Hemorrhoids

Anatomy or system affected:Anus, blood vessels, circulatory system, gastrointestinal system, intestines

Definition:Blood-swollen enlargements of specialized tissues that help close the anus, as a result of intravenous pressure in the hemorrhoidal plexus, sometimes called piles.

Causes and Symptoms

Hemorrhoids, some physiologists suggest, are one of the prices that humans pay for walking upright. The vascular system—the veins and arteries that circulate blood—evolved in an animal that walked on all fours. Now that humans spend most of their time standing, gravity puts awkward pressure on the system, and at the bottom of major parts of the system, as in the tissue around the anus, the column of blood above weighs heavily on the network of small blood vessels there. It does not take much additional pressure to cause a vessel’s wall to balloon out. When it does, the result is a hemorrhoid, a little pouch protruding on the surface of the anus, similar to a hernia or varicose vein. Most people have hemorrhoids, even if they do not realize it, and the major symptoms are rarely dangerous, although they can be annoying and often painful. Sometimes, however, hemorrhoids develop into or mask life-threatening diseases.

The term “hemorrhoid” derives from Greek words meaning “blood flowing,” an apt description of the circulatory activity in the anal walls and an inadvertently apt warning of what most alarms people—hemorrhoids occasionally bleed. (The alternative, and now obsolescent, term “piles” comes from the Latin pila, a ball, apparently a metaphor for the appearance of hemorrhoids.) Specifically, the “blood flowing” refers to the supple blood vessels of the internal rectal plexus, a series of pouches that act as cushions to help seal the anus shut. When these pouches become enlarged, they turn into hemorrhoids, which jut from the anus wall and swell up to three centimeters in length.

Because of the sphincter that controls defecation, not all hemorrhoids are visible without the aid of special instruments. The anus, an oval opening about three centimeters in front of the spine, is the valve ending the digestive tract. Like the mouth’s lips, which begin the tract, the anus can purse shut, a state made possible by two concentric, circular sphincter muscles which act like drawstrings on a cloth bag. When sensors in the rectum signal the time to defecate, these muscles relax to pass stool and then immediately contract to close the anus again. As in the mouth, external skin meets the internal mucosal membrane in the anus; the meeting place is a corrugated joint called the dentate line (or, alternatively, the anorectal juncture or pectinase line). It is in this area—between the skin covering the external (or lower) sphincter and the mucosa over the internal (or upper) sphincter—that hemorrhoids form. Those that bulge out from the dentate line or above are hidden from sight by the closed anus and are called internal hemorrhoids; those that protrude below the closed anus, and so can be seen or felt, are called external hemorrhoids.

External hemorrhoids are the ones famed for vexing people. When the skin is stretched over swelled hemorrhoids, its sense receptors are activated, making the hemorrhoids burn and itch, sometimes so intolerably that the urge to scratch them is uncontrollable. Scratching, especially with abrasive materials, such as toilet paper, often scrapes and tears the tissue. The bright red blood from these lesions is easily noticeable on the toilet paper and may even drip into the toilet bowl or onto underclothes. Likewise, the passage of a hard, dry stool often abrades hemorrhoids to the point of bleeding.

Internal hemorrhoids do not itch or burn and rarely cause pain because the mucosal tissue over them has no nerve endings, but they can also bleed when a passing stool damages them. (Pain may be “referred,” however, from a damaged internal hemorrhoid to the sciatic nerve, bladder, lower back, or genitals; that is, a person feels little or no pain in the anorectal area, but suddenly pain flares in one of these other areas.) An especially elongated internal hemorrhoid, at times, can protrude through the anus, a condition called prolapse. Usually, it spontaneously recedes or can be pushed back inside with a finger, but upon rare occasion, a group of internal hemorrhoids prolapse, swelling and sending the internal sphincter into painful spasms. A doctor’s help may then be required to reduce the pain and fit the hemorrhoids inside.

The blood vessels in the internal rectal plexus swell so easily because they lack valves. Without valves to regulate the local flow of blood, the walls are vulnerable to any sudden increase in pressure. Even a small, transient increase above the normal pressure of blood circulation can cause the vessels to bulge. Often, these bulges disappear when the excess pressure disappears or remain swollen only briefly afterward. If the increased pressure is high enough, however, a permanent protrusion results, drooping from the anal wall. Even then, if the hemorrhoid is internal, the patient may feel no discomfort and may not realize that a hemorrhoid has formed.

