Haemorrhoids are enlarged veins around the anal canal.
Haemorrhoids develop when the normal veins around the anal opening become abnormally enlarged or dilated. This happens because of habits or medical conditions that cause increased pressure on veins in the pelvis. The most frequent cause is a refined diet with not enough grains and bulky foods. This causes constipation, leading to increased pressure.
Haemorrhoids are classified as internal or external depending on where they are in relation to a line (the dentate line) that separates the two types of anal skin.
External haemorrhoids develop below the line and are generally painless. They rarely need medical treatment, unless a vein bursts, blood pools under the skin and a painful lump forms (this is called a clotted or thrombosed haemorrhoid).
Internal haemorrhoids develop above the dentate line. They can range in size from a slight swelling under the wall of the canal to large, sagging veins that stick out of the anus all the time. For treatment purposes, internal haemorrhoids are graded according to their size:
- Grade I: The vein bulges during bowel movements.
- Grade II: The vein comes out of the anus during bowel movements, but goes back by itself.
- Grade III: The vein comes out during bowel movements, but doesn't go back by itself. It has to be replaced by hand.
- Grade IV: The vein sticks out all the time and cannot be replaced.
It is possible for a person to have both internal and external haemorrhoids at the same time.
- Poor bowel habits - straining from long-term constipation or diarrhoea
- Overweight, which often leads to straining to pass stools
- Standing or sitting for long periods of time
- Breathing improperly while lifting heavy weights (inhaling rather than exhaling while pushing against the weight)
- Pregnancy, which results in increased blood flow to the pelvic area
- Medical conditions, such as long-term (chronic) heart and liver disease, which causes blood to pool in the abdomen and pelvic area
- Coughing, sneezing or vomiting
- Genetic (inherited) factors
Internal and external haemorrhoids manifest differently.
- Slight swelling of the veins near the anus generally goes unnoticed. It may only be felt as extra skin around the anus.
- These skin tags can become inflamed, causing a feeling of pressure in the anus. They can also make it hard to keep the anal area clean, which can lead to skin irritation, itching and burning. If a vein becomes quite large, it may cause discomfort, especially during bowel movements. The discomfort may discourage you from cleaning the anal area as well as you should, which can also lead to skin irritation.
- A clotted haemorrhoid can be very painful. The pain may be so bad that you cannot sit or walk. The skin covering the lump may be blue (because of the collection of blood under the skin) and shiny due to stretching of the skin.
- If the lump is not removed within 24 to 48 hours, the pain will gradually lessen over the following four to five days. The skin covering the lump may break open on its own, causing mild bleeding. With good self-care, pain and bleeding will stop within two weeks.
- The most common symptom of internal haemorrhoids is painless rectal bleeding. You may notice bright red streaks of blood on toilet paper after having a bowel movement or blood on the surface of stools. If you strain to pass stools, blood may spurt (spraying the sides of the toilet bowl) or trickle (colouring the water in the toilet bowl) from your anus.
- You may have an uncomfortable feeling of fullness after passing stools because of the bulging of the haemorrhoid in the anal canal.
- Haemorrhoids that are large enough to stick out of the anus (grade III and IV) may secrete mucus, causing mild skin irritation and itching. Good hygiene can keep this from becoming a problem.
- You may see or feel protruding haemorrhoids as moist pads of skin sticking out. It may recede into the rectum on its own or can be pushed back into place.
- Very large haemorrhoids may become painful if they swell and are squeezed by the muscles (anal sphincters) that control the opening and closing of the anus.
- At their worst, large internal haemorrhoids stick out of the anus all the time.
- In rare cases, the opening and closing of the anus may cut off the blood supply to the swollen veins. This causes tissues inside the rectum to die, and emergency surgery is required to prevent serious damage.
Haemorrhoids are very common. Most people will experience symptoms or problems at some point in life, most often between the ages of 20 and 50. Men and women are affected.
