Taking Care of Hemorrhoids

Frederick R. Jelovsek MD, MS

"I have avoided going to the doctor for my hemorrhoids by using over the counter remedies, but it is becoming unbearable. I eat a high-fiber diet but that has not helped either. Is there anything else I can do before I make that embarrassing doctor's appointment?" rf

Hemorrhoids are swollen veins just inside the anus. They produce pain if they come out of the anus with a bowel movement because they are constricted. Once they come out, the skin around them and the veins themselves can become inflamed.

It sounds as if you have tried diet modification to prevent constipation. What other creams or rectally applied compounds have you used? It would also be good to know what your occupation is and what your weight is. These can be factors that contribute to development of hemorrhoids.

Sometimes the veins just inside the anus become swollen if there is pressure on the vein itself to prevent blood flow from returning to the heart. The veins may become constricted by a large amount of stool that stays in the rectum just above the anus in someone who has constipation. A job in which a person sits all of the time can produce hemorrhoids just as a person who is on their feet may get varicose veins of the leg. Straining and sitting a long time on the toilet trying to have a bowel movement is also thought to produce hemorrhoids. Chronic diarrhea causes hemorrhoids by the same mechanism.

Heavy lifting or a chronic cough from asthma, smoking or any chronic lung disease causes hemorrhoids because of increased intraabdominal pressure. This increased pressure is just like straining at stool in that the pressure obstructs the flow of blood through the veins causing them to swell. Obesity can also cause an increased intraabdominal pressure just by the weight of the abdominal wall. It is associated also with hemorrhoids. Pregnancy produces swollen veins and hemorrhoids due to a moderately increased blood volume, and also because the pregnancy itself may slightly block some of the return venous blood flow from the lower pelvis and rectum. Rectoceles can also be associated with hemorrhoids when the rectal wall protrudes out of the vagina and obstructs the veins in the wall of the rectum below.

If one or more of the swollen veins becomes "scratched" by hard stool, it may cause bright red bleeding. Often this is painless bleeding and comes out in the toilet bowl water or on toilet paper. Most bright red rectal bleeding is due to hemorrhoids but there is always concern that a rectal cancer could be present so a rectal exam by a physician needs to be performed if there is bleeding.

Two sets of anorectal veins can become dilated. Internal and external hemorrhoidal veins. The external veins are just inside the anal sphincter while the internal veins are slightly higher up in the rectum. If a large internal rectal vein prolapses and falls through the anal sphincter muscle, the vein becomes even more distended and then very painful. Most of the pain of hemorrhoids is due to prolapsed internal hemorrhoid veins or external veins that are swollen.

Anal itching occurs because the surrounding skin tissue is traumatized due to excessive use of harsh toilet paper, a secondary irritant or allergic dermatitis due to soaps and creams used around the anus, and/or secondary yeast or parasite infections of the surrounding anal skin. The best treatment for this is avoidance of any substance touching the perianal skin other than water from a shower or bath. Soap does not need to be used to wash bacteria away; water is sufficient. An exception to this rule is that perhaps a non scented petrolatum gel or hemorrhoidal cream can be applied to the skin around the anus to protect from irritation. This is especially important if chronic diarrhea or loose stools result in greater soiling of the anal skin.

Almost always, a painful hemorrhoid is one that has prolapsed out of the anus. The treatment is:

• prevent the prolapse of the hemorrhoid
• replace the prolapsed hemorrhoid inside the anus

Preventing the prolapse of a hemorrhoid is aided by avoiding any constipation and also lubricating the stool. Glycerin rectal suppositories can provide lubrication that prevents hemorrhoid friction and irritation (1). Agar agar, a sea plant, can be used as a nutritional supplement both as a bulking agent as well as lubricating the stool. Cod liver oil, Senekot S ® and flaxseed are other supplements that can help provide a lubricated stool.

If the hemorrhoids prolapse only with a bowel movement, replacement of the hemorrhoid can be done manually by lubricating your finger with petrolatum gel and using it to push the vein or veins back inside the anal sphincter. If you are squeamish about using your finger inside the rectum without a covering, you can use a disposable glove or finger cot coated with the petrolatum gel. While it is slightly painful to push the veins back in, the relief is almost instantaneous and lasts until the next bowel movement. If the veins stay out all of the time or they come back out even without a bowel movement, then you must see your physician about further treatment.

Once the rectal veins have been stretched out and hemorrhoids created, they are very difficult to get rid of completely. They tend to recur with less and straining than it took to produce them initially. If chronic constipation has a role in creating or maintaining the hemorrhoids, then diet to avoid constipation is essential in treating them. See our article for further discussion on treatment and avoidance of constipation.

If you have a job involving sitting for long periods of time, make sure you get up and walk around for a short time at least every 45-60 minutes. If your job involves heavy lifting, practice breathing in and out slowly while lifting. This prevents you from holding your breath and causing a rise in intraabdominal pressure when you lift. If a chronic cough is part of your cause, do your best to get your lung disease in the best shape possible. Also practice Kegel exercises that emphasize the rectal sphincter rather than the perivaginal muscles. This will help protect the hemorrhoids from prolapsing during a cough.

If pregnancy is the main etiology of the hemorrhoids, there is not much you can do beyond avoiding constipation, until the pregnancy ends. Almost always they go away then. When rectoceles are associated with hemorrhoids, surgical repair often (but not always) results in resolution of the dilated veins.

Most creams or suppositories used in the treatment of hemorrhoids are directed at reducing the pain and itching symptoms. They do not make the dilated veins go away but merely give you relief until the precipitating cause is eliminated and the body heals them itself. The most effective creams contain hydrocortisone (e.g., Anusol-HC®[2.5%]) or some other steroid. These are only available by prescription although there are preparations with low doses of steroids (1% hydrocortisone) that do not require prescription.

Medicated pads containing witch hazel (Tucks®) is a popular over-the-counter treatment especially for the itching, burning and skin irritation. Another popular non prescription medication is Preparation H® which contains phenylephrine, 0.25%, a vasoconstrictor that makes the veins smaller.

There are some natural, herbal creams that may also be effective.

How does a doctor treat hemorrhoids?

Physician's will advise you of all of the preventive and home treatment modalities as listed above. In addition, they may prescribe various creams or suppositories containing pharmaceutical ingredients that not only relieve the pain (usually using steroids), but also that have direct action on the dilated veins. Various components have been reported such as nitroglycerin paste (2), calcium dobesilate with steroid and local anesthetic (3) and even a standardized leech extract (4). The mainstay of treatment however is a topical preparation usually containing steroid and local anesthetic.

Surgical treatment is usually reserved for large hemorrhoids, chronic anal fissures or perirectal abscesses (5). Surgical treatment can include banding of the veins, surgical excision, laser or electrocautery and even injection of the veins with sclerosing agents that scar shut the hemorrhoid.