Diagnosis of Hemorrhoid Disease and Treatment of Hemorrhoid
Hemorrhoids are the veins in the anus and rectum that have enlarged to form protruding lumps or masses. Hemorrhoids develop when these veins swell and become congested with blood, often becoming itchy and painful. In addition, the prolonged pressure on the associated nerves can result in pain while sitting and during bowel movements, while bleeding may be noticed with bowel movements.
Hemorrhoids can occur either within the anus (internal hemorrhoids) or under the skin around the anus (external hemorrhoids). The following article will focus primarily on treating internal hemorrhoids, but much of what is discussed here applies to both types of hemorrhoids.
It is now understood that hemorrhoids are caused by tiny varicose veins that develop inside the routine anal canal. These abnormal veins may cause symptoms when they swell and become congested with blood or when non-blood fluids (e.g., mucus) accumulate in them, causing inflammation.
The resulting symptoms can sometimes be severe enough to require surgery or other invasive treatment; however, many patients respond well to less aggressive measures such as dietary changes and over-the-counter medications.
Hemorrhoid disease has been associated with many factors, including genetic predisposition, obesity, lack of physical activity, prolonged periods of sitting/squatting (e.g., during bowel movements), pregnancy (usually third trimester), chronic constipation or diarrhea, chronic liver disease, heart failure, vascular insufficiency (e.g., from atherosclerosis), and prolonged periods of standing or sitting without taking regular walking breaks.
Varicose veins are relatively common in the general population; however, hemorrhoids are much less common. The prevalence of hemorrhoids among the U.S. population has been estimated at 3 percent or higher; nearly half of these cases may be found in persons age 50 years or older.
Only about 35 to 45 percent of patients with hemorrhoid symptoms present for medical attention; most others either learn to live with their symptoms or seek relief by purchasing over-the-counter medications (e.g., sitz baths, suppositories, topical creams, witch hazel pads).
Pregnancy itself is not a risk factor for hemorrhoids. Still, the dramatic increase in the size of a woman’s uterus during pregnancy may cause an intravaginal vein to become “stretched out” and eventually develop into a hemorrhoid. Additionally, the enlarged uterus displaces other pelvic organs, which can also cause increased pressure on veins in the anus and rectum.
Other factors that may play a role in developing hemorrhoids during pregnancy include: slow fetal descent (the fetus remains in a high position near the cervix), constipation, repeated lifting or pushing during labor or delivery, prolonged sitting directly after delivery (while nursing), and heavy blood loss at delivery.
Postpartum hemorrhoids are often diagnosed when a patient notices that bleeding has begun again after delivery. Postpartum hemorrhoids occur because the normal pressure of the uterus on the veins in the pelvic area is suddenly relieved after delivery, allowing the veins to become distended with blood.
Fecal incontinence may be associated with internal or external hemorrhoids; however, it should be noted that not all persons suffering from hemorrhoid disease have a history of fecal incontinence before developing their condition.
Some patients report having had constipation for years before noticing that they were suffering from some degree of discomfort/pain due to hemorrhoidal varicosities.
Symptoms include itching and pain around the anus, which usually occurs at night while awake and tends to get better when lying down. This is because blood flow in hemorrhoidal veins is temporarily slowed when a person is upright, causing pressure on the walls of these vessels. This temporary slowing of the blood may cause the accumulation of waste products within these veins, which can then become painful or itchy.
When acute external hemorrhoids occur near the anal opening itself (anal fissure), bleeding during bowel movements may be copious and bright red, staining underpants or toilet paper with streaks of blood. Symptoms are usually worse during bowel movements but may also be present at other times throughout the day and while lying down.
Internal hemorrhoids are painless but commonly accompanied by itching, irritation, discharge, inflammation, and swollen tissue around the anus. In addition, the skin around the anus may become skin-colored or red (erythema) and may protrude out of the anal canal.
A band of muscle fibers surrounds internal hemorrhoids called the internal sphincter; when these muscles contract, they allow for the passage of stool while simultaneously closing off the opening to the anus.
When persons strain during bowel movements (due to constipation or other factors), blood flow is reduced within particular veins in the anal canal; this localized reduction in blood flow causes swelling and pain.
The presence of an external hemorrhoid does not necessarily mean that there is also internal hemorrhoid as well. Internal hemorrhoids can be present without any outward bulging/protrusion (i.e., they may be entirely internal), and not all external hemorrhoids require surgery.
Anal fissures are often present at birth or during early childhood, but they may also occur in adults following a long-term history of constipation. Anal fissures can cause local pain and discomfort around the anal opening, with bright red blood that may be visible on toilet paper or underpants after passing a bowel movement.
In some cases, an anal fissure may develop into a large tear within the lower portion of the anal canal, extending from the outside of the anus to its inner lining. This type of tear is known as a “high-riding” or “permanent” internal hemorrhoid.
Some patients experience internal hemorrhoids without external hemorrhoids, and some patients never experience any visible swelling or protrusion from the anus. In addition, a few rare cases have been reported of internal hemorrhoids with a small perianal hematoma without accompanying inflammation, itching, or discomfort.
In many cases, a high-riding “permanent” internal hemorrhoid can be seen during a digital rectal exam (DRE), where it appears as a rounded mass protruding from the anal canal.
Symptoms include pain around the anus which usually occurs at night while awake and tends to get better when lying down. This is because blood flow in hemorrhoidal veins is temporarily slowed when a person is upright, causing pressure on the walls of these vessels. This temporary slowing of the blood may cause the accumulation of waste products within these veins, which can then become painful or itchy.
