Hemorrhoids bother about half of all Americans at some time in their lives, usually after age 30. Many others have hemorrhoids without even realizing it. One recent study showed that, of 241 healthy people reporting for physical exams, 82 percent had hemorrhoids.
Hemorrhoids are essentially swollen blood vessels in the anal canal and lower rectum. These vessels bulge inward and narrow the anorectal passage. Hemorrhoid sufferers may experience bleeding during bowel movements, itching in the anal area, and a feeling of lingering fullness in the rectum after a bowel movement. Occasionally, hemorrhoids also cause outright pain.
There are two types of hemorrhoids, internal and external.
Most experts now regard internal hemorrhoids as normal anatomic structures. They result when the “cushions” of blood vessels and connective tissue that line the lower rectum and anal canal become swollen and protrude from the rectal wall. The cushions gradually become elongated and descend toward the anus. There are three main cushions, which is why the typical case of internal hemorrhoids involves three hemorrhoids.
What transforms the cushions into hemorrhoids? Aging seems to be one factor. The connective-tissue fibers that anchor the cushions to the rectal wall become looser and weaker as people age. That may explain why hemorrhoids are quite rare in childhood. Perhaps more important, however, are the forces that propel the cushions downward toward the anus. Most authorities believe that chronic constipation is the main cause of hemorrhoids. Over time, as constipated people strain to evacuate their bowels, the increased pressure in the rectum causes blood vessels in the cushions to become chronically engorged with blood. That gradually distends and weakens the vessel walls. The hemorrhoids then tend to bleed easily as passing feces buffet the stretched and fragile mucous-membrane covering.
Pressure from the frequent bowel movements associated with diarrhea can also cause hemorrhoids. Indeed, any prolonged period on the toilet focuses considerable pressure on the anal area—even if all you do there is read.
Hemorrhoids are also encouraged by other factors that create chronic increased abdominal pressure. They’re common during pregnancy, for example, and among people who exert themselves strenuously at work or who stand in one place for long periods. Additional factors contributing to hemorrhoids include heredity (hemorrhoids tend to run in families), low daily intake of liquids, and faulty bowel function due to overuse of laxatives and enemas.
The most common symptom of internal hemorrhoids—and often the only one in mild cases—is bleeding, apparent from bright red blood on the toilet paper or coating the feces. (Hemorrhoid comes from the Greek words haema, “blood,” and rhoe, “flow.”) Bleeding often occurs intermittently, with weeks or months between episodes. As the downward pressures exerted on internal hemorrhoids stretch them toward the anus, the sufferer may also experience a feeling of incomplete evacuation following a bowel movement.
On wiping, you can feel a hemorrhoid as a lump that gradually recedes into the rectum by itself or can be gently eased back in with a finger. (Piles, from the Latin word for ball, is another term for hemorrhoids.) In severe cases, an internal hemorrhoid projects from the anus and can’t be pushed back. This “completely prolapsed hemorrhoid” can be quite painful.
In most cases, however, internal hemorrhoids are not painful, since their mucous-membrane covering has no nerve endings to sense pain. As anyone who has seen ads for hemorrhoid remedies knows, internal hemorrhoids often cause irritation, itching, and burning. Those symptoms are generally caused by mucus and feces that adhere to the bulging hemorrhoid and irritate the skin around the anal opening.
External hemorrhoids are another story. These arise from swollen clumps of blood vessels located around the rim of the anus or just inside. External hemorrhoids are not covered by nerveless mucous membrane but by one of the body’s most sensitive areas, the skin in and around the anus. When a small blood clot forms in one of the swollen blood vessels, it stretches this sensitive skin and brings on sudden and often severe pain. Such a hemorrhoid “attack,” which usually results from strenuous physical exertion, is known as a thrombosed external hemorrhoid. It can be felt with a finger as a firm, tender, rounded mass about the size of a pea. The pain lasts until the clot softens—usually in a few days, with or without the use of hemorrhoid remedies. In very painful cases, a doctor can provide almost immediate relief by making a small incision and releasing the clot.
