likely to seek medical attention.  Pregnancy is the major physiologic changes that predispose women to symptomatic hemorrhoids. External hemorrhoids are more common in young and middle-aged adults.  Hemorrhoids are most common among the Caucasians, the rural populace and the wealthy.

Fortunately hemorrhoids are treatable. Many effective treatment options are available for hemorrhoids problems. Many people can get relief with home treatments and lifestyle modifications.  Although hemorrhoids can be recurrent, painful intrusion and discomforting, they are not life-threatening and can disappear on their own without treatment. Generally, the long-term outcomes of hemorrhoids problems are good, though some people may have recurrent symptomatic episodes. But only a little percentage of people requires surgery finally. The application of the information from this document is essential for boosting your participation in the management and treatment of your hemorrhoids.

WHAT ARE HEMORRHOIDS?

Hemorrhoids or piles are swollen and distended veins inside the anus or in the lower rectum similar to varicose veins. Often the walls of these blood vessels get so thinly stretched that the veins bulge and get irritated, especially during bowel evacuation, leading to the disease called hemorrhoids. Hemorrhoids contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during bowel evacuation.  In their normal state, they are helpful cushions in controlling bowel movements. Hemorrhoids are believed to result when these vascular structures slide downwards or when venous pressure is increased excessively. Bleeding during bowel movements is the most common sign/symptom of hemorrhoids.

Piles are not dangerous but can cause extreme pain and swelling that may need to be lanced and drained. Hemorrhoids are more likely with aging because the tissues that support the veins in the rectum and anus can weaken and stretch.

There can be internal or external hemorrhoids. Internal hemorrhoids originate inside the rectum. External hemorrhoids occur outside the anus. External hemorrhoids are the most common and troublesome. Globally, hemorrhoids (also termed piles) have caused discomforts of pain and irritation throughout human history.

CAUSES/RISK FACTORS OF HEMORRHOIDS

There are possible factors which interfere with blood flow to and from the hemorrhoidal veins, causing it to distend and enlarge the vessels. They include:

  • Hepatic disease
  • Obesity which is diet-related can cause hemorrhoids
  • Consistent lifting of heavy weights and body strain
  • Elevated anal resting canal tone or pressure
  •  Lack of erect posture and spinal cord injury
  • Loss of rectal muscle tone
  • Long standing posture
  • Family history
  • Holding of  breath while straining to do physical labour
  • High socioeconomic status
  • Chronic and acute diarrhea
  • Colon malignancy
  • Previous rectal surgery
  • Episiotomy
  • Constant anal sexual intercourse
  • Inflammatory bowel disease including ulcerative colitis and Crohn disease
  • Pregnancy: As the uterus enlarges during pregnancy, it presses on the vein in the colon, causing it to bulge. Also, hormonal changes with pregnancy may weaken the muscles that support the veins in the rectum and anus resulting to hemorrhoids
  • Aging: Hemorrhoids are most prevalent among adults aged 45 to 65 years. At this period, the connective tissues that support and hold hemorrhoids in place can weaken, causing hemorrhoids to bulge and prolapse
  • Chronic constipation: Straining during bowel movements put additional pressure on the walls of the blood vessels which can lead to hemorrhoids
  •  Long sitting or squatting posture: Especially on the toilet can cause hemorrhoids.
  • Lack of guided exercise
  • Nutritional factors (low-fiber diets)
  • Chronic coughing, sneezing and vomiting
  •  Pelvic floor dysfunction

TYPES OF HEMORRHOIDS

Hemorrhoids can be either internal or external. Internal hemorrhoids are normally deep inside the lower rectum; and are painless and most troublesome. The common initial sign of internal hemorrhoids are presence of rectal bleeding. Internal hemorrhoids are typically painless, even when they bleed. Sometimes straining can cause an internal hemorrhoid to protrude through the anus. This is called a protruding or prolapsed hemorrhoid which can be painful. Prolapsed hemorrhoids can usually recede on their own or can be gently pushed back. When an internal hemorrhoid becomes inflamed, it can cause swelling. This in itself does not cause pain because there are no or few pain-sensing nerves fibers attached to the veins above the pectinate line. Passage of hard feces can scrape off the thin lining of the hemorrhoid causing painless bleeding. Internal hemorrhoids can also thrombose (clot) leading to severe pain. Sometimes the presence of stool, inflammation and constant moisture can lead to anal itchiness (pruritus ani), and constant feeling of the urge to evacuate the bowel.