Some people are more susceptible to chronic hemorrhoids than others because of a hereditary lack of elasticity in the blood vessels. In such people, standing for long periods of time can add enough pressure to make hemorrhoids swell. Nevertheless, anyone can get hemorrhoids—all that is needed is enough pressure in the lower abdomen. Straining on the toilet due to constipation to pass stool is the most common cause. Since a poor diet can lead to constipation, hemorrhoids can be a secondary effect of poor eating habits. Those who like to sit on the toilet for a long time, reading or watching television while waiting for a bowel movement, also increase pressure on the anus because of the posture and the compressing effect of the toilet ring, and they are likely to develop hemorrhoids. People who regularly lift heavy weights as part of their jobs or for recreation are especially susceptible if they hold their breath while lifting: this action pushes the diaphragm downward on organs below it, including the anus, putting pressure on them. Similarly, during pregnancy, women can develop hemorrhoids as the expanding womb crowds and increases pressure on nearby organs; these hemorrhoids are exacerbated by delivery, but they usually go away afterward. Psychologists add to these causes the guilt that some people feel about eating and excreting, guilt spawned by overindulgence in food or bad toilet training; they bear down on their bowels to defecate as quickly as possible and by doing so, stress the hemorrhoidal vessels. Finally, hemorrhoids occasionally develop because of some serious diseases, such as heart failure and cirrhosis of the liver, which elevate pressure in the veins, and rectal cancer, which can create a false sense of fullness so that the person strains to pass a stool that is not really there.

Although they seldom do more than itch, external hemorrhoids can thrombose—develop clots of coagulated blood from a burst or swollen vessel under the skin—and grow as large as a grape. A doctor can relieve the pain by slicing open the hemorrhoid and squeezing out the clot. Left alone, a thrombosed hemorrhoid may rupture, causing a painful and bloody mess that is ripe for infection. Yet the greatest threat of hemorrhoids lies not in the symptoms themselves but in how they might be confused with those of other deadly diseases. Colorectal cancer, inflammatory bowel disease, and sexually transmitted diseases, such as syphilis, gonorrhea, and herpes, can lead to discharges of blood, as can anal fissures (cracks in the anal canal), fistulas (tunnel-like passages between an infected gland and mucosa or skin), and abscesses (pus-filled sacs under the mucosa). A person who dismisses the bloody discharge as simply a flare-up of hemorrhoids may be delaying treatment for the real cause. In the case of colorectal cancer, one of the most common cancers in the United States, such a delay can be fatal. Only a doctor has the tools and vantage point to distinguish between relatively benign hemorrhoids and a dangerous disorder.

Treatment and Therapy

Since hemorrhoid-like symptoms can be produced by deadly diseases, a thorough checkup at the doctor’s office includes an examination of the anus and rectum, especially if the patient has noticed bleeding. In addition to the visual inspection and “digital” examination, during which the doctor inserts a finger and feels around for enlarged hemorrhoids or other masses, patients provide clues by describing the color, amount, and time of bleeding. If the blood is bright red and occurs in small quantities during or just after defecation, hemorrhoids are most likely to blame. If dark red blood or clots appear in the stool or seep out randomly, however, the doctor will look for other causes, inspecting the anus, rectum, and colon with various types of endoscopes, fiber-optic-filled flexible tubes that can also collect tissue samples. Once the doctor rules out other diseases, the patient has three basic choices: change habits, rely on therapy, or have the hemorrhoids removed.

If a person’s hemorrhoids do not cause severe discomfort, the doctor will likely recommend a diet with high fiber and water intake. Fiber and water together make stools bulky and soft. They pass more easily during defecation than small, hard, dry stools. The patient does not have to strain, so no further pressure is put on existing hemorrhoids. Furthermore, soft stools do not scrape hemorrhoids and cause them to bleed. The doctor will also suggest regular exercise since this helps the bowels work more efficiently and reduces the chance of constipation. Finally, the patient may receive instructions on the proper way to breathe during heavy exertion so as to lessen the stress on the hemorrhoids. With a better diet, more exercise, and less physical straining, patients may find that hemorrhoids have disappeared completely. Weight loss may also improve hemorrhoids.

