Hemorrhoids: symptoms, causes, and treatment

What are hemorrhoids?


Hemorrhoids are swollen, inflamed veins in the anus and rectum that can cause pain, itching, and anal bleeding. The hemorrhoid can be internal, when it is hidden inside the rectum, or external, when it is easily seen around the anus. The passage of feces through these enlarged veins can cause injury, which manifests itself with symptoms such as pain when defecating, anal itching, and bleeding in the stool.

Although widely used, the more correct term is actually not hemorrhoids, but rather hemorrhoidal disease. Hemorrhoids is the name we give to the collection of veins and arteries that are located in the anal canal. We all have hemorrhoidal veins and hemorrhoidal arteries. So, technically, we all have hemorrhoids. However, even doctors often don’t make this distinction and treat the terms hemorrhoidal disease and hemorrhoids as synonymous.

In this article we’ll use the more popular terminology. When we talk about hemorrhoids we are referring to hemorrhoidal disease.

How they arise


Most of our veins contain valves that help the blood to go always in the same direction, preventing it from returning even against gravity. For example, the blood in the leg veins always flows against gravity. Thanks to the valves, it can rise without being trapped in the legs. When the veins become diseased and their valves stop working, varices appear, which are tortuous veins in which the blood becomes congested (read: VARICES – Causes and Treatment).

Unlike the veins in the rest of the body, the hemorrhoidal veins do not have valves to prevent the blood from backing up. Therefore, any increase in pressure in these veins leads to engorgement. Hemorrhoids are like varicose veins of the hemorrhoidal veins. As with any varicose vein, the dammed blood increases the risk of thrombosis and inflammation of the veins.

Hemorrhoids are therefore enlarged veins in the rectum and anus, which may be accompanied by inflammation, thrombosis, or bleeding.

Approximately 5% of the population suffer from this problem. In Brazil, it is estimated that about 2 million people have hemorrhoids. The disease is more common in adults between the ages of 40 and 60. In women, it usually appears earlier, especially during pregnancy (30 to 40% of pregnant women suffer from hemorrhoids).

Classification


The hemorrhoidal disease can be divided into:

  • Internal hemorrhoids: when they occur in the rectum.
  • External hemorrhoids: when they occur in the anus or at the end of the anal canal.

Internal hemorrhoids are further classified into four grades:

Grade I: do not prolapse through the anus.
Grade II: they prolapse through the anus during bowel movements or during straining, but return to the original position spontaneously.
Grade III: they prolapse through the anus and return inside only with manual help.
Grade IV: they prolapse through the anus and the return is not possible even with manual help.
Grade I internal hemorrhoids are not visible and grade II hemorrhoids usually go unnoticed by patients, since no one stares at the anus while defecating. Since the rectum and anal canal have little innervation, this type of hemorrhoid does not usually cause pain.

External hemorrhoids, as well as internal hemorrhoids grades III and IV, are easily identified and usually become inflamed, causing pain and/or itching.

About 73% of the cases are grade I hemorrhoids, 19% are grade II, 8% are grade III and less than 1% of the patients have grade IV hemorrhoids.

Risk factors


Hemorrhoidal disease is a very common disorder. It is estimated that more than half of the population over the age of 50 suffers from this problem to varying degrees.

The main risk factors are:

  • Constipation (constipation).
  • straining to evacuate
  • Obesity
  • Chronic diarrhea
  • Frequent stool holding, avoiding defecation whenever you feel like it
  • A diet low in fiber
  • Pregnancy
  • Anal sex
  • Family history of hemorrhoids
  • Smoking.
  • Liver cirrhosis and portal hypertension
  • Sitting on the toilet for long periods (some people believe that the design of the toilet itself is conducive to the development of hemorrhoidal disease).
  • Squatting, very common in the Middle East and Asia, is associated with a lower incidence of hemorrhoids. On the other hand, squatting, as most of us usually do, seems to increase its incidence.

