Hemorrhoids

Hemorrhoids are veins which reside inside and outside of the anus. They are organs just like lungs, heart, kidneys and spleen are organs. Hemorrhoids are venous cushions which have a blood supply (artery which pumps blood into the hemorrhoid) and a venous return (veins which return the blood to the body). They are a part of our anatomy just like our eyes, nose, ears, toes, etc. We are born with at least 6 hemorrhoids, three within the anus (internal hemorrhoids) and three outside the anal opening (external hemorrhoids). External hemorrhoid veins are abundant in nerve endings. The internal hemorrhoid veins lack pain fibers. Internal and external hemorrhoid veins are like apples and oranges. Although they are both venous cushions, their symptoms and treatment are completely different. Though we have theories as to the function of hemorrhoids, there is no real scientific evidence of their purpose. It is proposed that the function of hemorrhoids is to aide in keeping stool from leaking out of the anus.

When hemorrhoid veins become inflamed and enlarged they can become symptomatic. The blood pumped into the hemorrhoid is thin and normal, however; when the blood enters the inflamed hemorrhoid the inflammatory proteins made by the body thicken the blood so it is difficult to leave the hemorrhoid. This is called chronic venous insufficiency (CVI). With CVI there is more blood leading into the hemorrhoid than returning to the body. Think of a water balloon on a faucet but the balloon has tubes allowing water to flow back to the system. If the of water coming into the balloon becomes thick like maple syrup, more water will enter the balloon than will leave the balloon so the balloon becomes bigger. Furthermore, the proteins cause fluid to flow into the hemorrhoid and weaken the muscle surrounding the hemorrhoid both of which increase the hemorrhoid swelling. This is what happens with inflamed hemorrhoids. As they become larger they start to cause symptoms. 

 MYTHS ABOUT HEMORRHOIDS:

• All bumps around the anus which cause pain and bleeding are hemorrhoids.
• Laser hemorrhoidectomy hurts less than cold scalpel hemorrhoidectomy
• Hemorrhoids are hereditary (don’t forget we are all born with hemorrhoids)
• All hemorrhoids require surgery to treat the problem.

 SYMPTOMS:

Internal hemorrhoid symptoms:

• Pain (throbbing, aching)
• Itching
• Painless bleeding
• Anorectal Pressure
• Prolapse (protrude outside of the anus)
• Urgency (feeling of having to have a bowel movement butt no stool comes out)
• Mucous discharge
• Necrosis (the hemorrhoids become trapped outside the anus and the hemorrhoid tissue starts to die). This is a surgical emergency.

 External hemorrhoid symptoms:

• Thrombosis (clot within the hemorrhoid) causing pain, itching and sometimes bleeding with clots (if the hemorrhoid ruptures). A painful swollen lump that looks like a purple grape is a thrombosed hemorrhoid. 95%of the time thrombosed hemorrhoids will resolve on their own and recurrence in the same spot is unlikely therefore only conservative therapy is needed.
• Necrosis (the external hemorrhoid becomes thrombotic and due to the pressure in the hemorrhoid the tissue starts to die). This is a surgical emergency.
• Swelling without clotting

 CAUSES OF HEMORRHOID SYMPTOMS:

•  Constipation
• Diarrhea
• Straining to have a bowel movement
• Reading on the toilet for long periods of time
• Time – like most tissues, hemorrhoids sag as we get older which increase the chances of hemorrhoid symptoms.
• Chronic Venous Insufficiency

DIFFERENTIAL DIAGNOSIS (CONDITIONS THAT CAUSE THE SAME SYMPTOMS):

•  Inflammatory bowel disease (Crohn’s and Ulcerative Colitis)
• Polyps (bleeding)
• Colon cancer (bleeding)
• Rectal cancer (bleeding)
• Anal Cancer – Squamous Cell Carcinoma or Anal Melanoma- (pain and or bleeding)
• Rectal prolapse (the whole rectal lining protrudes from the anus)
• Anal fissure – a tear of the skin around the anus (pain and bleeding)

HEMORRHOIDS IN PREGNANCY:

