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Family Health Magazine
FAMILY MEDICINE

Hemorrhoids
The bottom line

People complaining of itching, burning, pain or bleeding around the anus often go to their doctor complaining of hemorrhoids. Interestingly they are often wrong. It may be hemorrhoids causing the problem, but is also quite likely another unrelated problem ranging from an easily treatable skin condition to a much more serious condition such as cancer of the anus or rectum. The biggest error patient’s and physicians alike make when dealing with these common complaints, is to assume the diagnosis of hemorrhoids is correct and embark on a treatment program that doesn’t help and often hurts.

The good news is that it is usually easy to avoid making the wrong diagnosis by asking a few questions and most importantly looking at and feeling the area. This exam is dreaded by most patients ( and possibly by some physicians) but is essential and usually takes no more than a few minutes to arrive at the correct diagnosis. An appropriate treatment can then be prescribed, leading to prompt relief in most cases.

Brief Anatomy

Everyone is surprised to learn that we are all born with hemorrhoids in two locations. Up inside the rectum where we normally can’t see or feel them, are the internal hemorrhoids. On the outside under the skin around the anus, are the external hemorrhoids. Both kinds of hemorrhoids cause problems only when they become enlarged or irritated.

External Hemorrhoids

External hemorrhoids are blood vessels under the skin at the edge of the anus. They are covered with skin and are therefore often blamed for irritation resulting from various skin conditions. Unless the external hemorrhoids are enlarged however, they are usually not the problem.

Skin tags

When external hemorrhoids are enlarged they are called skin tags. Skin tags get itchy and cause burning pain because it is hard to clean around them after bowel movements. The small amount of feces left on the skin causes irritation with burning and itching.

The simplest way to deal with itchy, burning skin tags is to make a healthy change to your diet. Increasing the fibre content in your diet will change the consistency of the stools in such a way that it is easier to clean after a bowel movement. Drinking 6 to 8 glasses of water each day also helps. These simple steps often cure the problem. Other measures that will help are washing with warm water after bowel movements and applying zinc ointment to the skin after bowel movements and before bed.

If these simple measures fail to control the itching and burning it is because the skin tags are too big or too numerous. In this situation, removing them surgically will help. If there is only one or two, this can be done quite easily in the office with local anesthetic. If there are too many tags, or a person prefers, the tags are removed in the operating room under general anesthetic. This requires a one-day visit to the hospital.

External hemorrhoids sometimes become extremely enlarged and painful. This happens when a blood vessel under the skin breaks. The hemorrhoid then fills up with blood with such pressure that there is severe pain when sitting or moving and especially with touching. The blood quickly clots making the external hemorrhoid hard and giving it a blue color. This condition is called a thrombosed external hemorrhoid. This is usually so painful that people will immediately go to their doctor’s office or the emergency room. A brief, gentle inspection is all that it takes to make the correct diagnosis.

The best treatment for thrombosed external hemorrhoids is to remove the blood clot. This is often done with a combination of a small cut and vigorous squeezing. However, this technique should be abandoned because it too often fails to relieve the pain and in many situations the cure is more painful than the disease. The preferred method of treatment is to freeze the area with local anesthetic and completely cut away the clotted hemorrhoid. This more often gets rid of the pain, often the same day. It also permanently removes the external hemorrhoid preventing it from recurring. It does, however, work best when done within 48 hours of the onset of pain. An urgent referral to a surgeon or emergency room is therefore appropriate.

Internal Hemorrhoids

Internal hemorrhoids are small collections of blood vessels and soft tissue inside the anus at the bottom of the rectum. They normally cushion and protect the anus and rectum during bowel movements. Internal hemorrhoids are only rarely responsible for sudden onset of severe pain. Internal hemorrhoids more often cause painless bleeding or protrude from the rectum after bowel movements.

