Hemorrhoids are clusters of veins that lie under the skin of the anus. They extend from inside the anus (internal hemorrhoids) to just outside the anus (external hemorrhoids). Things that cause increased pressure on these veins (pregnancy, prolonged sitting on the toilet, straining, long-term constipation, long-term diarrhea, liver disease, etc.) cause them to enlarge. Everyone has hemorrhoids, but not everyone is bothered by them.
Internal hemorrhoids can bleed when enlarged and inflamed. This is usually red blood that is seen on the toilet paper or on the stool or in the toilet bowl. It is rarely a large amount of blood, but it takes very little blood in the toilet to look like a lot.
Internal hemorrhoids can also grow large enough to prolapse, or fall out of the anus, usually with bowel movements. They can go back in on their own, but sometimes they have to be pushed back in. Rarely, they cannot be pushed back in, in which case you should go to the emergency room.
External hemorrhoids form skin tags when enlarged. These are usually noticed when wiping after bowel movements. If a blood clot forms under an external hemorrhoid, it is said to be “thrombosed”. This tends to happen suddenly and is quite painful. If emergency care is sought promptly, the clot can be removed by a colon and rectal surgeon, and the duration of pain can be shortened.
Many diseases that are much more deadly than hemorrhoids have similar symptoms. Any bleeding from the rectum should be evaluated by a doctor.
History and physical exam are usually adequate to diagnose hemorrhoids. Anoscopy, in which a small tube is inserted into the rectum in the doctor’s office, is the best way to see and evaluate hemorrhoids. It is actually better for hemorrhoids than colonoscopy.
Probably 95% of patients with hemorrhoid trouble can be treated without surgery. The principles of non-operative treatment of hemorrhoids are:
- A high fiber diet or taking a fiber supplement
- Having soft, formed bowel movements
- Avoid sitting on the toilet beyond the time needed for each bowel movement (Do not read or watch TV on the toilet. If you did not really need to go or are not sure if you’re done, get up and come back if needed)
- Use baby wipes instead of toilet paper if you have pain, itching or irritation
Operative Treatment: Minimally Invasive Hemorrhoid Surgery
Minimally invasive techniques to treat hemorrhoids are good for internal hemorrhoids, since that area has nerve endings for pressure but not for pain.
The internal hemorrhoid is lifted up and a tiny rubber band dropped around it, effectively choking it off and scarring it down.
Stapled Hemorrhoidectomy (PPH)
A ring of rectal tissue above the internal hemorrhoids is cut out and stapled together, drawing the hemorrhoids up and cutting off their blood supply. This is most effective for patients with large circumferential internal hemorrhoids. This is performed in the operating room under spinal or general anesthesia.
External hemorrhoids, unfortunately, cannot be treated with “painless” techniques because the skin over them is very sensitive.
Traditional surgery for hemorrhoids involves cutting out an ellipse of skin over the hemorrhoid (usually both the internal and external parts) and sewing it up in a straight line. It is very effective, but the discomfort that it causes means that colon and rectal surgeons reserve it for those who will truly benefit.