Hemorrhoids

What are hemorrhoids?

Everyone has cushions of tissue in the anus made of blood vessels, connective tissue and a little muscle. When this tissue becomes swollen and inflamed and causes symptoms, it is called hemorrhoids. They are nothing to be ashamed of and are very common; according to ASCRS, about 5% of people develop symptoms.

• Internal hemorrhoids sit inside the anal canal, where the lining does not feel pain. They usually show up as painless bright red bleeding or as prolapse (tissue that pushes out).
• External hemorrhoids sit under the sensitive skin outside the anus and can be swollen and painful. If a clot forms inside (thrombosis), they become a painful bluish lump.

Anything that raises pressure in the abdomen, such as straining, constipation, diarrhea, pregnancy and long toilet sittings, contributes.

Symptoms

• Bright red blood during a bowel movement or on the tissue paper
• A lump that pushes out and sometimes goes back by itself or has to be pushed back in with a finger
• Itching, burning, mucus discharge, a feeling that the bowel has not emptied fully
• Sudden pain and swelling in a clotted external hemorrhoid

ASCRS grades prolapse: grade 1 does not prolapse, grade 2 prolapses and goes back by itself, grade 3 has to be pushed back in, and grade 4 cannot be pushed back and is often painful.

Blood means hemorrhoids? Not always

Hemorrhoids are a common cause, but we should not decide this ourselves without an examination. ASCRS says more serious conditions such as anal and colorectal cancer have to be ruled out, and the surgeon may want to look higher up with a sigmoidoscopy (about half of the colon) or a colonoscopy (usually the whole colon). The NHS also says painless bleeding from the bottom should be seen sooner. The article “Is every blood in the stool a hemorrhoid?” explains this.

Treatment options

1. Habits and home care (for everyone)

• 20 to 35 grams of fiber a day, sometimes with a fiber supplement (per ASCRS), and 8 to 10 glasses of fluid, preferably water
• Do not sit long on the toilet or strain; stay physically active
• Warm sitz baths several times a day to ease pain
• Simple pain relief suggested by a doctor or pharmacist. The NHS says not to take ibuprofen if the hemorrhoids bleed
• The NHS says a prolapsed hemorrhoid can sometimes be gently pushed back

Most mild cases improve with these steps.

2. Office procedures (for internal hemorrhoids)

If home care is not enough, some procedures are done as outpatients without anesthesia. ASCRS and NIDDK name these:

• Rubber band ligation: a band is placed at the base of the hemorrhoid to cut off its blood supply so it falls off (about 5 to 7 days). One to three bands per session, sometimes several sessions. A few days of pressure or mild pain is normal. People taking blood thinners may not be candidates.
• Injection (sclerotherapy): an irritant solution is injected to shrink the hemorrhoid.
• Infrared or electrical coagulation: heat causes scarring and shrinkage. Several short sessions may be needed.

ASCRS says these methods are mostly suited to grades 1 and 2 and sometimes 3.

3. Clotted external hemorrhoid

Pain usually peaks 48 to 72 hours after it starts and often eases after about 4 to 5 days. If it is getting better, conservative care (warm sitz baths, a cream or pain relief, fiber) is enough. If the pain is severe, the doctor can sometimes remove the clot and the skin over it in the office under local anesthesia.

4. Surgery

ASCRS says fewer than 10% of people with symptoms need surgery, for example with large external hemorrhoids, combined internal and external hemorrhoids, or grade 3 and 4 prolapse when other methods have not worked. The options:

• Hemorrhoidectomy: removing the excess tissue in the operating room under spinal anesthesia, sedation or general anesthesia. It is very effective and recurrence is uncommon, but it involves more pain and time off than office procedures.
• Hemorrhoidopexy (stapled or sutured): lifts the tissue back to its normal position and may reduce pain after the operation.
• The NHS also names tying off the artery that feeds the hemorrhoid.

Which one suits you is decided after an examination and a conversation with the surgeon.

Recovery after an operation

• Pain is expected after surgery. Full return to activity can take 2 to 4 weeks (ASCRS).
• Combined pain relief, aiming to limit opioids. Warm sitz baths 2 to 3 times a day, 10 to 15 minutes each.
• ASCRS says it is best to pass stool within the first 48 hours; fiber, fluids and, if needed, a stool softener help.
• Urination: if you cannot pass urine, you are advised to try sitting in a bath; if that does not work, call the surgeon or go to the emergency department. ASCRS warns that delay may cause permanent bladder damage.

Risks

• Banding: bleeding, pain, infection (uncommon)
• Surgery: more pain, bleeding, infection, trouble passing urine after the operation, and more complications than office procedures
• Any treatment may not remove the hemorrhoids completely, or they may return later

Your own risks are explained by the doctor after an examination.

When to call

• Home care has not worked after about a week
• The hemorrhoid is badly prolapsed or the bleeding keeps coming back
• You have painless bleeding; the NHS says it should be seen soon
• The hemorrhoid discharges pus, you have a fever or you feel generally unwell
• Severe anal pain with fever, abdominal pain or diarrhea

Bleeding that does not stop, a lot of blood or large clots, or severe pain is an emergency: call 115 (Iran’s emergency number) or have someone take you to the emergency department. The full list is on the page “When should I call urgently?”. Every patient’s treatment plan is different; ask your doctor about your own situation.