Hemorrhoids (Internal and External)

Picture of internal and external hemorrhoids

Hemorrhoids (piles) are blood vessels located in the smooth muscles of the walls of the rectum and anus. They are a normal part of the anatomy and are located at the junction where small arteries merge into veins. They are cushioned by smooth muscles and connective tissue and are classified by where they are located in relationship to the pectinate line, the dividing point between the upper 2/3 and lower 1/3 of the anus. This is an important anatomic distinction because of the type of cells that line hemorrhoids, and the nerves that provide sensation.

• Internal hemorrhoids are located above the pectinate line and are covered with cells that are the same as those that line the rest of the intestines.
• External hemorrhoids arise below the line and are covered with cells that resemble skin.
• Hemorrhoids become an issue only when they begin to swell, causing itching, pain, and/or bleeding.

Hemorrhoids are normal tissue and only raise concern when they swell, become inflamed, or bleed. Hemorrhoids will recur after nonsurgical treatment about 50% of the time, while the recurrence rate after surgery is only 5%. The goal is to control hemorrhoid inflammation by diet and hydration so that surgery is not required. In this respect, hemorrhoids are a life-long condition to be controlled and not cured.

External hemorrhoids are located underneath the skin that surrounds the anus and is lower than internal hemorrhoids.

Normal hemorrhoidal tissue cannot be seen since it must first swell and become inflamed or develop a clot to cause symptoms. One can see swollen external hemorrhoids or internal prolapsed hemorrhoids exposed outside the anus but internal hemorrhoids cannot be seen because they remain inside the anus. A thrombosed hemorrhoid will appear as a lump at the anal verge, protruding from the anus, and will be dark bluish in color because of the blood clot contained inside the swollen blood vessel. Non-thrombosed hemorrhoids will appear as a rubbery lump. Often more than one swollen hemorrhoid appears at the same time.

Hemorrhoids are caused by swelling in the anal or rectal veins. This makes them susceptible to irritation.

While the presence of hemorrhoids is a reflection of the normal anatomy, most people and care professionals refer to hemorrhoids as an abnormal finding because they only present when they swell and cause problems.

Hemorrhoid swelling occurs when there is an increase in the pressure in the small vessels that make up hemorrhoids causing them to swell and engorge with blood. This causes them to increase in size leading to symptoms. Increased pressure may be caused by a variety of factors:

• A low-fiber diet and smaller caliber stool cause a person to strain when having a bowel movement, increasing the pressure within the blood vessels.
• Pregnancy is associated with hemorrhoid swelling and is likely due to increased pressure of the enlarged uterus on the rectum and anus. In addition, hormonal changes with pregnancy may weaken the muscles that support the rectum and anus.
• Prolonged sitting on the toilet may increase pressure within the hemorrhoid blood vessels.
• Obesity
• Diarrhea, both acute and chronic
• Colon cancer
• Previous rectal surgery
• Spinal cord injury and lack of erect posture

External hemorrhoids can cause problems, however, when there are blood clots inside them. This is referred to as thrombosis. Thrombosis of such a hemorrhoid causes an anal lump that is very painful, tender, and often requires medical attention.

Hemorrhoids are the most common cause of rectal and anal complaints. The most common complaint symptoms are

• painless bleeding from the anal area,
• anal itching,
• pain in the anal area,
• swelling, and
• feeling a lump at the anus are all associated with inflamed hemorrhoids.

It is important to remember that rectal bleeding or blood in the stool is never normal and, while it may come from a relatively benign cause like hemorrhoids, more serious causes can be life-threatening. These include bleeding from ulcers, diverticulitis, inflammatory bowel disease, and tumors. If rectal bleeding occurs, it is important to contact your health care professional or seek emergency medical care. This is especially important if the person is taking blood-thinning medications.

When an internal hemorrhoid becomes inflamed, it can cause swelling. This in itself does not cause pain because there are no pain fibers attached to the veins above the pectinate line. Passing a hard stool can scrape off the thinned lining of hemorrhoids causing painless bleeding. However, swollen hemorrhoids can also cause spasms of the muscles that surround the rectum and anus causing pain, especially if they protrude or prolapse through the anus. A lump can be felt at the anal verge. Internal hemorrhoids can also thrombose (clot) leading to severe pain.

Inflamed hemorrhoids can leak mucus that can cause inflammation of the skin surrounding the anus causing burning and itching, known as pruritis ani. However, other causes of itching include yeast and other skin infections and parasites like pinworms. Most importantly, just as blood in the stool should not be ignored because it might be a sign of colon cancer, anal itching or bleeding should not be presumed to be due to hemorrhoids because it can be a sign of an anal cancer tumor.

External hemorrhoids behave differently since they are covered by "regular skin" and have pain fibers associated with them. A thrombosed external hemorrhoid occurs when an underlying vein within hemorrhoid clots off causing intense pain from the rapid stretching of the skin covering hemorrhoids. A hard painful lump can be felt at the anus. External hemorrhoids can also result in excess skin tags that can be felt at the anal verge and can cause difficulties with cleaning after a bowel movement, leading to secondary skin infections.

The common symptoms of hemorrhoids include itching, pain, rectal fullness or lump, and bleeding. The diagnosis is made by history taking and physical examination. The history may focus on the associated symptoms including

• constipation,
• hard bowel movements, and
• straining while going to the toilet.

