Hemorrhoids

Definition

Hemorrhoids (HEM-uh-roids), also called piles, are swollen and inflamed veins in your anus and lower rectum. Hemorrhoids may result from straining during bowel movements or from the increased pressure on these veins during pregnancy, among other causes. Hemorrhoids may be located inside the rectum (internal hemorrhoids), or they may develop under the skin around the anus (external hemorrhoids).

Hemorrhoids are common ailments. By age 50, about half of adults have had to deal with the itching, discomfort and bleeding that can signal the presence of hemorrhoids.

Fortunately, many effective options are available to treat hemorrhoids. Most people can get relief from symptoms using home treatments and lifestyle changes.

Symptoms

Signs and symptoms of hemorrhoids may include:

• Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet bowl
• Itching or irritation in your anal region
• Pain or discomfort
• Swelling around your anus
• A lump near your anus, which may be sensitive or painful
• Leakage of feces

Hemorrhoid symptoms usually depend on the location. Internal hemorrhoids lie inside the rectum. You usually can't see or feel these hemorrhoids, and they usually don't cause discomfort. But straining or irritation when passing stool can damage a hemorrhoid's delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

When to see a doctor
Bleeding during bowel movements is the most common sign of hemorrhoids. But rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer. Don't assume that bleeding is coming from hemorrhoids without consulting a doctor. Your doctor can do a physical examination and perform other tests to diagnose hemorrhoids and rule out more serious conditions or diseases. Also consider seeking medical advice if your hemorrhoids cause pain, bleed frequently or excessively, or don't improve with home remedies.

If your hemorrhoid symptoms began along with a marked change in bowel habits or if you're passing black, tarry or maroon stools, blood clots or blood mixed in with the stool, consult your doctor immediately. These types of stools can signal more extensive bleeding elsewhere in your digestive tract.

Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness or faintness.

Causes

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins — hemorrhoids — can develop from an increase in pressure in the lower rectum. Factors that might cause increased pressure include:

• Straining during bowel movements
• Sitting for long periods of time on the toilet
• Chronic diarrhea or constipation
• Obesity
• Pregnancy
• Anal intercourse

It's also possible to inherit a tendency to develop hemorrhoids. Hemorrhoids are more likely as you get older because the tissues that support the veins in your rectum and anus can weaken and stretch with aging.

Complications

Complications of hemorrhoids are rare but include:

• Anemia. Chronic blood loss from hemorrhoids may cause anemia, in which you don't have enough healthy red blood cells to carry oxygen to your cells, resulting in fatigue and weakness.
• Strangulated hemorrhoid. If blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be "strangulated," which can cause extreme pain and lead to tissue death (gangrene).

Treatments and drugs

Rubber band ligation of hemorrhoid

Most of the time, treatment for hemorrhoids involves steps that you can take on your own, such as lifestyle modifications. But sometimes medications or surgical procedures are necessary.

Medications
If your hemorrhoids produce only mild discomfort, your doctor may suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel or hydrocortisone, that can relieve pain and itching, at least temporarily.
Don't use an over-the-counter cream or other product for more than a week unless directed by your doctor. These products can cause side effects, such as skin rash, inflammation and skin thinning.

Minimally invasive procedures
If a blood clot has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision, which may provide prompt relief.
For persistent bleeding or painful hemorrhoids, your doctor may recommend another minimally invasive procedure. These treatments can be done in your doctor's office or other outpatient setting.

• Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week. This procedure — called rubber band ligation — is effective for many people. Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four days after the procedure but is rarely severe.
• Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
• Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel. While coagulation has few side effects, it's associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Surgical procedures
If other procedures haven't been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Surgery can be performed on an outpatient basis or you may need to stay in the hospital overnight.

• Hemorrhoid removal. During a hemorrhoidectomy, your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic. Hemorrhoidectomy is the most effective and complete way to remove hemorrhoids, but it also has the highest rate of complications. These may include temporary difficulty emptying your bladder and urinary tract infections related to this problem. Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a warm bath also may help.
• Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. Stapling generally involves less pain than hemorrhoidectomy and allows an earlier return to work. Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Talk with your doctor about what might be the best option for you.

Lifestyle and home remedies

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

• Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.
• Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet. You can get one at most drugstores.
• Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Soap isn't necessary and may aggravate the problem. Gently dry the area with a hair dryer after bathing.
• Don't use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn't contain perfume or alcohol.
• Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.
• Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away in a few days. See your doctor if you don't get relief in a few days, or sooner if you have severe pain or bleeding.

Prevention

The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

• Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids or worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
• Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
• Consider fiber supplements. Most people don't get enough of the recommended amount of fiber — 20 to 35 grams a day — in their diet.  Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular. If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.
• Don't strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
• Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
• Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
• Avoid long periods of standing or sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.