Regardless of the risk factors, hemorrhoids form when there is increased pressure in the hemorrhoidal veins or weakness in the tissues of the anus wall that are responsible for supporting them.

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Which foods cause hemorrhoids?


Contrary to popular belief, there is no specific food that causes hemorrhoids. There is also no scientific evidence that pepper, coffee or soft drinks can worsen an already existing hemorrhoidal disease.

What can actually do harm is a diet low in fiber. But the effect is indirect, since it is the constipation that arises because of the diet that is responsible for the increased risk of developing hemorrhoids.

Symptoms


Hemorrhoids can be symptomatic or not. As previously stated, internal hemorrhoids tend to be less symptomatic. The only sign of their existence is usually the presence of blood around the stool when defecating.

Bleeding from hemorrhoids typically presents itself as a small amount of bright blood that remains around the stool. Sometimes the patient may notice blood dripping into the toilet bowl after a bowel movement has been completed. It is also common to have blood on the toilet paper after cleaning.

Internal hemorrhoids can cause pain if a thrombosis develops or when chronic straining to defecate causes the hemorrhoid to prolapse out into the anal canal. Grade III and IV internal hemorrhoids may be associated with fecal incontinence and the presence of a mucous discharge, which causes anal irritation and itching.

External hemorrhoids are usually symptomatic. They are associated with bleeding and pain on evacuation and sitting. In cases of thrombosis, the pain can be intense. Itching is another common symptom. External hemorrhoids are always visible and palpable.

Although it is a common cause of anal bleeding, it is important to never assume that the bleeding is due to hemorrhoidal disease without first consulting a doctor. Various diseases such as anal fissure, cancer of the rectum, diverticular disease, and infections can also manifest themselves with blood in the stool. In addition, there is nothing to prevent the patient from having hemorrhoids and another disease that also cures with anal bleeding, such as cancer. Therefore, all anal bleeding should be evaluated by a doctor.

Bleeding from hemorrhoids is usually small, but if it is frequent it can even lead to anemia due to iron deficiency. Bleeding in large volumes is not common, but may occur in some cases.

An important differential diagnosis for hemorrhoids is anal fissure. Both cause pain and bleeding, but the bleeding from a fissure is usually less and the pain on bowel movement more intense.

Can hemorrhoids turn into cancer?


No, hemorrhoids do not become cancer. That said, it is important to note that the symptoms of a tumor of the intestine, rectum or anus can be confused with those of hemorrhoids, especially bleeding when defecating. Therefore, in every patient with anal bleeding, especially in those over 50 years of age, you need to be sure that the cause is really a bleeding hemorrhoid and not a tumor.

Diagnosis


In external hemorrhoids, the physical examination is sufficient for diagnosis. In internal hemorrhoids it is necessary to perform a rectal examination and, if there is still doubt, an anuscopy (a mini endoscopy where the rectum is visualized by video).

In elderly patients with bleeding from the rectum, even if hemorrhoidal disease is identified, it is advisable to perform a colonoscopy to rule out other causes. Since hemorrhoids are very common in this age group, nothing prevents the patient from having a second cause for the bleeding, such as cancer of the bowel or a diverticulum.

Which specialist doctor should I go to?


The doctor who specializes in diagnosing and treating hemorrhoids is a proctologist, nowadays called a coloproctologist.

Coloproctology is a medical and surgical specialty, responsible for diseases of the large and small intestine, rectum, and anus.

Besides hemorrhoids, the coloproctologist also usually treats: anal fissures, perianal abscesses, perianal fistulas, pilonidal cysts, rectal prolapse, constipation, fecal incontinence, benign and malignant tumors of the colon, small intestine or rectum, diverticular bowel disease, and inflammatory bowel diseases.

Are there cures for hemorrhoids?


Yes, there are several therapeutic options that can cure hemorrhoids for good. Procedures such as elastic bandaging, sclerotherapy, infrared coagulation, hemorrhoidectomy, and THD are usually effective in treating hemorrhoidal disease.

