What are hemorrhoids?

Hemorrhoids are one of the most common ailments known. More than half the population will develop hemorrhoids, usually after age 30. Hemorrhoids are often described as "varicose veins of the anus and rectum." A type of anorectal disorder, hemorrhoids are enlarged, bulging blood vessels that occur in the anal canal and anal skin. There are two types of hemorrhoids—external and internal, which refer to their location.

External (outside) hemorrhoids develop near the anus and are covered by very sensitive skin. If a blood clot develops in one of them, a painful swelling may occur. The external hemorrhoid feels like a hard, extremely sensitive lump. If the overlying skin becomes thin or ruptures, bleeding may occur.

Internal (inside) hemorrhoids develop within the anal canal. Internal hemorrhoids are typically not painful, but swelling may be perceived as a dull ache or rectal pressure. The most common symptoms of internal hemorrhoids are painless bleeding and protrusion (prolapse) during bowel movements. In uncommon cases, internal hemorrhoids can cause severe pain if they become permanently "prolapsed" and cannot be pushed back inside.

What causes hemorrhoids?

The exact cause of hemorrhoids is unknown; however, the upright posture of humans alone forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge. Over time, the tissues supporting the veins stretch. As a result, the veins dilate; their walls become thin and bleed. If the stretching and pressure continue, the weakened veins protrude.

Other contributing factors that cause hemorrhoids include:

  • Aging
  • Chronic constipation or diarrhea
  • Pregnancy
  • Heredity
  • Faulty bowel function due to overuse of laxatives or enemas; straining during bowel movements
  • Spending long periods of time (e.g., reading) on the toilet

Hemorrhoids symptoms

If you notice any of the following symptoms, you could have hemorrhoids:

  • Bleeding during bowel movements
  • Protrusion of rectal tissue during bowel movements
  • Itching in the anal area, difficulty keeping the anus clean
  • Pain
  • Sensitive swellings on the anal skin

There is no relationship between hemorrhoids and cancer, but it is important to note that both problems can have symptoms that are similar. Rectal bleeding, changes in bowel habits or the presence of a lump can be a result of cancer; therefore, it is important that all symptoms are investigated by a colorectal surgeon. Please see a colorectal surgeon with the first sign of hemorrhoids symptoms, so that the underlying cause can be properly evaluated and treated. Do not rely on over-the-counter medications or other self-treatments alone as hemorrhoids treatment.

Hemorrhoids treatment

Mild hemorrhoids symptoms can be relieved frequently by increasing the amount of fiber (e.g., fruits, vegetables, breads and cereals) and fluids in the diet. Eliminating excessive straining reduces the pressure on hemorrhoids and helps prevent them from protruding. A sitz bath—sitting in plain warm water for about 10 minutes—can also provide some relief from hemorrhoids symptoms.

With these measures, the pain and swelling of most symptomatic hemorrhoids will decrease in two to seven days, and the firm lump should recede within four to six weeks. In cases of severe, persistent pain, your physician may elect to remove the hemorrhoid containing the clot with a small incision. Performed under local anesthesia as an outpatient, this procedure generally provides relief.

Severe hemorrhoids may require special treatment, much of which can be performed on an outpatient basis. Some hemorrhoids treatment options include:

  • Ligation—The "rubber band treatment" works effectively on internal hemorrhoids that protrude with bowel movements. A small rubber band is placed over the hemorrhoid, cutting off its blood supply. The hemorrhoid and the band fall off in a few days, and the wound usually heals in a week or two. This procedure sometimes produces mild discomfort and bleeding that can last for 36 hours.
  • Hemorrhoidectomy—Hemorrhoid surgery is the best method for the permanent removal of hemorrhoids. It is necessary when clots repeatedly form in external hemorrhoids, ligation fails to treat internal hemorrhoids, the protruding hemorrhoid cannot be reduced or there is persistent bleeding. A hemorrhoidectomy removes excessive tissue that causes the bleeding and protrusion. Hemorrhoid surgery is done under anesthesia any may, depending upon circumstances, require hospitalization and a period of inactivity. Laser hemorrhoidectomies do not offer any advantage over standard operative techniques. They are also quite expensive, and contrary to popular belief, are no less painful.
  • Infrared coagulation can also be used on bleeding hemorrhoids that do not protrude. This method is relatively painless and causes the hemorrhoid to shrink.

Fistula

A perianal abscess is a collection of pus located near the anus or rectum. These can be painful and can make a person feel unwell due to the presence of infection. Perianal abscesses occur as a result of an infection in the small glands just inside the anal opening. When these glands become clogged, bacteria becomes trapped causing infection. A collection of pus, also called an abscess, forms at this site. As this collection grows it tunnels its way to the skin and can either spontaneously drain or require surgical drainage.

An anal fistula, also called fistula-in-ano, is a connection from the inner glands of the anal canal to the outside skin. This connection forms in 50% of people who develop a perianal abscess. It is a remnant tunnel through which bacteria makes its way from the anal gland to the skin. Anal fistula symptoms include persistent drainage of stool from an opening in the perianal skin. This area may feel firm or thicker than surrounding skin due to the presence of a cord.

What causes a perianal abscess or fistula?

It is not known why some people develop perianal abscesses and fistulas in the average population. Crohn's disease is a condition that can present with multiple or recurrent perianal abscesses or fistulas and should be considered as an underlying diagnosis in people who have recurrent or severe fistula disease.

Perianal abscess treatment options

The treatment for a perianal abscess is incision and drainage of the abscess. This is usually done by making a small cut in the skin overlying the abscess and draining the pus. Simple drainage is enough to treat the infection. Placement of a drain may be needed to help continue drainage of pus as the abscess cavity heals.

Half of the time, a fistula tract will form. This means that the site of drainage will not completely close and will continue to drain stool from the opening where the abscess was drained.

Often a closer look at this tract is needed via an examination under anesthesia (EUA). At the time of EUA, the surgeon can identify the opening on the skin and find the connection to the inside of the anal canal. Once this is identified the surgeon will be able to see how much muscle the fistula tunnel goes through. A fistula can cross the anal sphincter muscle (trans-sphincteric), run above the sphincter muscle (supra-sphincteric), or may be superficial to the sphincter muscle (extra-sphincteric). This will determine treatment options.

If the fistula goes through a small amount or no muscle, a "fistulotomy" can be performed where the fistula is cut open and allow it to heal. This the most effective method of removing a fistula; however it carries a small risk of causing loss of bowel control from injury to the sphincter muscle.

If too much muscle is involved or if a person is at high risk for developing loss of bowel control, a fistulotomy is not recommended. A number of procedures are available in this case and your surgeon will discuss the risks and benefits of each when developing your treatment plan.