Until hemorrhoids shrink, they plague the patient, and to reduce the itching and burning, a number of therapies prove effective, if only temporarily. An ice compress eases the discomfort, as does a sitz bath (sitting for at least fifteen minutes in shallow warm water), which also cleanses the site of potentially infecting wastes and promotes healing in damaged tissue. Should these relatively simple and cheap measures be impracticable, a variety of ointments, creams, medicated pads, and suppositories, either prescription or nonprescription, may provide relief. Some are inert, such as petroleum jelly, and coat and lubricate the hemorrhoids, protecting them from irritation. Some have an astringent effect, tightening and sealing tissue and thereby protecting it. Others have anesthetic ingredients, numbing the tissue, or anti-inflammatory effects, decreasing swelling. None of these medications has a proven capacity to make swelling go away entirely, and those with active ingredients may cause an allergic response. For patients with constipation, doctors may prescribe stool softeners to eliminate straining during defecation. Laxatives are usually to be avoided because the chemicals in them irritate hemorrhoids, and the resulting diarrhea often causes urgency and pressure in the rectal area.

When hemorrhoids become chronically and unusually swollen, or the patient can no longer endure the discomfort, removing them is the last resort. This cure is certain, although not necessarily permanent, but it has its cost in pain and recovery time. There are seven basic methods, six that cause the target hemorrhoid to shrivel, to drop off on its own, or both, and one, surgery, that removes it directly.

The surgical removal of hemorrhoids, called hemorrhoidectomy, is a relatively simple operation; nevertheless, it is usually reserved for those patients who cannot undergo one of the other methods. The patient is given a local anesthetic to deaden sensation in the anus, although some patients are rendered unconscious with a general anesthetic. The surgeon cuts off the hemorrhoid at its base and then sews the wound closed with absorbable sutures. The recovery period may require hospitalization for up to a week, during which pain medication, stool softeners, and anal pads are necessary until the tissues heal. Bed rest after hospitalization and sitz baths may also be beneficial. Because of this recovery time—as much as a month—hemorrhoidectomies are not widely popular among patients or physicians. Moreover, urine retention, infection, and hemorrhaging after the operation are possible complications.

The remaining methods avoid the trauma of cutting, and the first of them, ligation, is one of the oldest of all the methods. Ancient Greek physicians tied a thread around a hemorrhoid to strangle its blood supply; modern gastroenterologists or proctologists use special rubber bands. The effect is the same: The hemorrhoid dries up, shrivels, and falls off. Little pain accompanies the procedure, which is done in the doctor’s office.

Likewise, sclerotherapy, cryosurgery, and infrared coagulation are only for internal hemorrhoids because the pain would be too intense on external hemorrhoids. In sclerotherapy, the doctor injects a liquid—usually phenol in oil or quinine in urea—that seals closed the blood vessels at the base of the hemorrhoid. With no blood in them, the vessels eventually shrink to normal dimensions, and if stressing pressure on them is not resumed, the hemorrhoid disappears. In cryosurgery, super cold liquid nitrogen or nitrous oxide is applied to the hemorrhoid, freezing it and killing the tissue. The hemorrhoid slowly melts and, as it does, shrinks and finally sloughs off. Popular in the 1970s and early 1980s, cryosurgery lost favor because of the messy and extended recovery time. Useful for mild, small hemorrhoids, infrared coagulation involves a beam of infrared light that, aimed at the hemorrhoid, shrinks it by cauterizing the tissue. The heat of the beam can cause pain in other parts of the anus during the procedure.

The remaining methods, laser surgery and electric current coagulation, can be used on external hemorrhoids. Like infrared coagulation, laser surgery trains a beam of light—in this case, intense visible light—that burns and shrinks the hemorrhoid to a stub. Since the laser cauterizes as it destroys tissue and therefore seals off blood vessels, its main advantage over regular surgery lies in reduced bleeding. Recovery time is shorter, about a week, and hospitalization is usually not necessary. In electric current coagulation, electrodes pass either direct or alternating current through the hemorrhoids. Because tissue is a poor conductor, the resistance to the current creates heat, which cooks the hemorrhoid, coagulating and shrinking it.