Let’s talk a little bit about the most popular treatment options.

Treatment


The treatment of hemorrhoidal disease can be divided between conservative treatment, which is based on ointments, medication, diet, and sitz baths, or surgical treatment, which can be done in the doctor’s office or in an appropriate surgical center. In most cases of external hemorrhoids and internal hemorrhoids grades 1 or 2, the treatment is initially done conservatively, without the need for surgery.

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We will review the main treatment options for hemorrhoids below.

Conservative treatment – medication, ointments and diet
Conservative treatment of hemorrhoids can be divided into 3 modalities: medication (pills or ointments), general measures, and diet. We will briefly discuss each of them:

General measures and home treatment

During flares, sitz-baths with warm water two or three times a day can bring relief from acute symptoms. In pregnant women we suggest warm damp compresses.

In case of pain, cold compresses can also provide relief. Be careful not to cause frostbite in the anus region.

You should also avoid wiping the anus with toilet paper, preferring the bidet or warm water jets. Not rubbing the anus when cleaning is an important part of the treatment.

Avoid sitting on the toilet for too long. It is also important not to hold the stool when the urge to defecate arises.

The patient should try at all costs not to scratch the anus, as friction can cause further damage.

Loose, cotton-based clothing is preferred, as it is cool and decreases local humidity.

Diet for people with hemorrhoids

Drinking plenty of water is important because it helps to moisten the stool, reducing constipation and the friction that the passage of stool causes in the rectum and anus.

Increased fiber intake has been proven to improve symptoms. Results can be noticed after only 15 days of dietary changes. The use of supplements based on methyl cellulose or psyllium shows good results.

Attention, the use of fiber does not treat hemorrhoidal disease, but helps control the symptoms, especially itching and bleeding.

Avoiding spicy foods is a very famous tip for those with hemorrhoids, however, as already mentioned, there is no evidence that pepper or any other spicy food actually aggravates symptoms.

The response to spicy foods seems to be very individual. There are hemorrhoid patients who eat pepper at will and feel no worsening, while others swear that a little bit of pepper is enough to “irritate” their hemorrhoids. It is likely that the placebo effect plays an important role in this relationship.

Another common tip, but one that also lacks scientific evidence, is to avoid coffee or caffeinated beverages. In fact, in some people, coffee has the effect of speeding up the intestinal transit, which may even facilitate bowel movements.

Ointments and medicines

In people with constipation, laxatives are then indicated to reduce the need to push when evacuating. The passage of very large, hard stools can cause damage to the hemorrhoids.

Ointments and creams, such as Proctyl, Proctosan, or Xyloproct, can be used temporarily, as they serve as a lubricant for the passage of stool and contain anesthetics in their formula.

Some ointments, such as Ultraproct, also contain corticoids, which help to “dry out” the hemorrhoid and reduce inflammation. However, ointments containing corticosteroids should not be used for more than 7 days at a time as they can cause atrophy of the anal mucosa, favoring the appearance of new sores.

Relief with creams or ointments is only temporary and should not be used without medical advice.

The most common hemorrhoid ointment options are:

  • Ultraproct (fluocortolone pivalate, fluocortolone caproate, clemizole undecylate, and cinchocaine hydrochloride).
  • Proctyl (polyresulene and cinchocaine hydrochloride).
  • Hemovirtus (Hamamelis virginiana L, Davilla rugosa, Atropa belladonna L, menthol and lidocaine hydrochloride).
  • Proctosan (lidocaine hydrochloride, menthol, azulene, horse chestnut and Hamamelis virginiana L.).
  • Xyloproct (lidocaine, hydrocortisone, zinc oxide, and aluminum subacetate).
  • Suppositories with corticoids (Ultraproct is also available in suppository form) are another option when there is a lot of pain or itching, however, it is a treatment that should not be used for more than a week due to its possible side effects

Of the hemorrhoid tablet remedies, the one that seems to have the best effect is Daflon. Still, it only improves the symptoms, it doesn’t definitively treat the disease. Other drugs, such as Varicell, have no proven effectiveness.

