Hemorrhoids and Treatment

Introduction

Hemorrhoids are essentially varicose veins of the rectum. Strictly speaking there are two types of hemorrhoids, internal and external. Internal hemorrhoids are located inside the rectum and are covered with a relatively fragile lining called the rectal mucosa. Internal hemorrhoids tend to bleed but do not generally cause pain. External hemorrhoids are located outside the rectum and are covered with very sensitive anoderm. These tend to cause pain, burning and itching but do not bleed. Most people however have complex hemorrhoids that originate internally but become so large that they take on characteristics of both internal and external hemorrhoids.

Hemorrhoids are classified based on severity into four grades. First degree hemorrhoids bleed but do not prolapse outside of the anal canal; second degree prolapse outside of the anal canal, usually upon defecation, but retract spontaneously. Third degree hemorrhoids require manual placement back inside of the anal canal after prolapse, and fourth degree hemorrhoids consist of prolapsed tissue that cannot be manually replaced. Fourth degree hemorrhoids are at high risk of becoming strangulated leading to thromboses and severe pain.

Signs and Symptoms

Many anorectal problems, including fissures, fistulae, abscesses, or simple irritation have similar symptoms and may be confused with hemorrhoids. Hemorrhoids usually are not dangerous or life threatening but can occasionally cause profuse bleeding leading to anemia. In some cases hemorrhoid symptoms simply go away within a few days. But in most cases, these symptoms eventually return, often worse than they were before. The most common symptoms of hemorrhoids include bright red blood on the stool, toilet paper, or dripping into the toilet bowl. Other symptoms include pain, itching and mucus discharge. Severe hemorrhoids can even lead to fecal incontinence.

Risk Factors

Any condition that increases venous pressure in the rectal vessels can lead to hemorrhoids. Chronic constipation, straining with bowel movements or strenuous physical activity can lead to the development of hemorrhoids. Pregnancy and childbirth are also leading causes.

When to Seek Medical Advice

Hemorrhoids, like many diseases are best treated in the early stages. When symptoms are present for more than a week or recur frequently you should seek medical advice.

Diagnosis

A thorough evaluation and proper diagnosis by a doctor is important any time bleeding from the rectum or blood in the stool occurs. This is because bleeding may also be a symptom of other digestive diseases including colorectal cancer. Your doctor will examine the anus and rectum to look for swollen blood vessels or other abnormalities. This exam usually includes a digital rectal exam with a gloved, lubricated finger to feel for abnormalities. Anoscopy using a small hollow tube is usually performed for a closer evaluation. If significant hemorrhoids are not identified, your doctor may recommend a colonoscopy to evaluate other causes of gastrointestinal bleeding.

Treatment Options

Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Many treatments can be done at home. Warm sits baths several times a day in plain, warm water for about 10 minutes can relieve pain and swelling. Application of a steroid containing hemorrhoid cream such as hydrocortisone to the affected area can improve symptoms for a limited time but should not be used for a prolonged periods. Eliminating the pressure and straining of constipation will minimize symptoms and recurrence of hemorrhoids. Increasing fiber in your diet and drinking six to eight glasses of water result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Good sources of fiber include fruits, vegetables, and whole grains. Fiber supplements such as psyllium, metamucil and senna soften and moisten the stool. Chemical softeners such as colace or Exlax also soften the stools but over time lose their effectiveness. Newer agents such as Mira lax help the stool retain water and can be used safely for longer periods of time. In more advanced cases, surgery is required to provide satisfactory, long term relief.

Conventional surgery

Traditional hemorrhoid surgery involves excising the hemorrhoids and the redundant overlying mucosa. Most commonly the lining is closed with absorbable stitches but in some cases the incisions may be left open to avoid narrowing of the anus. Other techniques using the harmonic scalpel can be used to close the mucosa without sutures. Regardless of technique, traditional surgery is accompanied by severe pain usually lasting one to two weeks. Complete healing may take four to five weeks. Conventional hemorrhoidectomy can be performed as an outpatient but because of severe postoperative pain may require a two to three day hospital stay. Recurrence after this type of treatment is common but may take many years. Complications following conventional hemorrhoid surgery include recurrence, anal stenosis, infection, bleeding, and fecal incontinence.

PPH (Stapled) Hemorrhoidectomy

PPH (Procedure for Prolapse and Hemorrhoids) is a revolutionary technique developed in the early 90's that removes excess hemorrhoidal tissue with the use of a circular stapling device. During the PPH procedure the redundant hemorrhoidal tissue is drawn into this specialized device that allows the excess tissue to be removed while remaining hemorrhoidal tissue is stapled or pexed back to its proper anatomic position.

The procedure begins with the introduction of a circular dilating anoscope into the rectum. This causes the reduction of the prolapsed hemorrhoids and rectal mucosa. After removing the obturator, the redundant hemorrhoidal tissue falls into the lumen of the dilator.