Return of blood from hemorrhoids passes through the inferior vena cava, which is a large vein that carries blood to the heart. As the fetus grows within the uterus, the uterus becomes larger and heavier. The uterus begins to put pressure on the inferior vena cava making it more difficult for the blood from the legs and pelvic area to drain back into the heart. Since the blood from the hemorrhoids does not drain as well, the hemorrhoids swell causing pain, bleeding, or both. Furthermore, constipation is a precipitating factor to symptomatic hemorrhoids. Many pregnant women become constipated for various reasons. In pregnancy, the treatment of hemorrhoids is most often conservative (see “Non-Surgical Treatment”). Surgery is rarely indicated because of the risks to the mother and the fetus. Conservative therapy consists of steroid creams, sitz baths with a sitz tub, topical anesthetics and avoidance of constipation.

Positioning is also helpful. Lying on the floor with the legs on a couch and rolling onto the left hip and thigh will improve blood flow via gravity. The left side down position will displace the fetus (uterus) off of the vena cava which allows for better venous return from the lower extremities and pelvis. Make sure the floor is well padded. Warm to hot baths can cause labor and are not recommended in pregnancy. A sitz tub is a special plastic tub which sits directly on the toilet. The tub is filled with warm to hot water and place on the toilet seat. Sitting in the hot water only submerses the buttock and therefore dies not increase the risk of causing labor. This will help to relieve the pain. (see “sitz bath” in Non-Surgical Treatment”). If defecation is painful I recommend my patients to defecated (have a bowel movement) in the hot sitz tub. This trick can decrease pain with and after defecation by up to 80% or more. Cleaning the tub is simple, just dump the water and feces in the toilet and wash the tub. Put more hot water in the tub and soak another 5 minutes. I understand this seems unconventional, butt when in a lot of pain sometimes you need to do what you need to do even if it means you have to sit in a hot tub of water to poo.

A statement from a journal article on hemorrhoids in pregnancy states that “the prevailing mindset among physicians and patients has been that anorectal complaints are common and expected and, like other ‘normal’ changes of pregnancy, are to be tolerated and endured.” 1 I feel that this statement is unacceptable as the new treatments available work very well to help relieve the symptoms. As a patient you should not feel that anal problems are something that should be tolerated and will go away in time.

TREATMENT OF HEMORRHOIDS

Non-Surgical treatment:

• Dietary Measures
  • Fiber is a complex carbohydrate, which binds with water, like a sponge, in the colon creating larger, softer, stool (bigger better bowel movement). Contrary to logical thinking, a larger bowel movement is more advantageous than smaller or looser bowel movements. Larger, softer, stools stretch and relax the sphincter muscles helping the blood to flow. Large, soft, stools also require little pressure to pass. The less one has to bear down to have a bowel movement the less blood is engorged into the hemorrhoids. Personally, the bulking agent I recommend the most is a pure psyllium husk fiber. I try to get 5 grams of psyllium fiber in one dose. I also eat a lot of fiber rich foods. It is important to drink enough water during the day in order for the fiber to work. (see “Water” below) Eating fiber without enough water can lead to constipation. It is recommended to eat 30-35 grams of fiber per day. The average daily American diet contains only 10-13 grams of fiber! It is also wise to eat foods lower in fat and cholesterol. Fiber is also known to help regulate blood sugar and lower cholesterol.
    • Personally the bulking agent i recommend the most is PERFECT P.O.O.P. which is raw psyllium formulated for me to test better and go down smooth. No sugar, sugar substitutes, flavorings, colorants, additives or preservatives. I take this every morning. When shaken (not stirred) with about 4-5 oz of juice or almond milk it goes down smooth and comes out solid, long, soft and clean. Other health benefits of psyllium include improving colorectal/anorectal health, lowering cholesterol, weight control, blood sugar control and improved immunity.. One teaspoon of psyllium fiber adds 5 grams of fiber. It is important to drink enough water during the day in order for the fiber to work. Eating fiber without enough water can lead to constipation. It is recommended to eat 30-35 grams of fiber per day. The average daily American diet contains only 6-10 grams of fiber! It is also wise to eat foods lower in fat and cholesterol.
  • Water is very important as it is soaked up by the fiber making the stools bulky and soft. Water also is a natural lubricant and is extremely important for good bowel regularity. Think of the colon as a 6 foot water slide. Remember the days of sitting on a dry slide at the pool? You were stuck at the top because both the slide and the skin were dry and sticky. Pour one bucket of water on the slide and down we went. This is what happens in the colon if we are dehydrated. Water is removed from the colon to replenish our cells. This makes the stool and lining of the colon dry and sticky so it becomes hard to pass the stool. Drinking extra water bulks the stool and lubricates the colon making the stool slide through the colon smoothly and easily. Passing the large volume of stool is a breeze when we eat a lot of fiber and drink a lot of water. Caffeine and liquor are diuretics which increase urination causing dehydration. The colon’s function is to reabsorb more water during times of dehydration. When this happens the stool becomes harder. Therefore, coffee, tea, caffeinated sodas, and liquor do not count as water. My advice to patients to improve their water intake is to drink water with each meal. This will add 3 glasses of water a day. Avoid coffee, tea and soda at meal time and only drink water. At least four 8 ounce glasses are necessary per day. Eating vegetables also adds water to the diet as vegetables are composed of water as well. As we get older and lose muscle mass it is important to drink even more water. Muscle holds water and as we lose muscle mass we can’t use our muscle stores to recoup the water as the stores are too small. Therefore seniors are usually more dehydrated and must drink more water on a regular basis to keep hydrated.
  • Probiotics and Prebiotics – Most Americans can benefit from probiotics for a few reasons. Firstly probiotics improve our immunity (proven in the literature). Secondly most Americans have bacterial overgrowth. Probiotics are good bacteria which are needed for normal intestinal health and for normal bowel movements. Good bacteria also improve our body’s immune system. Start taking probiotics either with over the counter pills or yogurt. Prebiotics are the food that feed the bacteria. Inulin and Fructooligosaccharides are prebiotics. When the good bacteria eat food (prebiotics) they produce amino acids which fuel the colonocytes (colon cells) allowing them to proliferate and re-establish continuity of the lining of the colon. The amino acids also mildly acidify the stool which prevents the bad bacteria from growing as they do not like an acidic environment. This keeps harmony between the good and bad bacteria. This is beneficial for colorectal health.
  • Micronized Diosmin – Diosmin is an antioxidant and the active ingredient in immature (green) orange peels. In prospective randomized trials in humans and studies on animals, Diosmin was found to be safe and effective. Diosmin increased venous and lymphatic vascular tone which improved symptoms of both varicose veins and hemorrhoids. Diosmin binds to inflammatory proteins (Prostaglandins, Leukotrienes and Thromboxanes) and decreases their production. This leads to a decrease in chronic venous insufficiency (CVI) associated with symptomatic hemorrhoids. Reducing CVI allows for better blood flow through the hemorrhoids which decreases their size.
    Furthermore, Diosmin increases the concentration of localized Epinephrine in the hemorrhoids. Epinephrine causes the smooth muscle surrounding the hemorrhoid to contract. By increasing the concentration of Local Epinephrine there is an increased contraction of the muscle around the hemorrhoid which helps to shrink its size. Because Diosmin is a flavonoid or plant metabolite and not a medicine it is safe to use on a daily basis. Micronized means broken down into smaller particles. Micronizing the Diosmin improves its bioavailability (makes it easier to absorb from the GI tract).
    The Diosmin should be micronized as much as possible. The European brand, Daflon, used in the prospective randomized human and animal trials is micronized to 4 microns which is less than the size of a red blood cell. I take Micronized Diosmin for hemorrhoid symptoms and have done so since 2012. Daflon is not available in the US.