When to see a Doctor
A visit to a doctor is indicated when:
- Rectal bleeding occurs for no apparent reason and is not associated with trying to pass stools
- Rectal bleeding continues for more than one week
- Stool becomes more narrow than usual
- A lump near the anus gets bigger or becomes more painful
- Pain and/or swelling due to haemorrhoids is severe
- Moderate pain lasts longer than one week after home treatment
- Any unusual material seeps from the anus
- Tissue from inside the body sticks out of the anus and does not return to normal after three to seven days of home treatment
- Rectal bleeding becomes heavy and/or changes in colour from bright red to dark red or if stools change in colour
A number of ailments that affect the anal canal, rectum, and colon (large intestine) can cause bleeding, discharge, itching, and discomfort. Most people who have these symptoms assume they have haemorrhoids, but this is often not the case.
The purpose of a visit to the doctor is to evaluate symptoms and confirm the diagnosis. Even more importantly, he or she should rule out life-threatening conditions. If the diagnosis is confirmed, a treatment plan can be initiated.
Diagnosis is based on:
- Medical and social history, including personal habits
- Visual examination
- Digital rectal examination, i.e. feeling inside with a lubricated gloved finger
- Anoscopy, the use of a small, hollow lighted tube to help see into the anal canal and lower part of the rectum
- Proctoscopy - as above, but this makes a more thorough rectal examination possible
- A faecal occult blood test - this may be done if internal haemorrhoids cannot be detected with a digital rectal examination or anoscopy.
- Flexible sigmoidoscopy - because people older than 50 are at higher risk for cancer of the colon and/or rectum (colorectal cancer), this procedure may be undertaken to view the lower colon and so rule out other causes of rectal bleeding, even if haemorrhoids are evident.
- Further examination of the entire colon with colonoscopy, when indicated
- A barium X-ray can also be done which will show the colon's interior.
Home and medication
The best treatment is prevention and such strategies are also effective when haemorrhoids have already developed.
In addition, most small internal haemorrhoids can be treated at home with the following techniques:
- Try not to sit for long periods. Take frequent breaks.
- A doughnut-shaped cushion can make sitting more comfortable and ease haemorrhoid pressure and pain.
- Insert petroleum jelly just inside the anus to make bowel movements less painful.
- Ointments that contain hydrocortisone may help decrease inflammation and speed healing.
- Resist the temptation to scratch haemorrhoids, as this irritates the inflamed veins more, damages the surrounding skin and intensifies the itchiness. Non-prescription haemorrhoid creams may help for the itching and pain.
- When wiping, be gentle. If toilet paper is irritating, try dampening it first, or use cotton balls or alcohol-free baby wipes. You may prefer washing yourself and then dabbing the area dry.
- Bathe regularly to keep the anal area clean, but be gentle. Excessive scrubbing, especially with soap, can intensify burning and irritation.
- External haemorrhoids usually do not need treatment, unless an enlarged vein near the anus bursts, forming a hard and extremely painful lump under the skin (thrombosed haemorrhoid).
- If the pain is not too severe, stool softeners, topical pain-relieving creams and Sitz baths (sitting in a bathtub of warm water for 15 minutes several times a day, especially after a bowel movement) may be sufficient. If pain is severe, surgical treatment may be required. If the lump is not removed within 24 to 48 hours, the pain will gradually lessen over the next four to five days. The skin covering the lump may break open on its own, causing mild bleeding. With good self-care, pain and bleeding stop within two weeks (although the lump may remain for several weeks).
- Anaesthetising creams and suppositories to reduce inflammation may relieve irritation and pain due to internal haemorrhoids.
- Internal haemorrhoids that continue to bleed after a trial of home treatment or become so large that they stick out of the anus may require professional treatment.
Surgery and fixative procedures
This section discusses surgery and fixative procedures for internal and external haemorrhoids.
- If an external haemorrhoid causes a lump with severe pain, it is more effective to surgically drain it, as this provides immediate relief from pain. It is best if it is removed during the first 24 to 48 hours after formation of the lump. This procedure is easily performed in the doctor's office using a local anaesthetic to numb the skin.