Often, symptoms that people attribute to hemorrhoids are not a result of hemorrhoids at all. Itching may be caused by poor anal hygiene, perianal warts, intestinal worms, overgrowth of fungi from use of antibiotics, psoriasis, nervous scratching, and many other causes. Pain can result from fissures (small cracks in the skin surrounding the anus) or from infections in the anal area.
But the most serious misdiagnoses involve bleeding, the most common symptom of hemorrhoids. For instance, bleeding can be a symptom of colorectal cancer—a disease that kills more than 50,000 Americans each year. Persistent or recurrent bleeding demands medical attention. Unfortunately, many people tend to ignore rectal bleeding—either out of embarrassment about being examined or out of fear of discovering they have cancer. Chances are, hemorrhoids are responsible. But you owe it to yourself to rule out other causes. That requires investigations that may include barium X-ray studies or the use of instruments (the sigmoidoscope or colonoscope) to examine the wall of the bowel. Once more serious conditions have been ruled out, various treatments can help alleviate hemorrhoid symptoms.
Prevention and Self-Treatment
There are two major steps people can take on their own to minimize the symptoms of hemorrhoids. One is to increase the amount of fiber in the diet—a step that may also help prevent hemorrhoids from developing. Since straining on the toilet due to constipation is probably the main cause of hemorrhoids, it follows that avoiding constipation is an important part of prevention and, in mild cases, cure. Adding fiber to the diet is the only treatment necessary for about half of all cases of hemorrhoids.
The other way to minimize symptoms is to practice good anal care. Hygienic habits can help control irritation and itching, whether caused by hemorrhoids or not. Most important is to keep the skin around the anus clean and dry. Residual fecal matter keeps the area moist and can irritate the skin. But vigorous wiping with dry toilet papef may make things worse. Instead, swab the area after each bowel movement using toilet paper moistened with warm water. Then gently pat the area dry. For convenience and a soothing effect, some people like premoistened wipes such as Gentz Wipes, Mediconet, Preparation H Cleansing Pads, Rantex, or Tucks Pads.
Soap residues can irritate, so always rinse off completely after showering or bathing. If soaps do cause irritation, you can clean the anal area with a product like Balneol perianal cleansing lotion.
A sitz bath—sitting in warm tap water a few inches deep for 10 to 15 minutes—is a time-honored treatment for anal discomfort. Three or four sitz baths per day for a few days may provide considerable relief. A bathtub works fine, or you can buy a portable plastic sitz bath that fits over the toilet.
Since perspiration can irritate the anal area, avoid tight undergarments and pantyhose. Loose cotton underwear is best. A light sprinkling of talcum powder in the area can help absorb moisture.
Before seeking professional care, most hemorrhoid sufferers try to treat themselves—typically for a year or longer—with over-the-counter (OTC) remedies. By far the biggest seller is Preparation H. According to industry sources in 1986, this product alone accounts for more than half the $200 million Americans spend yearly in search of relief at the drug counter. Next in line are Anusol, Tronolane, Nupercainal, and others.
CU’s medical consultants have reservations about the use of some of the leading OTC remedies. They contain a number of ingredients, including anesthetics, astringents, counterirritants, and skin protectants. Some of these ingredients can trigger an allergic reaction and make irritation worse. Peruvian balsam, an astringent used in Anusol ointment and other products, caused allergic reactions in 10 to 20 percent of patients tested with it.
The worst offenders are the “caine” anesthetics—benzocaine, dibucaine, and others. These chemically similar anesthetics are notorious for causing allergic skin reactions. CU’s medical consultants recommend against products containing them, including Americaine, BiCozene, Lanacane, Nupercainal, and Medicone. Another anesthetic, pramoxine hydrochloride, differs chemically from the “caine” anesthetics and appears to cause fewer allergic problems. It is found in Tronolane and other products.