Stage 1: bleeding

With hard bowel movements or prolonged pushing and straining the internal hemorrhoids come away from the wall of the rectum and get pushed down into the anal canal. Here they get torn and squeezed, causing bleeding, the earliest stage of internal hemorrhoid problems. The bleeding usually happens only with bowel movements, but can happen anytime. The blood is usually bright red, fresh-looking blood on the toilet paper , on the stool or actually spraying or dripping into the toilet bowel. Blood mixed in with the stool is unusual and suggests another problem such as rectal inflammation or a tumour of the bowel. There is usually no pain. Pain strongly suggests another problem like a tear in the anal canal.

The correct diagnosis at this stage cannot be made without a proper examination. This includes looking at the outside of the anus, feeling the inside of the anus and rectum, and looking up into the inside of the bowel. All of this can be done quickly and easily in a doctor’s office. The most important point of this examination is to exclude other more serious causes of rectal bleeding, including cancer of the anus or rectum. The treatment of this early stage of internal hemorrhoids is also a healthy change in your diet. Eating high-fibre foods and taking a fibre supplement will stop the bleeding in most cases, and prevent progression to the next stage.

If bleeding continues after a month of high-fibre intake it is possible to pin the hemorrhoids back up inside the rectum. There are many different ways of doing this. In Canada the most common way is to use tiny rubber bands. These bands are applied in the office in a few minutes. They are placed in the rectum above the internal hemorrhoids, where a person does not sense pain. The bands cause a scar which shortens and pulls the hemorrhoids up into a normal position. The bleeding then stops and usually does not return.

If the bleeding does not stop or comes back, then a hemorrhoid operation may be necessary to completely remove the hemorrhoids. This needs to be done in an operating room at the hospital and is thus the most complicated form of treatment for hemorrhoids. Laser surgery is not commonly used as it has been shown to be no better than traditional surgery and is very expensive. Fortunately, surgery is rarely required for bleeding internal hemorrhoids

Some people with small amounts of bleeding choose to do nothing about their internal hemorrhoids. This is acceptable as long as thorough examination has been done to rule out other problems. There is no risk of untreated bleeding internal hemorrhoids turning into cancer.

Stage 2 and 3: prolapse

If the internal hemorrhoids are pushed down far enough, they will protrude from the anus and be felt on the outside. It may even be necessary to push them back inside after bowel movements or exercise. Bleeding can also occur, but not always.

Again, a gentle, thorough examination is required to make the diagnosis and rule out more serious problems. A high-fibre diet and a fibre supplement should then be started. In many cases the hemorrhoids will stop hanging out after a few weeks. Avoiding pushing and straining or prolonged sitting on the toilet is also important.

If the problem persists, then placing rubber bands in the rectum will also work for this stage of internal hemorrhoids. This is usually the next step. The success of rubber bands in this stage however, is not as good as for stage 1. More people will end up going on to have a hemorrhoid operation. If there are a lot of symptoms from external hemorrhoids along with the internal hemorrhoids, it is then best to skip the rubber bands and proceed directly to a hemorrhoid operation if the high fibre diet doesn’t help.

Stage 4: Ouch!

Internal hemorrhoids that protrude easily may get stuck on the outside. No amount of pushing helps. This is the only time when internal hemorrhoids are painful. They become so large and swollen that the pressure on the muscles around the anus creates severe pain. Admission to hospital and strong pain-killers followed by an urgent hemorrhoid operation is the best treatment.

The Bottom Line

Itching, burning, swelling, bleeding and pain around the anus are common problems. Hemorrhoids, either internal or external, are also common, but not always the problem. A gentle, thorough examination is required to make the correct diagnosis and select the best treatment.

It is also the only way to rule out other much more serious problems such as anal or rectal cancer. Effective treatment is available and only rarely involves surgery. Early consultation with a specialist in Colon and Rectal Surgery, or a general surgeon with an interest in proctology, will help ensure the correct diagnosis is made and that the most appropriate treatment is selected.