Which method the surgeon, gastroenterologist, or proctologist uses depends partly upon the physician’s and patient’s preferences and partly upon the size and location of the hemorrhoid. Ligation remains the most frequently used method because it is relatively cheap and fast.

Perspective and Prospects

Certainly, hemorrhoids are no laughing matter. Yet the long-standing taboo in the United States about excretion and the anus has prompted many Americans either to laugh nervously about their hemorrhoids or to keep silent, preferring to suffer stoically rather than to risk becoming the target of jokes. For this reason, it is nearly impossible to say how many sufferers there are in the United States. The peak prevalence of hemorrhoids occurs between ages forty-five and sixty-five years, and men and women are equally affected. An estimated 5 percent of the general population in the United States is thought to be affected. Half of Americans over the age of fifty experience hemorrhoids. Hemorrhoids are also common during pregnancy and childbirth, although they usually spontaneously regress postpartum.

Whatever the exact statistic, clearly, many people share a problem that embarrasses them too much to discuss openly or that they believe is too trivial for medical attention. If they need relief from the itching and pain, they treat themselves. A large industry in home remedies and over-the-counter medications serves them. The benefits of such medications are difficult to assess, and some authorities claim that petroleum jelly eases the itching and burning as much as any preparation specifically intended for hemorrhoids. Folk remedies, such as suppositories made of tobacco or compresses soaked in papaya juice, can damage tissue outright, making the problem worse. Moreover, throughout the United States, specialized clinics offer surgical cures for hemorrhoids, promising patients quick relief on an outpatient basis and using expensive methods, particularly laser surgery.

Many people, therefore, spend considerable money and time to tend to a chronic discomfort that can as readily be prevented or palliated by a change in habits, doctors claim. Like colon cancer and many other intestinal ailments, hemorrhoids are most common in populations whose diet includes a high number of processed foods, which are low in fiber. While fiber is no panacea, people in cultures whose diet contains significant fiber have larger stools and fewer intestinal complaints in general. Increasing one's fluid and fiber intake is considered the first-line treatment of hemorrhoids.

Because hemorrhoids are, in most cases, preventable or controllable without treatment, they have been cited, along with deadly maladies such as colon cancer and inflammatory bowel disease, in criticisms of both the American diet and Americans’ eagerness to rely on medical intervention to save them from their own unhealthy habits. In the case of hemorrhoids—while they are not exclusively a malady of Western civilization—the fast pace and pressures of life, the attitudes about defecation, and the eating habits of industrial cultures help give them a distracting prominence.

Bibliography

“Definition & Facts of Hemorrhoids.” National Institute of Diabetes and Digestive and Kidney Diseases, Oct. 2016, www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/definition-facts. Accessed 3 Aug. 2023.

“Help for Hemorrhoids Includes Fiber, Fluids, and Fitness.” Environmental Nutrition 23.4 (2000): 7. Print.

Jacobs, Danny. "Clinical Practice: Hemorrhoids." New England Journal of Medicine 371.10 (2014): 944–51. Web. 23 Feb. 2015.

Litin, Scott C., ed. Mayo Clinic Family Health Book. 4th ed. New York: HarperResource, 2009. Print.

Lohsiriwat, Varut. "Approach to Hemorrhoids." Current Gastroenterology Reports 15.7 (2013): 1–4. Print.

Minkin, Mary Jane. “Prevent Hemorrhoids.” Prevention 50.6 (1998): 76. Print.

Okus, Ahmet. "Local Pain-Reducing Methods after Hemorrhoidectomy." World Journal of Surgery 37.8 (2013): 2007–8. Print.

Peikin, Steven R. Gastrointestinal Health. Rev. ed. New York: Quill, 2001. Print.

Raspallo, Benjamin M., and Philip Salinitri D. Hemorrhoids: Symptoms, Diagnosis and Treatment. New York: Nova Biomedical, 2010. Print.

Yang, Hyung Kyu. Hemorrhoids. Heidelberg: Springer, 2014. Print.