Patients often seek a lot of help from ointments, when, in fact, sitz baths and dietary changes are often similarly effective for much less cost and with fewer risks of side effects.

Minimally invasive treatment options


If conservative treatment is not enough to control the symptoms of hemorrhoids, minimally invasive treatments can be tried. In these cases, treatment can be performed in the proctologist’s own office.

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a. Elastic bandage

In more severe cases, which cannot be controlled with simple measures, elastic ligation of the hemorrhoid may be necessary. Through anuscopy, a rubber is introduced at the base of the hemorrhoids, causing strangulation and necrosis of the hemorrhoids. After a few days, usually two to four, the hemorrhoid “falls off”, coming out by itself through the anus along with the rubber band. It is a technique that can be done in the proctologist’s office. It is usually painless, and many times no anesthesia is even used. The elastic bandage is indicated for grade I and II hemorrhoids. Eventually, it can be used in some grade III hemorrhoids. It is the most used technique today and has a success rate of 80%.

Elastic banding is not an option for external hemorrhoids because, in this case specifically, the treatment causes intense pain.

b. Sclerotherapy

Another option for the treatment of hemorrhoids is sclerotherapy. This technique consists of injecting, through a long needle, a chemical solution that causes necrosis of the hemorrhoids. The injected substance causes intense inflammation and causes the hemorrhoid to “dry out” and be absorbed.

Sclerotherapy is also done with the aid of anuscopy and does not require anesthesia because it is painless.

c. Infrared Coagulation

A third option is infrared coagulation, also mistakenly called laser coagulation. Like the previous techniques, infrared coagulation is performed with the aid of anuscopy and consists of the direct application of infrared waves to the hemorrhoids. The heat generated by these waves burns the lesion and causes the hemorrhoids to retract.

Of the three techniques mentioned above, the elastic bandage is the one that presents the best results for internal hemorrhoids grades I, II and III.

Surgical treatment


If symptoms of hemorrhoidal disease persist despite conservative or minimally invasive measures, surgical intervention should be indicated. In addition to cases where simpler techniques fail, surgery is also indicated in patients with grade IV hemorrhoids or those who have strangulated internal hemorrhoids. Surgery may also be necessary for symptomatic grade III hemorrhoids or for patients who present with thrombosed hemorrhoids.

Hemorrhoidectomy

Traditional surgery for hemorrhoid removal is called hemorrhoidectomy. There are two popular techniques:

Milligan Morgan or Ferguson, which is a surgery done under epidural anesthesia, which removes all the tissue around the region with hemorrhoidal disease;
Longo’s technique, which uses a device to staple the hemorrhoids.
The Longo technique is more modern and is usually better tolerated by the patient, since the post-operative period is much less painful.

THD for treating hemorrhoidal disease

A new treatment option for hemorrhoids is Doppler-guided transanal hemorrhoidal dearterialization (THD), a technique created in 1995 and perfected over the past few years. The technique consists of introducing a small Doppler device (ultrasound) into the anus to identify the hemorrhoidal arteries; through a small needle these arteries are sutured in order to reduce the flow of blood that arrives in the regions where there are hemorrhoids. As less blood arrives, the pressure inside the hemorrhoids decreases, causing them to “dry out.

The THD technique has no cuts and the risk of bleeding is very low. The post-operative period is less painful than in the techniques with incisions, and there is a low rate of hemorrhoid recurrence. The recovery time is shorter and the patient can return to normal activities within 48 hours. The procedure is done with local anesthesia and mild sedation.

THD is a relatively new technique and there are still no studies comparing its effectiveness in the long term with older techniques. However, the results are promising and the trend is that it will become the method of choice for the treatment of hemorrhoids.


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