What Are Hemorrhoids?

Hemorrhoids are cushions of submucosal tissue in the anal canal containing small arteries, veins, and smooth muscles. They are part of the normal structure of the anal canal and an important component of the continence mechanism that aids in complete closure of anus at rest and allow passage of stools as and when required. As hemorrhoids are a part of normal structure, their treatment becomes a necessity only when they’re symptomatic and cause considerable pain and discomfort in the patient. 

What causes hemorrhoids?

Hemorrhoids are caused by the engorgement of veins in the hemorrhoidal plexus that can prolapse through the anal canal and can be felt by the patient.  

The following factors are responsible for such a scenario:

• Excessive straining: either due to constipation or habituation. Sitting for a long time without straining can also cause hemorrhoids.
• Pregnancy: is the most common risk factor for hemorrhoids. The enlarged uterus presses on to the venous drainage of the perineal area and thus cause venous stasis and engorgement of veins. Constipation is also more common in pregnancy that is also an independent risk factor for hemorrhoids
• Heavy lifting:  Lifting heavy weights can also cause hemorrhoids.
• Diarrhea: Contrary to constipation, passing excessive stools can also cause hemorrhoids
• Obesity: Increased intraabdominal pressure due to obesity is an important contributing factor for hemorrhoids
• Anal intercourse: Having anal sex can damage the hemorrhoidal plexus and result in piles.
• Genetics: some people have a genetic tendency to develop hemorrhoids.

Types of hemorrhoids

There are two varieties of hemorrhoids:

1.    Internal Hemorrhoids

Internal hemorrhoids are situated 4cm from the anal opening (above the dentate line). The can either bleed or hang down to come out of the anal opening (prolapse) depending on the severity but are always painless. The internal hemorrhoids are classified into four degrees:

First-degree: No prolapse of contents, only bleeding is present

Second-degree: Prolapsed hemorrhoids but go back spontaneously

Third-degree: Prolapsed but have to be reduced manually with fingers

Fourth-degree: Prolapse and cannot be reduced. 

2.            External Hemorrhoids

They are situated within or less than 4cm from the anal opening. External hemorrhoids are usually painless but thrombosis (clotting of blood) within them can cause extreme pain. 

Sometimes, both the internal and external hemorrhoids are present and the condition is known as interno-external hemorrhoids. 

Symptoms of Hemorrhoids

Symptoms of hemorrhoids include

• Bright red and painless bleeding during defecation
• Itching or discomfort in the anal area
• Feeling of something hanging from the anal opening
• Mucous discharge or leaking feces

Diagnosis

The diagnosis of hemorrhoids is based on careful clinical history and examination. After taking a complete history that is indicative of hemorrhoids, the examination becomes equally important in identifying the type and degree of hemorrhoids. Your doctor may perform:

• Inspection to look for external or prolapsed hemorrhoids
• Digital rectal palpation in which a lubricated finger is inserted into the anus to confirm the presence and site of hemorrhoids
• Proctoscopy is only indicated in internal hemorrhoids. The hemorrhoids, if present, bulge into the lumen of the proctoscope 

Treatment

There are many treatment modalities available for the hemorrhoids and the choice of treatment regimen depends upon the type and grade of hemorrhoids as well as personal preferences.

Home-remedies

Over-the-counter medications and home remedies can be used to get relief from symptoms of hemorrhoids. These include

• Analgesics such as aspirin and ibuprofen can be taken orally to get pain relief
• Topical application of OTC creams containing hydrocortisone
• Numbing agents such as xylocaine gel can be applied for soothing effects
• Ice packs and cold compresses can reduce the inflammation
• Sitz bath either placed over the toilet seat or in the form of full bath is taken for at least 20 mins and is an effective remedy for hemorrhoids

Medical & Non-Surgical

Bleeding from first and second-degree hemorrhoids often improves with the addition of dietary fibers, stool softeners, increased fluid intake, and avoidance of straining. 

Injection sclerotherapy is often used as the first line of treatment for first and second-degree hemorrhoids. A sclerosing agent is injected into the base of each hemorrhoid that causes its shrinkage and fixation to the underlying muscle. This is an outpatient procedure and around 88% of the patients with first-degree hemorrhoids feel improvement in symptoms.

Band Ligation is a widely used treatment modality in which a rubber band is placed around the redundant mucosa. This causes cessation of blood supply to the prolapsed tissue which then sloughs off in 5-7 days, leaving a small ulcer that heals and fixes the tissue to the underlying muscle. The overall success rate with this technique is 60-80%.

Photocoagulation and Electrocoagulation are also available to choose from. 

Surgical

Hemorrhoidectomy is the surgical removal of hemorrhoids and is the most effective treatment modality for third and fourth-degree hemorrhoids. Indications of surgical intervention also include interno-external and thrombosed hemorrhoids. The surgery requires hospital admission and is performed under general anesthesia. Depending upon the type of surgery performed and the incidence of complications, most people can go home on the same day of surgery.