External hemorrhoids are covered by regular skin around the anus and have pain and temperature sensitive nerve fibers associated with them, so they tend to be painful and bleed. A thrombosed external hemorrhoid occurs when an underlying vein inside the hemorrhoid clots resulting to bleeding; and severe itching and pain from the rapid stretching of the skin covering the hemorrhoid. A hard painful lump can be observed at the anus. External hemorrhoids can also cause irritating excess skin tags which can be felt at the anal verge when the clot dissolves and can cause secondary skin infections and difficulties in cleaning after a bowel movement. External hemorrhoids will resolve on their own within weeks.

DEGREES OF INTERNAL HEMORRHOIDS

Internal hemorrhoids prolapse when their blood vessels swell and protrude from their position inside the rectum to the anus. It should be noted that the hemorrhoids’ prolapse can repeat with the next bowel movement. Their degrees of prolapsed are:

  • First-degree hemorrhoids: Hemorrhoids that may bleed, but do not prolapse outside the anus. These are just prominently enlarged hemorrhoids.
  • Second-degree hemorrhoids: Hemorrhoids that prolapse and spontaneously retract on their own (with or without bleeding) once the straining subsides. These may protrude from the anus during certain activities like, upon bearing down or bowel evacuation.
  • Third-degree hemorrhoids: Hemorrhoids that prolapse upon bearing down or without any straining and must be gently pushed in manually.
  • Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back into the anal canal manually. They include hemorrhoids that are thrombosed (containing blood clots) or that expose much of the lining of the rectum through the anus.

COMPLICATIONS OF HEMORRHOIDS

Most hemorrhoids resolve spontaneously or with conservative medical therapy alone. Early treatment of unresolved hemorrhoids often produces successful outcome void of complications.  However, the following rare complications do occur:

  • Strangulated hemorrhoid: This happens if the blood supply to an internal hemorrhoid is cut off. This can cause extreme pain.
  • Blood clots: Sometimes, blood may clot in the swollen and inflamed anal veins, causing severe pain.
  • Iron deficiency anemia: Occasionally, there may be chronic blood loss from hemorrhoids resulting to anemia due to insufficient healthy red blood cells to carry oxygen to the cells.
  • Urinary retention and pain
  •  Life-threatening blood infection (sepsis).

SIGNS AND SYMPTOMS OF HEMORRHOIDS

Internal and external hemorrhoids may present differently; however, many people may have a combination of the two. Generally, hemorrhoids cause signs and symptoms when they become enlarged, inflamed, thrombosed or prolapsed. The signs and symptoms can be unpleasant or alarming, but they are usually not of critical concern. Most signs and symptoms arise from enlarged internal hemorrhoids. The common signs and symptoms include:

  • Painless, bright red rectal bleeding
  • Extreme itching or irritation in the anal area
  • painful or itchy lumps and swelling in the anal region
  • Leaking feces
  • Discomfort, severe pain or soreness in the anal area which typically resolve in two to three days
  • Mucous discharge
  •  Fecal incontinence
  • Anal burning or painful bowel movements

CONSERVATIVE (HOME) TREATMENTS /PREVENTIVE MEASURES AGAINST HEMORRHOIDS ATTACK

Conservative treatment which is probably the most effective typically consists of:

  • Foods rich in dietary fiber such as fresh fruits, nuts, whole grains, vegetables, broccoli, beans, wheat, oat bran; and over-the-counter fiber supplements, such as Metamucil and Citrucel (25 grams a day for women and 38 grams a day for men) are essential in keeping the stool soft and increasing its bulk. Also, fiber makes stools easier to pass, decreasing hemorrhoidal pressure, bleeding, inflammation and enlargement. They may also reduce irritation caused by small bits of feces trapped around the blood vessels. Add fiber to your diet gradually to 25–30 grams of fiber per day to avoid problems of farting.
  • Intake of oral fluids (not alcohol), especially 3-5 litres of water help to maintain hydration and prevent your stool from hardening (constipation).
  • Use nonsteroidal anti-inflammatory drugs under prescription and counseling.
  • Sitz baths (the name comes from the German “sitzen,” meaning “to sit”): To minimize pain, relieve itching, irritation and spasms of the sphincter muscle; and reduce the inflammation of hemorrhoids, sit/soak your anus inside a tub filled with about two inches of plain warm water for at least 10-15 minutes, 2-3 times a day. Pharmacies sell small plastic tubs that fit over a toilet seat. Most experts recommend a 20-minute sitz bath after each bowel movement and extra 2-3 times a day. After each sitz bath, it is important to dry off the anal area completely to remove the moisture that can irritate the skin around the anus. Also you can sit on a warm water bottle to relieve the pain of external hemorrhoids. Using a cold compress on your anus can help reduce hemorrhoid swelling.
  • Resting, especially on cushion instead of hard surface reduces the anal pressure, swelling of existing hemorrhoids and prevents the formation of new ones.
  • Petroleum jelly or zinc oxide or shear butter is useful.
  • Use of small ice cold pack on the trouble spot severally per a day reduces pain and swelling for some time. Witch hazel wipes (Tucks) are soothing and have no harmful effects. Avoid scratching which could damage the skin and worsen the irritation and itching. Avoid alcohol-based or perfumed wipers.
  • Wear loose, soft cotton underwear to keep the area properly ventilated and stop moisture which can aggravate the discomfort from the hemorrhoids.
  • Seek emergency medical evaluation and treatment if large amounts of rectal bleeding, lightheadedness, dizziness or faintness are observed.
  • Avoid over-straining: When on routine business in the toilet, do not strain so as not to add undue pressure in the veins of lower rectum. Also avoid spending too much time or reading or holding your breath while on the toilet to defecate.
  • Physical activity: Sitting or standing still at any place for long time which puts pressure on the veins should not be allowed. Use sufficient exercises to make your bowel movements smooth and more regular.
  • Maintain a healthy body weight and avoid lifting heavy weight to reduce the risk of having hemorrhoids.
  • Antidiarrhea medications and diet adjustments: these are needed to check too frequent bowel movements (diarrhea) which may increase the amount of straining and pressure within the blood vessels of the anus.
  • Use the restroom as soon as you feel the urge to evacuate your bowel to avoid the formation of dry and harder stool. Do not wait for a more convenient time. Stool can back up, leading to increased pressure and straining. Also, it is better for you to establish a regular bowel habit by scheduling a set time each day to sit on the toilet for a few minutes.
  • Avoid use of soap which can aggravate hemorrhoids. Also avoid using dry or rough toilet paper to clean the anus after a bowel movement. Clean water is more ideal. If you want to wash the anus, use unscented soap and do not scrub the area.
  • Moderate aerobic exercise such as brisk walking 20–30 minutes a day for 4-5 times a week, can help stimulate bowel movements.

Medications, ligation, surgery and other medical procedures are options when the above remedies prove ineffective. They have their challenges. It is necessary to stress that symptoms can be relieved through the above ways but may not eliminate the hemorrhoids.

DIAGNOSIS AND TREATMENT OF HEMORRHOIDS

Usually, hemorrhoids can be diagnosed on the basis of a careful and simple medical examination or history and physical examination of the anus and surrounding areas by medical experts. Your doctor can carry out a physical examination and request for other tests to confirm hemorrhoids and rule out more-serious conditions or diseases. Generally, external hemorrhoids are apparent, especially with the presentation of a blood clot. The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus.  Make sure you get the right diagnosis and treatment from expert healthcare professionals.

Generally, since hemorrhoids get worse over time, it is medically advised that they should be treated as soon as they appear.  Hemorrhoids can be unpleasant and painful but they are easily treatable and very preventable. Often, no specific treatment is needed. The mild pain, swelling and inflammation of hemorrhoids can be relieved with home treatments alone.  In the majority of cases, simple preventive measures will alleviate symptoms and stop hemorrhoids without treatment. However, a number of minor procedures may be performed if symptoms are severe or do not improve with conservative management.

Therefore lifestyle modifications, drugs, surgery and nonsurgical treatment options are sometimes needed to treat hemorrhoids if other remedies are ineffective. Most hemorrhoid drugs are Over-The-Counter (OTC) which includes ointments or creams, pads or suppositories or gels for topical treatments. Consult with a doctor or pharmacist on any treatment procedure and if these drugs do not produce results after a week of treatment, for comprehensive medical interventions.

If you are pregnant, contact expert healthcare professionals before you try any drug or modify your diet. If an external hemorrhoid clots, the pain can be excruciating. If pain is tolerable and the clot has been present for more than two days, apply home treatments for the symptoms to resolve while waiting for it to disappear on its own. If the blood clot is recent, the hemorrhoid can be removed through surgery or the clot withdrawn from the vein in a minor office procedure. There are about 50% chances of hemorrhoids recurring after non-surgical treatment, while the recurrence rate after surgery is about 5%. Hemorrhoids are life-long condition to be controlled and not cured.

BEST DIETS THAT ALLEVIATE HEMORRHOIDS

A diet rich in high-fiber and with few processed foods is best for hemorrhoids. Eat mostly vegetables, fruits, nuts and whole grains. Sources of good dietary fibers which create bulk in the intestines, soften the stool and make bowel evacuation easier include:

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