    • R.H.O.I.D. – AID® is the brand of Diosmin I use daily, which is formulated for me with the same ingredients and specifications as Daflon. For more information visit www.rhoidaid.com. I feel it works so well I recommend it to all my patients suffering with hemorrhoid symptoms. If you are using Diosmin make sure it is micronized to 4 micrograms. Diosmin tablets have a combination of Diosmin 90% and Hesperidin 10%. There are other Micronized Diosmin products which are knock offs and use a Diosmin Salt which and the Micronization process only micronizes the Diosmin to 50 microns (10 times the size of the Diosmin in Daflon). R.H.O.I.D. – AID® is available on Amazon – Prime shipping.
      R.H.O.I.D. – AID®, which contains all natural citrus based bioflavonoids, is the most exciting development for the support of anorectal health. R.H.O.I.D. – AID® is not a temporary topical hemorrhoid solution. It’s an oral antioxidant supplement containing Diosmin/ Hesperidin, taken twice daily to get to the root of the problem. Prospective randomized trials on humans have shown micronized Diosmin to be both safe and effective in relieving hemorrhoid symptoms. R.H.O.I.D. – AID® is available on Amazon – Prime shipping. Learn more at www.rhoidaid.com.
• Sitz Baths
  • Sitz baths can be done using your bath tub or by purchasing a sitz tub. A sitz bath is a warm to hot tub of water. The warm/hot water helps to relax the anal muscles. This treatment is very effective when you are in the water. Unfortunately, once the sitz bath is over the symptoms usually return. I recommend sitz baths after each bowel movement for up to 2 weeks. If the pain with defecation is extremely severe, and unbearable than I recommend having the bowel movement in the sitz tub. Yes, I am recommending defecation in a tub of warm to hot water. Just put the tub on the toilet and fill it with warm to hot water (not so hot as to scald yourself) and sit in the tub when you have to have a bowel movement. Defecate in the tub and then turn it over into the toilet and flush. Cleaning the tub is simple, just dump the water and feces in the toilet and wash the tub. Put more hot water in the tub and soak another 5 minutes. Sitting in the hot water while having a bowel movement keeps your muscles relaxed. This trick can decrease pain with and after defecation by up to 80% or more. I understand this seems unconventional, butt when in a lot of pain sometimes you need to do what you need to do even if it means you have to sit in a hot tub of water to poo.
• Heating Pad
  • Sitz baths are great but we can’t sit in the tub all day. Sitting on a heating pad while at work, while watching television, or while in a chair on the computer has the same effect on relaxing the muscles as sitting in a hot tub and is more convenient. Be careful not to fall asleep while sitting on the heating pad because long term contact of even a warm heating pad on the skin risks burning the skin. I still recommend a sitz bath once a day during times of hemorrhoid flares.
• Ointments and Suppositories:
  • Preparation-H: A topical ointment which sooths the outside of the anus. Though it is believed that Preparation-H will shrink the tissue, there is no scientific evidence (that I am aware of) proving this phenomenon. I believe it is the soothing nature of the ointment that helps the symptoms. Since the ointment is steroid free it is safe to use on a daily basis. My philosophy on Preparation H is that if it is working keep using the ointment as it is a benign ointment.
  • Steroids: Steroids are known to decrease inflammation and therefore shrink the swelling. It can be used as ointments or suppositories. Typically I prescribe a 2.5% hydrocortisone cream with Pramoxine HCL or suppositories for internal hemorrhoid symptoms. Steroid suppositories melt within the anal canal and the steroid coats the internal hemorrhoids decreasing their swelling. For external thrombosed hemorrhoids I prescribe a steroid cream. Since 95% of all thrombosed hemorrhoids resolve without surgery conservative management including a topical steroid ointment and hot baths are the first line of therapy. If the thrombosis is not better in 4 weeks or it recurs in the same spot I suggest an excision in the office (see surgical treatment for thrombosed hemorrhoids below).
  • Pramoxine HCL: An anti-itch ointment. Anal Pram is an ointment which combines Pramoxine with a steroid. This treatment offers relief of anal itching and swelling.
  • Balneol: Another non-steroid soothing lotion. It is safe to use on a daily basis and I find it useful for patients with anal itching. My philosophy on Balneol is that if it is working keep using the ointment as it is a benign ointment.
• Stool Softeners:
  • If your stool is still hard after using fiber and water an over the counter stool softener such as Colace is recommended.
• Office Procedures (internal hemorrhoids only!):
  • Hemorrhoid injections (Sclerotherapy): In my experience this is the best first line therapy for symptomatic internal hemorrhoids. A substance (phenol mixed with olive oil) is injected into the internal hemorrhoids causing them to shrink. The procedure takes about 5 minutes and is painless. I know it sounds painful but remember, the internal hemorrhoid veins lack nerve endings which sense pain so it doesn’t hurt! I know this because not only have I injected over 15,000 hemorrhoid veins, I have had hemorrhoid sclerotherapy performed on my hemorrhoid veins for anal itching (yes we are all sufferers but no one wants to admit this). It worked very well. Symptomatic relief from itching, bleeding and discomfort begins as soon as the following day but it takes about 2 weeks for the injections to take full effect. The treatment typically lasts up to about 6-12 months. Repeat treatments are usually necessary.
  • Rubber Band Ligation: Placing a rubber band on the internal hemorrhoid in the office which over 2-3 days removes a portion of the hemorrhoid. This procedure is more uncomfortable than injections but has a longer lasting effect. Due to the amount of discomfort or pain associated with banding 3 hemorrhoids it is recommended to only band, at most, 2 hemorrhoids and band the remaining hemorrhoid in 6 weeks. Banding typically lasts longer than a year. The risks of banding are very small and include bleeding, severe infection and even death.
  • Infrared Coagulation: An office procedure where a focused infrared beam is used to burn the internal hemorrhoids. The burning causes a scarring reaction, which shrinks the hemorrhoids. This procedure is uncomfortable but not painful. It has a longer lasting effect than injections.

