Hemorrhoids – Diagnosis, Symptoms, and Treatment
What are Hemorrhoids?
Hemorrhoid is a medical condition characterized by dilation and herniation of veins in the rectum. The disease is typically caused by constipation due to low dietary fiber, inadequate fluid intake, and lack of physical activity. Other conditions (e.g., hypothyroidism, colon cancer) and medications (e.g., opiates) can contribute to constipation and the formation of hemorrhoids. Anal trauma during sexual intercourse is also a potential origin of hemorrhoids.
Mild cases of hemorrhoids tend to improve with conservative measures such as increasing dietary fiber and fluid intake. More severe cases may require topical ointments, and refractory patients may benefit from surgical approaches.
What Causes Hemorrhoids?
The following factors typically cause hemorrhoids:
- Inadequate physical activity – exercise promotes the movement of feces down the colon.
- Inadequate fluid intake – most people require 1.5-2 L fluid daily, and this requirement increases with exercise and illness (e.g., infection)
- Low dietary fiber consumption – the average person typically requires about 30g of fiber in their diet daily.
- Use of opiate analgesics for pain
- Other medical conditions
- Colon cancer (mostly in people age >50)
- Impaired intestinal motility – due to diabetes mellitus, advanced age
These features lead to slow transit of stool through the colon or mechanical obstruction of stool through the gastrointestinal tract.
Constipation leads to increased pressure in the colon and rectum. This promotes the dilation and protrusion of veins in the rectum. Individuals who sustain rectal trauma in the setting of sexual intercourse may also sustain damage to rectal veins. These dilated veins are more prone to bleeding and can irritate the rectal vault, causing itching. Hemorrhoids can also form blood clots, causing severe pain (thrombosed hemorrhoid).
How Common are Hemorrhoids?
Hemorrhoids are exceedingly common in the United States and responsible for frequent primary care visits. Complicated or severe cases may require referral to a gastroenterologist or rectal surgeon.
The prevalence of symptomatic hemorrhoids is approximately 4% in the United States. Hemorrhoids occur equally in both sexes, and the peak presentation is around age 45-65. Symptoms before age 20 are uncommon, and the prevalence of disease declines after age 65.
Signs and Symptoms
Symptoms of hemorrhoids typically include one or more of the following:
- Rectal bleeding
- Anal itching
- Rectal pain
- Fecal incontinence
Rectal bleeding is often characterized as drops of bright red blood in the toilet after a bowel movement. You may have blood on the toilet paper after wiping the bottom. Itchiness is a frequent complaint and is medically termed anal pruritus. Pain often occurs in the setting of a thrombosed hemorrhoid. This means that hemorrhoid has developed an acute blood clot that is causing irritation and discomfort.
The diagnosis of hemorrhoids is based on symptoms and physical examination. Your doctor will typically perform a rectal exam and a procedure called anoscopy. During anoscopy, a transparent, cone-shaped, plastic device is inserted in the anus, and the internal anal mucosa is examined for evidence of hemorrhoids. This is an office-based procedure. If your doctor is worried about a more proximal bleeding source, they may refer you to a gastroenterologist to undergo either diagnostic sigmoidoscopy or colonoscopy.
Although uncommon, more extensive rectal bleeding may warrant blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and PT/INR.
Hemorrhoids Medication and Treatment
Hemorrhoids are initially treated with dietary and lifestyle changes and conservative treatments. Patients are encouraged to increase their amount of dietary fiber – this can usually be achieved by increasing the consumption of fruits, vegetables, beans, nuts, and whole-grain foods. Most individuals should also be drinking about 1.5-2L of clear fluids on average daily. Physical activity is also encouraged in patients with constipation who can tolerate exercise. Most people are recommended to exercise for 30 minutes, 3 times a week.
If there is a known underlying cause of constipation – hypothyroidism, opiate use, colon cancer – these conditions should be reversed or treated.
Constipation may require treatment with laxatives, which typically include:
- Bulk-forming agents – Metamucil (psyllium), Citrucel (methylcellulose)
- Stool softeners – Colace (docusate)
- Stimulant laxatives – Senokot (senna), Dulcolax (bisacodyl)
- Osmotic laxatives – Constulose (lactulose), MiraLax (polyethylene glycol 3350)
Painful hemorrhoids can be treated with topical therapies such as hydrocortisone/lidocaine ointment. Antispasmodic agents can also be useful for decreasing sphincter spasm – these agents typically include 0.5% nitroglycerin ointment or topical nifedipine. Botox injections into the sphincter can also help reduce pain intensity. Lastly, Sitz baths can improve itching and irritation.
Patients with hemorrhoids that are refractory to conservative therapy may benefit from rubber band ligation or surgical hemorrhoidectomy. Sclerotherapy is also an option in a subset of patients.
- MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 1995; 38:687. - https://www.ncbi.nlm.nih.gov/pubmed/7607026
- Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum 2011; 54:1059. - https://www.ncbi.nlm.nih.gov/pubmed/21825884
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.