Despite their diverse composition, most hemorrhoid remedies make the same basic claim—temporary relief of pain and itching. But Preparation H is famous for an additional claim—relief of swelling. Any bland cream or ointment, even without active ingredients, can soothe irritated skin. Preparation H can probably do that job as well as its competitors. But none has been proved to shrink swollen hemorrhoids. The Medical Letter, a respected newsletter for physicians, concluded back in 1975: “There is no acceptable evidence that the heavily promoted Preparation H … can shrink hemorrhoids, reduce inflammation, or heal injured tissue.”
Hemorrhoid products are marketed in three basic forms—cleansers, suppositories, and creams or ointments.
The best hemorrhoid products, we believe, help keep the anal area clean. They include Preparation H Cleansing Pads and Tucks Pads.
It makes little sense to use hemorrhoid suppositories. After a suppository is inserted into the anus, it often slides up into the upper rectum, bypassing the spot that needs treatment. True, a suppository can lubricate the rectum, and thus make hard bowel movements less painful. But any effect on the hemorrhoids themselves is minimal at best. Many of the suppository products are also available as creams or ointments.
Creams and Ointments
These may help soothe irritation. Creams are generally preferable to ointments. Ointments, which are greasier, tend to retain moisture, which may encourage itching and irritation in the anal area. Hydrocortisone, present in several products, is an effective anti-itch ingredient. But its overuse may lead to dependency and can cause thinning of the skin, which results in more fissures and bleeding.
Self-treatment with hemorrhoid remedies may aggravate the trouble and sensitize the skin. But even worse, it can cause serious conditions to be overlooked. Persistent or recurring itching, pain, or bleeding in the anorectal area should not be ignored or treated in a casual fashion with OTC remedies. Each of these symptoms should be evaluated by a physician and treated appropriately.
If hemorrhoid symptoms persist despite self-treatment, you might want to seek professional treatment. Three relatively painless office procedures can ease most cases of internal hemorrhoids and may prevent them from worsening to the point where surgery is necessary. The procedures—injection, rubber-banding, and photocoagulation—relieve symptoms mainly by shrinking hemorrhoids somewhat and anchoring them in place.
To shrink the hemorrhoid and its blood vessels, the physician injects a liquid into the mucous membrane near the hemorrhoid. This technique works well for treating small bleeding hemorrhoids that haven’t yet protruded into the anal canal. It is also useful for treating hemorrhoids that protrude through the anus during defecation and then retract. Repeat treatments every two or three years may be necessary.
This technique, the most widely used office treatment, is mainly for hemorrhoids that protrude on defecation and retract spontaneously or are easily pushed back in. A special instrument fits a small rubber band over part of the hemorrhoid. The tight rubber band stops the blood flow to the pinched-off portion, which falls off in about a week. This procedure often causes some discomfort until the end result is achieved.
In this recently developed technique, a device called a photocoagulator focuses infrared light into a fine point at the end of a probe, which in effect spot-welds the hemorrhoid in place. Photocoagulation can often substitute for either of the other office procedures, and recent studies indicate that it may be the fastest and least painful of the three.
Hemorrhoids that reach the painful point where they protrude from the anus and can’t be pushed in may have to be removed surgically. The surgical procedure, called a hemorrhoidectomy, is performed less often now than it was 20 years ago, mainly because the newer office treatments described above often suffice.
A modern hemorrhoidectomy is much less painful than it once was. Previously, the operation was always done under general anesthesia. It required a week in the hospital and two to three weeks of recovery at home. Now local anesthesia is often used; many patients return home the day after surgery and go back to work after a few days of rest. Some doctors perform the operation on an outpatient basis.
Lately, some surgeons have begun to use a new and controversial operation, the laser hemorrhoidectomy. Proponents claim it is less painful than the traditional operation and removes hemorrhoids more completely; critics contend it is no better than traditional surgery. The verdict will have to await clinical trials.