One of the most common proctology issues that both men and women experience is the discomfort and bleeding from internal hemorrhoids. Hemorrhoids are veins which reside inside and outside of the anus.
Hemorrhoids are a part of our anatomy just like our eyes, nose, ears, toes, etc. They are venous cushions which have a blood supply – an artery which pumps blood into the hemorrhoid and a venous return – veins which return the blood to the body.
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 aid in keeping stool from leaking out of the anus.
Hemorrhoids Symptoms
Internal hemorrhoid symptoms
- Pain that is throbbing and/or aching
- Itching
- Painless bleeding
- Anorectal pressure
- Prolapse – protrude outside of the anus
- Urgency – feeling of having to have a bowel movement but 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 – a clot within the hemorrhoid which causes 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 for Hemorrhoid Symptoms
There can be several reason why hemorrhoid symptoms occur in individuals, including:
- 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.
The reason hemorrhoids swell is a condition called chronic venous insufficiency. When hemorrhoid veins become inflamed and enlarged they 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 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. This is what happens with inflamed hemorrhoids. As they become larger they start to cause symptoms.
In most cases, internal hemorrhoids can be treated with over the counter medicine or prescription hydrocortisone ointments or suppositories. Adding fiber and bulking the stool is very effective in helping symptoms. For persistent cases that need professional treatment, hemorrhoid banding is a great option and is done in the office without anesthesia..
Introduction to Banding Hemorrhoids
Hemorrhoid banding is a less-invasive alternative to traditional hemorrhoid surgery that your proctologist may recommend if you have hemorrhoids that do not respond to medicines. Often referred to as rubber band ligation or hemorrhoid ligation. Banding hemorrhoids is a simple and painless procedure that involves placing a rubber band around the base of a hemorrhoid. It is done in the office without the need for anesthesia. Patients can drive themselves to the appointment and home.
The band constricts a portion of the hemorrhoid leading to necrosis which then causes it to wither and fall off. This process takes 2-3 days. Those who require hemorrhoid banding, as recommended by their doctor, are patients whose symptomatic (bleeding, prolapse, discomfort) hemorrhoids have not responded to at-home treatments, prescription hydrocortisone therapy, fiber and in-office sclerotherapy.
Banding hemorrhoids, however, is only for internal hemorrhoid symptoms, not symptomatic external hemorrhoids.
How to Prepare for a Hemorrhoid Banding Procedure
If your doctor has recommended banding your hemorrhoids, they will walk you through the steps of the procedure to ensure you understand the process. They will ask if you are taking any current medications, including over-the-counter medication, Aspirin products or non steroidal anti inflammatory agents (NSAIDs), blood thinners like Plavix, Brilinta,Eliquis, Coumadin, Effient, etc.or supplements. Due to the increased risk of bleeding when taking these medications the doctor will ask you to stop taking them for a week prior to the rubber band ligation. For patients on Brilinta, Plavix etc. it will be important to speak with the doctor prescribing these medications to make sure it is safe to be off of them for up to 2 weeks. .
While the procedure is straightforward and you can return home afterwards, it’s a good idea to not have plans after the procedure as the discomfort will most likely prevent you from keeping the plans. It is best to go home, relax and take Tylenol if needed.
What to Expect During a Hemorrhoid Banding Procedure
Banding hemorrhoids is a relatively simple procedure which causes discomfort but typically not pain. It usually takes up to 5 minutes. I only band one hemorrhoid at a time as banding more will lead to pain. I also perform sclerotherapy for any of the smaller hemorrhoids to shrink them at the same time. I first shrink the smaller hemorrhoids with sclerotherapy then I band the largest internal hemorrhoid.
To begin, I inspect the outside of the anus, and then I perform a digital rectal examination to evaluate for any abnormalities and to also help relax the sphincter muscles. I insert a lubricated anoscope which is used to evaluate the internal hemorrhoids. Any smaller hemorrhoids are treated first.
I then place my attention to the largest internal hemorrhoid. I place a suction litigator, which is the instrument used to place the rubber band around the base of the internal hemorrhoid, into the anoscope. I suction a portion of the internal hemorrhoid into the ligator then ask if the patient is having any pain. If there is no pain I then deploy the rubber band over the internal hemorrhoid. Once the band is placed I remove the anoscope then use my finger to feel the placement of the rubber band.
After the band is placed, the internal hemorrhoid will wither and fall off in about 2-3 days Once the band falls off the wound forms an ulcer which heals over 3-4 weeks. The scar tissue that forms contracts and shrinks the hemorrhoid even more and holds the remaining hemorrhoid in place. Patients usually feel discomfort and will go home with discharge instructions.
After-Care for Banding Hemorrhoids
Following a hemorrhoid banding procedure, you may feel some discomfort in your rectum. This will pass overtime and can be eased with over the counter medications, if your doctor has approved them.
You also may have the urge to move your bowels, which is common, but will subside. In order to avoid any pain while having a bowel movement be sure to keep your stools soft by eating a high fiber diet and stool softeners, if your doctor suggests it.
Other care tips include:
Diet – Eat a regular diet and add fiber. I strongly suggest adding PERFECT P.O.O.P. raw psyllium fiber, Having a regular bowel movement the day post rubber band ligation is very important. A large, long, soft bowel movement is like physical therapy to the anus. It stretches the anus improving blood flow and decreasing spasm which can happen post surgery. Take the psyllium every day for life as this helps to reduce hemorrhoid symptoms and recurrences as well.
