Hemorrhoids

The rectum is the last few inches of the colon. The rectum is connected to the anal canal, which leads the fecal matter out of the body. The opening is called the anus. Problems in this part of the body are common, but people are often embarrassed to seek help. Common symptoms may include bleeding, pain and itching. When symptoms are persistent, it is important to have an evaluation by a doctor.

Hemorrhoids are blood vessels (veins) in the rectum or anal canal. When those blood vessels become swollen or dilated, symptoms may develop. Many people have hemorrhoids, but have no symptoms.

Hemorrhoids are very common and by age 50, nearly half of Americans have hemorrhoids. Nearly 5% of the US population (15,000,000 people) has sought medical care for symptomatic hemorrhoids. Many more have problems with hemorrhoids, but never seek formal medical attention.

External hemorrhoids are dilated veins covered by the skin near the anal opening. They may be felt as bumps or lumps near the outside of the anus, and become painful when they are swollen with blood. They can sometimes be confused with skin tags which are extra pieces of skin near the anus

Internal hemorrhoids are dilated veins that form inside the rectum and above the anal opening, and are therefore “internal”. However, in some situations they may enlarge and protrude (prolapse) out of the anus.

External hemorrhoids may be present and cause no symptoms. When they cause symptoms, the most common are pain or itching; they can often be felt as a bulge in the skin near the anal opening.

Internal hemorrhoids may be present and cause no symptoms. When they cause symptoms, the most common are painless rectal bleeding, which usually is seen as bright red blood on the toilet paper or in the toilet bowl. It is important to know that just a few drops of blood in toilet water can change the color of the water dramatically. Other symptoms are itching, pain/soreness or feeling tissue come out when having a bowel movement.

Hemorrhoids may develop as a result of repeated straining to have a bowel movement, sometimes as a result of longstanding constipation or diarrhea. They are also seen commonly in any condition that leads to increased pressure inside the abdomen. Common examples would include pregnancy and lifting heavy weights.

Hemorrhoids are suspected when they produce the characteristic symptoms listed above. External hemorrhoids may occasionally be seen on visual examination of the anus. A full exam usually includes a digital rectal exam, where the doctor will insert a gloved finger into the rectum. Internal hemorrhoids may be identified on external exam if they protrude with straining or may be detected during a check with a flexible or rigid tube with a light and a camera that is inserted in order for the doctor to see the inside of the anal canal and lower rectum. Alternatively, your doctor may insert a small plastic speculum to exam the rectum. The speculum is called an anoscope and the flexible tube is a sigmoidoscope.

Most hemorrhoids resolve spontaneously, or with simple measures. These measures include avoidance of straining, and treatment of hard stools or constipation with increased fluids, addition of increased fiber in the diet or taken as fiber supplements and stool softeners or lubricants. Soaking the affected area in a hot bath or using a sitz bath are also very effective. There are multiple over-the-counter creams and suppositories which can reduce symptoms of itching and pain. When these are not effective, your doctor may prescribe a steroid cream or suppository to use for 1-2 weeks. Some people find cleaning the anal region with a moist towel or "baby wipe" after a bowel movement to be soothing. It is important to remember that hemorrhoids commonly recur with people and that you may have no symptoms in between episodes.

In some circumstances, hemorrhoids that do not resolve or bleed repeatedly need other type of treatment. These include:

• Rubber band ligation: Small rubber bands are placed around the hemorrhoids, often in a doctor’s office. This will cause the hemorrhoid(s) to fall off in several days and form a small ulcer where the hemorrhoid was. This heals over time. This is generally a painless procedure and minor discomfort resolves in 24 hours. Using a pain reliever like Tylenol, Aspirin or Ibuprofen helps to remove discomfort after the procedure. The procedure is safe and has become common for a gastroenterologist to do at an office visit.
• Infrared coagulation: A small probe is inserted in the rectum and heat is applied to destroy a hemorrhoid. This should be mostly pain free.
• Sclerotherapy: A chemical is injected directly into the hemorrhoid to help destroy the hemorrhoid tissue.
• Surgery: Removal of the dilated, stretched veins. This is performed by a general or colorectal surgeon in an operating room.

An anal fissure is a tear in the lining of the anal canal. It often occurs after the passage of a hard bowel movement.

An anal fissure typically causes pain, especially with a bowel movement. Sometimes, bleeding occurs as well.

An anal fissure can be seen by a doctor on a visual exam of the anal region or can sometimes be felt by the doctor on an exam if it is not visible. If the fissure is touched, it will usually be painful. Sometimes an anoscope (see above) is used to look inside the anal canal a very short distance to see how far the tear extends.

Since anal fissures often result from the passage of hard bowel movements, keeping the stools soft and bulky (with fiber supplements) may help prevent them from occurring in the first place.

Most anal fissures will heal on their own within a few weeks if the stools are kept soft (possibly with stool softeners, and fiber supplements) and the area is not repeatedly re-injured.

Other measures may include:

• Sitz baths: These will soothe the affected area with water
• Medicated creams and/or suppositories to relieve pain and inflammation
• Occasionally, the use of nitroglycerine or diltiazem ointment applied to the area will be necessary
• Occasionally, injection of botulinum toxin, Botox®, may be helpful
• Surgery may be necessary if symptoms persist. The operation involves partially cutting a muscle that regulates the passage of stool out of the rectum. Cutting this muscle relieves pressure on the skin near the fissure, and allows the fissure to heal.