Other questions may be asked to look for other causes of rectal bleeding including

• tumors,
• inflammatory bowel disease, and
• gastrointestinal bleeding.

Physical examination is performed to confirm the diagnosis and includes a rectal examination where a finger is used to feel for abnormal lumps or masses. Interestingly, internal hemorrhoids cannot usually be felt. The rectal exam may be deferred if there is intense pain or swelling. In addition, hemorrhoids and constipation may be associated with anal fissures or cracks in the skin surrounding the anus. The associated pain and spasm make a rectal exam very uncomfortable.

If the health care professional is concerned that the symptoms, especially rectal bleeding, cannot be explained by hemorrhoids, anoscopy may be considered.

• Anoscopy is an office procedure where a lighted tube is inserted to look at the anus.
• Sigmoidoscopy or colonoscopy may be ordered if there is concern that the bleeding is arising from other areas of the colon.
• These procedures are usually performed by a gastroenterologist or surgeon.

Depending upon the situation, blood tests may be ordered. If there has been excessive bleeding, the hemoglobin or red blood cell count may be checked. If the patient is taking warfarin (Coumadin), an INR (international normalized ratio) or PT (time) may be ordered to check for appropriate blood "thinning." Please note that there are many newer anticoagulation medications available to "thin" the blood and their activity cannot be measured by routine blood tests.

Once hemorrhoidal symptoms develop, a variety of treatment options exist, depending upon the situation and severity of the hemorrhoids. Internal hemorrhoids are graded by the degree of prolapse below the pectinate line into the anal canal.

• Grade 1: Internal hemorrhoid bulges into the canal but does not prolapse or fall completely into it. These may bleed.
• Grade 2: Hemorrhoid protrudes past the anal verge with straining for a bowel movement or passage of flatus, but spontaneously returns to its original internal position once the straining has subsided.
• Grade 3: Hemorrhoid may protrude past the anal verge without any straining and requires the patient to push them inside manually.

A sitz bath may help decrease the inflammation of hemorrhoids.

Regardless of the size or swelling of a hemorrhoid, no treatment is required if symptoms do not exist. Prevention is perhaps the most effective treatment. Diet and adequate hydration are very important to maintain normal bowel movements. Hemorrhoid symptoms can occur with the passage of hard stool and constipation, as well as diarrhea and frequent bowel movements. People with constipation may require a high-fiber diet, adequate hydration, and stool softeners. Those with too frequent bowel movements may require antidiarrheal medications and diet adjustments. These preventive measures decrease the amount of straining that is required to have a bowel movement, thus decreasing the pressure within the blood vessels to prevent swelling. Internal hemorrhoid always stays protruded or prolapsed and is at risk for thrombosis or strangulation should the anal muscles go into spasm.

Grade 1 hemorrhoids are treated symptomatically. There can be some spasms of the anal muscles. Warm sitz baths, sitting in a warm tub for 20 minutes, two or three times a day may be helpful. Avoiding spicy food may also prevent anal itching. Over-the-counter medications may be helpful.

Stool softeners work by increasing the water and fat content within the stool allowing it to be passed more easily.

Medications are used to control symptoms by

• softening the stool,
• decreasing the inflammation of the hemorrhoids, and
• treating the pain.

Stool softeners work by increasing the water and fat content within the stool allowing it to be passed more easily.

• Docusate sodium is the most often recommended drug in this class (Colace, Surfak, Correctol).

Inflammation can be controlled with over-the-counter creams or suppositories.

• Some brand ingredients (Preparation H) include low-dose topical anesthetics to help with symptoms.
• Others (Anusol, witch hazel) contain astringents that help shrink the swollen tissues.
• Both may contain low-dose steroids (hydrocortisone) to decrease inflammation.
• People with diabetes should check with their pharmacist or health care professional before using OTC hemorrhoid treatments. If the medication contains a vasoconstrictor (for example, phenylephrine HCI, ephedrine, or epinephrine) it may elevate blood sugar levels if absorbed in large amounts.
  • Prescription-strength lidocaine or hydrocortisone may be offered by the health care professional.

Grade 2 and 3 hemorrhoids are initially treated the same way, using techniques to destroy hemorrhoids. These include

• injecting the hemorrhoid vein to make it sclerose or harden,
• using rubber bands to choke off the blood supply and make the hemorrhoidal tissue shrivel, or
• other procedures that cause the mucosa to shrivel and die.

Surgery options include hemorrhoid removal with laser surgery or hemorrhoidectomy.

People who have failed conservative therapy or who have grade 4 hemorrhoids are candidates for surgery to remove the swollen hemorrhoids and the larger external hemorrhoid skin tags. Options include

• hemorrhoid removal with laser surgery or hemorrhoidectomy (ectomy=removal) using a scalpel.
• Another alternative is stapled hemorrhoidectomy, where a special staple gun is positioned to remove hemorrhoids and surround the tissue with a ring of staples to close the area as well as control the bleeding.

A thrombosed external hemorrhoid indicates that a clot has formed in hemorrhoids causing significant pain.

• Treatment involves cutting into hemorrhoids to remove the clot and reduce the swelling.