- Surgical removal (haemorrhoidectomy) is only considered for external haemorrhoids when the veins are so large that they cause significant discomfort and make it difficult to keep the anal area clean.
- If skin tags cause repeated problems, they can be removed surgically.
- Larger internal haemorrhoids may require medical treatment. Non-surgical treatments are used to cure most smaller (grade I and II) and some larger (grade III) internal haemorrhoids.
The goal of most non-surgical procedures is to cut off the flow of blood to the enlarged vein, causing the vein to fall off and a scar to form in its place on the wall of the anal canal. These are called fixative procedures because the scar keeps nearby veins from drooping into the anal canal. Fixative procedures include the following:
- Rubber band ligation: a tiny rubber band is tied around a prolapsed haemorrhoid, shutting off its blood supply. Within a week, the haemorrhoid will fall off. This method is painless and successful 75% of the time.
- Coagulation or cauterisation: using an electric probe, laser beam or infrared light, a tiny burn painlessly seals the end of the haemorrhoid, causing it to close off and shrink.
- Injection sclerotherapy: haemorrhoids are injected with chemicals that create a scar and closes off the haemorrhoid. With a success rate of 90%, this is often the first choice. Results are not permanent, however; repeat injections may be needed every two or three years.
- Most internal haemorrhoids respond to non-surgical treatment. When compared to surgery, these procedures involve less risk and are less painful. These treatments often depend on the doctor's experience and the equipment available.
- Surgical removal of haemorrhoids (haemorrhoidectomy) is most successful for treating larger (grade III and IV) internal haemorrhoids.
- Smaller internal haemorrhoids are only treated surgically when they cause severe problems (usually when a person has several haemorrhoids, when bleeding cannot be controlled with other treatments, or when a person has both internal and external haemorrhoids).
- Surgery may be done under general, spinal or local anaesthetic. It can be done with a scalpel, cautery device or laser. The choice as to which is the most appropriate varies from patient to patient and is best left to the judgement of the surgeon.
- Complete healing from this operation can take two to four weeks. However, after one week most patients are able to return to their usual activities with minimal or no discomfort.
- The success rate of haemorrhoid removal approaches 95%, but unless dietary and lifestyle changes are made, haemorrhoids are likely to recur.
The best treatment is prevention. Initial treatment for haemorrhoids begins at home. Since haemorrhoids are made worse by straining to pass stools, changing some of your daily habits so you can have regular, smooth bowel movements may help relieve symptoms and keep haemorrhoids from getting bigger. Half of all haemorrhoid sufferers find relief with dietary changes alone.
- Avoid constipation by eating high-fibre foods (fruits, vegetables, whole grain breads, beans, and legumes) and avoiding refined and 'junk' food.
- If this cannot be accomplished with diet alone, adding bulk laxatives may be necessary.
- Drink plenty of liquids such as water, fruit juice and other beverages that don't contain caffeine - at least eight glasses of water a day.
- Limit alcohol consumption to one drink per day. Alcohol causes dehydration, which can lead to constipation.
- Monitor your sodium (salt) intake. Excess salt in the diet causes fluid retention, which will cause swelling in all veins, including haemorrhoids.
- Regular exercise is important, especially if you have a sedentary job. Exercise helps by keeping weight down, decreasing constipation and enhancing muscle tone. Exercise often to promote regular, smooth bowel movements.
- Practice good bowel habits. Go to the bathroom as soon as you have the urge to move your bowels. Try to set up routine times when you can go to the bathroom without feeling as if you have to rush or strain. Once on the toilet, don't sit there any longer than necessary, because this can put additional pressure on the haemorrhoidal veins. Don't strain to pass stools. Be relaxed and give yourself time to let things happen naturally. Never hold your breath while passing stools.
- Modify your daily habits. Avoid prolonged sitting and/or standing at work or during leisure time. Take frequent short walks. If possible, avoid frequent lifting of heavy objects. If you must do heavy lifting, always exhale as you are lifting the weight; don't hold your breath when you lift.
(Reviewed by Prof Don du Toit)