A purse-string suture anoscope is then introduced through the dilator. This enables the placement of a circular stitch that incorporates not only excess hemorrhoidal tissue but also the venous blood supply. The Hemorrhoidal Circular Stapler is then introduced and positioned proximal to the purse-string, which is then tied with a closing knot.

With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the body of the PPH device. The instrument is then closed and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 3 minutes before firing and approximately 30 seconds after firing acts as a tamponade, which may help promote hemostasis and eliminate bleeding.

Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue. A circumferential column of mucosa and redundant hemorrhoidal tissue is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed.

Benefits of PPH over other Surgical Procedures

• Performed completely inside the rectum where there are minimal nerve endings
• Less pain as compared to conventional techniques
• Quicker return to normal activities
• Virtually always performed as an outpatient
• Permanently disrupts the blood supply to hemorrhoids minimizing recurrence
• Does not require post operative wound care

Risks of PPH

• Complications following PPH are rare but include:
• Bleeding
• Inadvertent damage to the rectal wall
• Short or long term incontinence
• Infection
• Prolonged pain

For more information about this procedure, http://pphinfo.com/

Do it Yourself

Anal Hygiene: Proper Cleaning & Wiping Technique

Avoid rubbing with toilet paper. This aggravates the hemorrhoids and irritates the skin. Whenever possible, clean the area in a bath or a shower without using soap. Plain water or natural cleansing products are usually OK. Be sure to rinse the area well. Then gently dry the area by blotting it with a towel, or use a blow dryer set to cool. Thick-quilted disposable baby wipes can be a suitable substitute for toilet paper. Be sure to blot and try to avoid scrubbing.

Anal Hygiene: Proper Way to Experience a Bowel Movement

Use the toilet whenever you feel the urge to have a bowel movement, even if it is several times throughout the day. Try to go as soon as you feel the urge to go; if you delay this urge by more than a few minutes, you might get a reflex constipation and loose the urge to go again for several hours.

Prolonged sitting or excessive straining while on the toilet, allows the hemorrhoidal venous cushions to expand unnecessarily, causing hemorrhoid disease to develop or worsen. Avoid excessive straining with any bowel movement. A gentle pressure or straining of the abdominal and pelvic muscles is OK, but not for more than 30-consecutive seconds. Limit your time on the toilet from 3-5 minutes for any one sitting. If you have not completed an entire bowel movement, get off the toilet, walk around for a bit, and wait for the urge to have a bowel movement return.

Diet to reduce itching

A diet designed to lower the acid in your stool can be beneficial. Avoiding soda beverages, citrus fruits and juices, as well as beer and wine can provide relief. In addition, avoid caffeinated products, especially coffee, because this lowers the anal sphincter pressure, promotes flatulence, and generally heightens anal skin sensitivity.

Avoiding Constipation

Constipation is a leading cause of hemorrhoids. In most cases dietary and lifestyle changes will help relieve symptoms and help prevent constipation.

A high fiber helps to form soft, bulky stools. A doctor or dietitian can help plan an appropriate diet. High-fiber foods include beans; whole grains and bran cereals; fresh fruits; and vegetables such as asparagus, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber such as ice cream, cheese, meat, and processed foods is also important.

Other changes that can help treat and prevent constipation include drinking enough water and other liquids such as fruit and vegetable juices and clear soup, engaging in daily exercise, and reserving enough time to have a bowel movement. In addition, the urge to have a bowel movement should not be ignored.

Enemas

Enemas may be used to relieve constipation and fecal impaction. To keep the bowels clean, plain warm water enemas can be effective. As a bowel stimulant, enemas are administered directly into the rectum. It is best to hold the enema for 10-15 minutes to allow passage into the colon then expel the feces along with the enema in the toilet. Do not use chemicals exceede more than one quart of water per day.

Ice Packs

Acutely inflamed hemorrhoids respond well to icing the area. Apply an ice pack to the anal area on and off for 10-15 minutes, 5-times a day. Ice can also be gently applied internally by freezing water in a small popsicle mold.

Keep the Anus Dry

A moist anal area is prone to irritation and infection of the skin. Sprinkle the anus with cornstarch or baby powder to absorb any moisture. A feminine napkin may be used to absorb excess moisture. If redness or irritation persist, this may be a sign of candidal overgrowth. This can be treated with vaginal creams designed to fight candida or other fungi.

Sits Bath

A "sits bath" is a bath in which buttocks are immersed in warm water for the therapeutic effect of moist heat in the anal region. It is one of the best treatments a person can use to get relief from hemorrhoids. Nothing should be added to the water while soaking. Fill up your bathtub with warm water and sit in it for 10-15 minutes as often as you want for relief. Hot water is not recommended and may injure the tissues that you want to heal.

Topical Ointments and Creams

A coating of petroleum jelly, and some commercially available "diaper rash" creams and ointments can be applied directly to the anal area to soothe irritated skin surfaces. Creams that contain 1% hydrocortisone can provide significant relief but should be used for only short periods of time.

Further Online Support

Click Here for a National Medical Library video tutorial about hemorrhoids

Click to learn more about the PPH procedure.