A digital rectal exam (DRE) performed by a physician during a physical examination often demonstrates one or more enlarged, round masses (i.e., hemorrhoids) in the anal canal; such groups are typically soft and compressible but will become hard when touched.
Anoscopy with directed light helps visualize internal hemorrhoids and distinguish them from other anorectal pathologies such as fissures, fistulae, skin tags, lichen sclerosis, condylomata acuminata, and cancerous lesions. A pudendal nerve terminal motor latency test is also helpful in distinguishing between internal and external hemorrhoids.
The patient sits on a wooden or plastic board for such a test while the examining physician stimulates the anal canal with a gloved finger. The pudendal nerve carries sensory information from the anus to the brain; in persons with untreated internal hemorrhoids, this test will reveal an abnormal delay (10–25 seconds) between initial stimulation and muscle contraction/peripheral blood flow response due to compression of nearby veins by swollen tissue within internal hemorrhoidal plexuses.
Also, even without digital examination or diagnostic testing, observation of external hemorrhoids during defecation may reveal bleeding caused by the protrusion of such tissues through the anus.
Blood test results typically show typical values for complete blood count (CBC) and erythrocyte sedimentation rate (ESR); other blood work may reveal mildly elevated C-reactive protein and lactate dehydrogenase values.
Preperitoneal pelvic packing with surgical gauze is superior to digital evacuation alone, but there is tentative evidence that rubber band ligation may sometimes be more effective than either method.
Surgery appears to be a reasonable option when conservative treatment fails or if significant anorectal pathologies such as anal cancer are present; however, the rates of postoperative recurrence and symptom resolution after surgery remain high despite advances in currently available hemorrhoidal therapies.
A case report of successful management using bromelain has been published.
Hemorrhoids are a prevalent condition, especially among people over age 50. They often develop as part of the normal aging process. External hemorrhoids are estimated to affect up to half of all middle-aged and older adults. However, many people never have symptoms, so it is difficult to know how common they are.
Internal hemorrhoids can be even more common than external ones because they often become large enough to protrude through the anus without resulting in symptoms that would cause them to be noticed.
Hemorrhoids can also develop after pregnancy due to increased pressure on the veins during pregnancy and childbirth (piles) or later in life due to constipation, diarrhea, heavy lifting, obesity, or straining during bowel movements (ruptured, thrombosed, or strangulated hemorrhoids).
A variety of different treatments are available for both internal and external hemorrhoids. Treatment depends on the severity of symptoms, how long they have lasted, and whether the condition appears acute or chronic.
It may include lifestyle changes, over-the-counter medications, home remedies, surgery, or other options. The best approach is often unclear before the diagnostic work-up has been completed.
What is an Internal Hemorrhoid?
Internal hemorrhoids are inflamed veins in the anus and lower rectum. Most people don’t know they have them until bleeding or prolapse occurs. The three types of internal hemorrhoids are called:
1) anterior,
2) lateral and
3) posterior.
Posterior (backward facing) hemorrhoids can be itchy, uncomfortable, and bothersome, but rarely do they cause severe pain; however, surgical intervention may be combined with other issues such as anal fissures or fecal impaction be needed.
Many natural remedies for internal hemorrhoids will help decrease their discomfort and stop bleeding without surgery and medication. A straightforward home cure is to take a cold bath every day and apply a cold compress to the anus.
Internal Hemorrhoid Symptoms:
The symptoms of this condition depend on the type and location of the hemorrhoids, thus, varying from person to person. However, there are some common symptoms, such as
1) painless bleeding while passing stools or after a bowel movement
2) mucus discharge from the anus
3) swelling around the rectal area
4) lumpy stool. The patient may also experience itching around the anal area and sometimes pain during attempts to pass motion. If you notice any changes in your bowel habits, contact your doctor immediately because it can indicate other health problems, too, such as fissures and abscesses.
Also, suppose the patient experiences pain during bowel movements or any other stool changes (i.e., it becomes bloody). In that case, they should immediately see a doctor because these are signs of an impending condition called proctitis.
The patient may discharge mucus, blood, and pus from the anus; however, this is not always associated with hemorrhoids alone, but it may be due to another problem such as anal fissures, abscesses, or fistula.
Internal hemorrhoids symptoms and signs:
The most common symptom of internal hemorrhoids is bright red blood that appears on the toilet tissue, in the toilet bowl, or mixed with stool during a bowel movement. The blood may also be combined with mucus; it depends on the hemorrhoid location and its type (there are three types: ulcerative, thrombotic, and increasing).
Blood from internal hemorrhoids usually indicates only minor conditions such as anal fissures or hemorrhoid itch; still, if you notice any changes in your stools or anus area, contact your doctor immediately because sometimes they can be an indication of severe health problems—anal itching.
Another quite common internal hemorrhoid symptom is itching around the anus and rectal area. Itching may be caused by different medical conditions such as urinary tract infection, yeast infections, fistulae, abscesses, etc.
However, it is not always associated with hemorrhoids alone—abnormal stools. The most common symptom of internal hemorrhoids is blood on toilet paper or in the chair; however, this condition can also produce abnormal stools such as mucus (without blood), pus, and diarrhea (watery).
Anal burning sensation. A less common sign of internal hemorrhoids is mild pain which intensifies when you sit down, usually after bowel movements or during prolonged sitting, for example, while driving or working at the office. Other symptoms that accompany this problem are anal itching and fissures.