What are hemorrhoids?

Hemorrhoids (or 'piles') are swollen veins in the anal canal and anal skin. The anus is the opening of the rectum through which bowel movements pass. There are two types of hemorrhoids. Those primarily in the anal canal are called "internal"; those primarily in the anal skin are "external". Some people have both or "mixed" internal and external hemorrhoids.

External hemorrhoids are the ones that people can see or feel. They can become swollen, tender or painful as a result of local injury from hard bowel movements and constipation, or because of thrombosis (small blood clots) that may form in them.

Internal hemorrhoids are rarely seen or felt. They are usually painless but they sometimes cause bleeding. If the internal veins stretch and even push out (prolapse) through the anus during hard bowel movements they can bleed and cause pain as well.

There are three hemorrhoidal zones: right posterior, right anterior, and left lateral. Although hemorrhoids are common, many more people think that have problems with hemorrhoids than actually do. There are many other causes of anal pain and bleeding, such as anal fissure.

How do they occur?

Hemorrhoids can result from too much pressure in the rectum and anal canal. Many women have this trouble during pregnancy. Things that can put pressure on the veins and make them swell or bleed include:

• straining from constipation or hard bowel movements
• holding back or delaying emptying of the bowels
• sitting and pushing for a long time on the toilet, which puts strain on the anal area
• pregnancy
• obesity

Flare-ups of hemorrhoids may occur during periods of stress which leads to irregular diet and bowel habits. Pregnant women frequently have problems with both hemorrhoids and constipation. In the last trimester of pregnancy, the enlarged uterus pressing on blood vessels in the anal area can cause hemorrhoids. Also, the strain of childbirth sometimes leads to anal pain after delivery. Usually these go away after delivery when the pressure of the baby is gone and the body is back to normal.

What are the symptoms?

Symptoms of hemorrhoids include:

• itching, mild burning and tenderness.
• bleeding with bowel movements (bleeding with pain is more often from anal fissure.)
• pain and swelling from thrombosed external hemorrhoids. These are tender lumps around the anus ranging in size from a pea to, in severe cases, a walnut, that develop rapidly and are extremely painful.

How are they diagnosed?

Your health care provider will examine your anus and rectum. He or she may use a lighted viewing tool called a proctoscope or anoscope to look inside the anal canal and rectum. If you have persistent symptoms in the anal area, you should see your doctor. If you have persistent anal pain, bleeding or other symptoms that don't improve with eating a healthier diet with more fiber, don't assume you have "hemorrhoids".

How is it treated?

The following treatments usually help to relieve most cases of hemorrhoids:

• High-fiber diet
  
  Eat more high-fiber foods, which will help prevent constipation. Good sources of fiber include breakfast cereals such as All Bran, Fiber One, Bran Buds, which have approximately 10 grams of fiber per serving. Check the box to be sure. Fresh fruit, beans, prunes, raw or cooked vegetables, especially asparagus, cabbage, carrots, corn, and broccoli, are also good sources of fiber. Try to have 20-30 grams of fiber per day (or more) in your diet.
  
  An alternative source of fiber is psyllium or similar fiber supplement product (Metamucil, Citrucel, Benefiber, etc.) You may need to use more than the amount recommended on the package. Lots of fluid is also necessary for these products to work.
  
  High fiber diet must be adhered to daily, to avoid constipation cycles. The fiber you eat today will not have an effect for 2-3 days.
  
  
• Fluids
  
  Drink plenty of fluids, especially water. Drink six to eight 8-ounce glasses of fluid without caffeine (not coffee) a day. Fluid helps to soften bowel movements so they are easier to pass. Avoid beverages with alcohol and with caffeine (coffee, pop) that tend to dehydrate you.
  
  
• Sitz baths and cold packs
  
  Soaking in water can be comforting and improve hygiene. Sitting in lukewarm water 2 or 3 times a day for 15 minutes cleans the anal area and may relieve discomfort. Also, you might try putting cold packs on the anus to relieve pain of thrombosed hemorrhoids.
  
  
• Medications
  
  Stool softener ("docusate") can be helpful in softening your bowel movements in the short run. It is available without prescription. It is not a substitute for high fiber diet, however.
  
  No local medications are effective although many say they are. Sometimes a local anesthetic salve or ointment is helpful. Suppositories and Preparation H are not all that helpful.

Procedures and surgeries
If the pressure caused by constipation and straining is reduced by improved diet and bowel habit, the hemorrhoids will shrink. This is the best way to get rid of hemorrhoids. Surgery is rarely needed. If you have a thrombosed external hemorrhoid, your doctor could cut the hemorrhoid open, and remove the blood clot, but this does not relieve the pain for long and is only done if the thrombosed hemorrhoid is very large. If you have enlarged internal hemorrhoids only, your health care provider might be able do a procedure called hemorrhoid banding. Or your provider may, in some instances, try to shrink the hemorrhoid by injecting a concentrated salt solution around the vein.

For severe cases of hemorrhoids that are large and/or prolapse, a surgical procedure called a hemorrhoidectomy is done. For this procedure you are first given an anesthetic, usually spinal or regional, to prevent you from feeling pain. Then your provider cuts around the hemorrhoids and removes them. This is an outpatient procedure. It corrects the problem, but can cause local pain for several weeks until you are healed.

How long will the effects last?

Usually hemorrhoids do not pose a danger to your health. In most cases the symptoms go away in a few days if you adjust your diet properly. The painful lumps of thrombosed external hemorrhoids should improve in 2 weeks.

How can I take care of myself?

Always tell your health care provider when you have rectal bleeding or pain. Although bleeding may result from hemorrhoids, it is most often caused by anal fissure. More serious illnesses such as colon cancer can also cause bleeding.

Follow these guidelines to help prevent hemorrhoids and to relieve their discomfort:

• Do not strain during bowel movements. Straining makes hemorrhoids swell.
• Follow your high-fiber diet and drink plenty of water. Add fiber to your diet, bran or psyllium (see above). Softer stools may make it easier to empty the bowels and lessen pressure on the veins in the short term.
• Don't overuse laxatives. Diarrhea can be as irritating to the anus as constipation.
• Exercise regularly to help prevent constipation.
• Avoid a lot of wiping after a bowel movement if you have hemorrhoids. Wiping with soft, moist toilet paper (or a commercial moist pad or baby wipe) may relieve discomfort. If necessary, shower instead of wiping, then pat dry the anus gently.
  

Edited by Richard E. Burney, MD, UMHS General Surgery, November 2005

This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.