Surgical Treatment For Internal Hemorrhoids:

• Excisional hemorrhoidectomy: The old fashioned surgical excision of hemorrhoids. The surgery is done as an outpatient at a same day surgery center or hospital. Though painful, we now have a new injectable numbing agent called Exparel which keeps the anus numb up to 2-4 days. There is still pain post surgery but it is much less than prior to using Exparel. My experience is that Exparel works very well and the recovery is 10-14 days. Due to Exparel I have been offering this surgery for all of may patients as the recovery is much more tolerable and the surgery usually lasts 10-15 years. This therapy is reserved for patients who have failed conservative therapy or whose hemorrhoids prolapse (protrude) so much that they will not go back inside. Risks are small and include; severe bleeding, severe infection, abscess, fistula, recurrence, incontinence and anal stenosis (narrowing of the anus).
• Doppler Guided Hemorrhoid Artery Ligation and Rectoanal Repair (DGHAL/RAR): This is a procedure first developed in Europe in 1995. This surgery uses a Doppler guided anoscope to identify the feeding arteries to the hemorrhoids. Once identified the arteries are sutured to cut off the blood supply to the hemorrhoids. There are usually 6 arteries. Once performed the hemorrhoids begin to decrease in size. To perform the internal hemorrhoidopexy (hemorrhoid lift), the anoscope identifies the enlarged hemorrhoid and a stitch is placed at the top of the hemorrhoid. Using a continuous running stitch, the tissue is sutured all the way down to the bottom of the hemorrhoid stopping at an area before the nerve endings begin. The final stitch at the bottom is tied to the begging stitch at the top of the hemorrhoid lifting the enlarged hemorrhoid upward (hemorrhoidopexy). Since the internal and external hemorrhoids lay along the same plane of tissue, this procedure also pulls the external hemorrhoids up which can markedly reduce the symptoms of external hemorrhoids. Because the whole procedure is done above the nerve endings there is no sharp pain, just a dull ache for about 5-7 days. Due to my experience of seeing more recurrence of hemorrhoids than I felt was acceptable after performing over 500 procedures I stopped performing this procedure and perform the excisional hemorrhoidectomy (see above).
• Transanal Hemorrhoid Dearterialization – Same as DGHAL/RAR (different manufacturer of a similar product).
• Procedure for Prolapse and Hemorrhoids A.K.A Stapled Hemorrhoidectomy: The stapled hemorrhoidectomy, or more accurately, stapled hemorrhoidopexy uses cutting and stapling to treat hemorrhoids. A special instrument is used to cut and remove a rim of tissue at the top of the internal hemorrhoids which cuts off the blood supply to these hemorrhoids making them shrink. At the same time it pulls the hemorrhoids up inside the anus holding them in their original position. The pain after words is much less than the old fashioned hemorrhoid surgery. This procedure is not indicated for large external hemorrhoids. If the procedure fails to cure the hemorrhoids it is risky to do again. The risks are small but can be severe such as; hemorrhage, severe pelvic infection (sepsis), vaginal fistula formation, and anal stenosis. Newer literature on this procedure indicates the surgery does not work as well as originally anticipated. Due to the risks and the higher than expected recurrence rate I abandoned performing this procedure in 2005. For internal hemorrhoid surgery I perform the excisional hemorrhoidectomy (see above).