Sitz Bath – Sitz baths are shallow baths where you sit in the water up to your hips and are filled with warm water and epsom salts. The bowls are placed over the toilet to make it more comfortable than a traditional bathtub, especially when recovering from a hemorrhoid banding or surgery. Taking a sitz bath one to two times a day, or after every bowel movement, will help relieve any pain in the area.
Don’t Resist a Bowel Movement – If you need to go, go. It might feel a little scary right after a hemorrhoid banding procedure, but holding in your bowel movement will make it worse. If you feel the need to use the bathroom, go, but don’t force it or push too hard.
Avoid Heavy Lifting – Any type of straining, both in the bathroom and out, will cause unnecessary stress to the hemorrhoids while you are healing. Like with other surgeries, take time to rest and avoid any heavy lifting. Although hemorrhoid banding is a simple procedure, it takes time for bodies to heal.
Avoid Toilet Paper – As you heal, avoid using toilet paper for wiping. Toilet paper can irritate the anus and cause itching and discomfort. Instead, try medicated wipes, baby wipes, or just water and soap to clean the area.
Side Effects of Hemorrhoid Banding
After a hemorrhoid banding procedure, you may notice some side effects as the hemorrhoids dry up and fall off.
Minor side effects include:
- Bloating or swelling in the abdomen with slight pain
- Constipation
- Occasional bleeding in the first day or two following the procedure
Serious Side Effects Include:
- Severe bleeding which does not stop. Usually about a coffee cup worth of blood call your doctor.
- Severe Infection – If you experience excessive pain, fever of 100.8 Fahrenheit or greater and can not urinate, these are signs of a serious infection and you need to call your doctor immediately.
Risks of Rubber Band Ligation
There are inherent risks to having rubber band ligation. Though the complications are not frequent they can occur. The risks to the banding include but are not limited to: bleeding, infection, post operative fissure and recurrence of hemorrhoid symptoms. Patients need to be in town for 2 weeks post procedure in case there is a complication.
Alternatives to Hemorrhoid Banding
Although banding hemorrhoids is the preferred method for removing internal hemorrhoids, your doctor may suggest other procedures, including surgery depending on the findings after examination.
Sclerotherapy
Sclerotherapy is a common procedure used not only on internal hemorrhoids, but other parts of the body.. A doctor injects a chemical into the hemorrhoid which cuts off the blood flow to it, allowing the hemorrhoids to wither and fall off. It is my first line of therapy as it is painless, works very well and I can treat all 3 internal hemorrhoids at the same time. If this fails to work for 6 months or longer, or the patient wants something more permanent I will then perform rubber band ligation to the largest internal hemorrhoid.
Cryosurgery
Cryosurgery involves freezing hemorrhoids with a cryoprobe and either nitrous oxide or liquid nitrogen. The frozen hemorrhoids will then fall off in about three weeks, compared to only about a week with hemorrhoid banding. Cryosurgery is not very effective and leads to a weeping wound. Cryosurgery is not performed anymore.
Infrared coagulation therapy
Opposite to cryosurgery is infrared coagulation therapy, which uses heat to cut off the blood supply to a hemorrhoid. A doctor will use a power beam of infrared light to heat up the hemorrhoid. The process can take anywhere from thirty seconds to a few minutes, depending on the size of the hemorrhoid.
I don’t perform this therapy as I didn’t find it worked better than sclerotherapy and it is more expensive.
Traditional surgery
Surgery is done at an outpatient center with anesthesia. While the patient is asleep, the surgeon will excise the internal and external hemorrhoids and suture the wound to prevent bleeding.
In my practice, hemorrhoid surgery is not usually recommended to a patient unless they have internal hemorrhoid symptoms which fail conservative therapy. There is a longer recovery time and more risks of complications with hemorrhoid surgery. When needed it is very effective and the recovery is usually 10-14 days. The majority of patients are very satisfied with the results when hemorrhoid surgery is needed and performed.
I only perform surgery in about 10-20% of patients suffering with hemorrhoids because conservative therapies like the addition of PERFECT P.O.O.P. raw psyllium fiber, the addition of all natural hemorrhoid shrinking antioxidants like Diosmi /Hesperidin (R.H.O.I.D. – AID) and office based therapy works well to alleviate the symptoms for long periods of time.
Conclusion
If one is suffering from internal hemorrhoid symptoms including prolapse (coming out and going back in), bright red bleeding, pressure, urgency to have a bowel movement or mucous discharge it is best to see a proctologist. With dietary modifications such as adding PERFECT P.O.O.P. raw psyllium fiber, addition of all natural hemorrhoid shrinking antioxidants like Diosmin/Hesperdin (R.H.O.I.D. – AID) and a painless office procedure like sclerotherapy, the symptoms can reside for a year or longer.
If all fails or if the patient wants to be more aggressive with therapy a rubber band ligation of the largest hemorrhoid is very safe and effective. It has small risks of severe bleeding and severe infection so I advise my patients to stay in town for 2 weeks post procedure. For more information read my blog “How Your Hemorrhoids Can Save Your Life.”