Surgical Treatment For Thrombosed Hemorrhoids:

• • For external thrombosed hemorrhoids two surgeries are available:
    • Enucleation: For the acute phase of the swollen lump, if patients are having severe pain removing the clot (enucleation) is performed. In the office the hemorrhoid is injected with Lidocaine. A small elliptical incision is made over the lump and the clot is removed. The swelling usually persists for 3-4 weeks, however; the acute pain is gone. If the patient is not having a lot of pain or it is starting to resolve, my philosophy is to leave the thrombosed hemorrhoid alone and treat it conservatively with a steroid ointment, sitz baths fiber and water. The natural course of action for a thrombosed hemorrhoid vein is to resolve completely in 4-5 weeks. The pain resolves in 4-5 days but the lump lasts for 4-5 weeks. The thrombosis will most likely not recur. Removing the clot will also cure the problem, with post-operative pain, and the hemorrhoid will not recur. So as you can see, whether I do surgery or not, the same result will happen and therefore I chose not to cut on my patients when they do not need the surgery. If it were me I would not want a surgery if it were not necessary.
    • External hemorrhoid excision: For thrombosed hemorrhoids which persist for longer than 5 weeks or recur in the same location I suggest excising the whole external hemorrhoid in the office. Lidocaine is injected in the hemorrhoid and the hemorrhoid is excised completely.

Surgical Treatment For External Hemorrhoids:

• The only cure for external hemorrhoids is to excise them. Because they are surrounded by nerve endings painless procedures cannot be performed. For patients with external hemorrhoid symptoms who want their hemorrhoids removed I do this in the office. The recovery is very tolerable and lasts 3- 7 days. Rarely are stitches needed. When a patient wants his/her external hemorrhoids excised I have a long discussion regarding the procedure and the risks which are minimal.

CONCLUSION

It is important to remember that hemorrhoid symptoms when diagnosed properly are not life threatening. Other diseases, which produce the same symptoms, can be more serious. Therefore, if you have symptoms such as an anal lump, bleeding, discharge, pain, prolapse, or itching, it is important to see a specialist for a consultation. To help prevent hemorrhoid problems it is essential to increase the amount of fiber and water in your diet. The antioxidant supplement, Micronized Diosmin, has been shown to improve hemorrhoid symptoms. Decreasing the amount of fat and cholesterol is also helpful. Furthermore, do not be afraid of having your hemorrhoids treated as the office procedures are quite painless and can prevent the need for a surgical hemorrhoidectomy.

References

• Medich D, Fazio V. Hemorrhoids, Anal Fissure, and Carcinoma of the colon, Rectum, and Anus During Pregnancy. Surgical Clinics of North America 75:1 77-88, 1995
• Faucheron J, Ganger Y: Doppler-Guided Hemorrhoidal Artery Ligation for the Treatment of Symptomatic Hemorrhoids: early and Three-Year Follow-up Results in 100 Consecutive Patients. Disease of the Colon and Rectum 51:945-949, 2008