Hemorrhoids

What are hemorrhoids?

Hemorrhoids are blood vessels that provide blood supply and nutrients to the anus.  They act as vascular cushions and play some role in anal sensation and continence.  The tissues supporting the hemorrhoids can stretch and become weakened leading to enlargement and protrusion of the hemorrhoids.  There are 2 types of hemorrhoids: internal and external [Figure 1]. Internal hemorrhoids are inside the anus and external hemorrhoids are near the anal opening and are covered by sensitive skin.

Figure 1 – Internal and external hemorrhoids

What causes hemorrhoids?

Hemorrhoidal symptoms are very common and can occur from early childhood to old age.  Both men and women are affected.  During a lifetime, most people will develop hemorrhoidal symptoms to some extent.  Irregular bowel habits with either constipation or diarrhea, excessive straining and sitting on the toilet can aggravate the hemorrhoids and cause symptoms.  Women can develop symptomatic hemorrhoids during pregnancy or after childbirth.

What are the symptoms of hemorrhoids?

The symptoms of hemorrhoids can vary depending on whether a patient has internal, external, or mixed type of hemorrhoids.  Internal hemorrhoids can become inflamed causing bleeding, irritation, pain with a raw sensation inside the anus, itching, protrusion, and a feeling of moisture related to mucus drainage.  External hemorrhoids can itch and cause severe pain if they become clotted (thrombosed hemorrhoids).  Difficulty with maintaining anal hygiene (the need to wipe and clean several times, smearing of the skin) can occur with either type of hemorrhoids.  The bleeding associated with internal hemorrhoids tends to be bright red blood in the toilet bowl or on toilet paper upon wiping.  In some patients the bleeding can be burgundy in color.  While the bleeding is minor in most patients, it can be heavy and can cause iron deficiency anemia.

Internal hemorrhoids are classified from grade 1 to grade 4:

• Grade 1 do not protrude
• Grade 2 protrude to outside the anus but then reduce back inside spontaneously
• Grade 3 protrude and require manual reduction (pushing back inside the anus)
• Grade 4 protrude and cannot be reduced.

How are hemorrhoids diagnosed?

While most patients attribute anal symptoms to hemorrhoids, it is important to note that many other proctologic conditions can present with similar symptoms.  Making the proper diagnosis is critical to provide an effective treatment.  The history and physical examination are important in making the diagnosis.  An office-based examination includes visual inspection, finger palpation of the anus, and Anoscopy or Proctoscopy to look inside the anus and rectum.  Patients with abdominal symptoms, heavy bleeding, anemia, a family history of colorectal cancer or polyps are advised to undergo Colonoscopy. 

How are hemorrhoids treated?

Internal hemorrhoids

Most internal hemorrhoids heal spontaneously within a few days and often without the need for treatment except for avoidance of constipation, adequate water and fiber intake.   When internal hemorrhoids symptoms persist, they are initially treated medically with a combination of remedies:

• Sitz Bath. Sitting in a tub with warm water twice a day. This is especially helpful after bowel movements to clean the area and relax the anal sphincter muscle
• Adequate water intake with at least 8 glasses of water per day to prevent hard stools
• High Fiber Food and Fiber Supplements. A minimum of 25 grams of fiber is recommended a day
• In case of severe constipation, the use of Laxatives and Stool Softeners
• Ointment for pain, healing medications and suppository
• Dr. Maher Abbas will prescribe the best ointment for you
• Flavonoid medications. Medications such as Daflon can reduce the size of the hemorrhoids.

For patients with severe symptoms or those who do not respond to initial treatment, an office-based procedure or a surgical procedure is advisable.  Minimally invasive office-based procedures include Rubber Band Ligation [Figure 2] or Infrared Coagulation [Figure 3]. These procedures are typically helpful in patient with Grade 1 and 2 internal hemorrhoids and in a select group of patients with Grade 3.  Patients with more severe symptoms, Grade 3 and 4 internal hemorrhoids and those with external hemorrhoids are best treated with a surgical procedure.   Several options are available including:

• Minimally Invasive Procedures for Hemorrhoids. If a patient is not a candidate for an office-based minimally invasive procedure such as rubber band ligation or infrared coagulation, several procedures are available in the operating room.  They include laser hemorrhoidal surgery, transanal ligation [conventional or under ultrasound doppler guidance], or hemorrhoidopexy (lifting of the hemorrhoids)
• Excisional hemorrhoidectomy. Various techniques are available to excise hemorrhoids using the traditional electrocautery or Ligasure device

Figure 2 – Rubber band ligation of internal hemorrhoids

Figure 3 – Infrared coagulation for internal hemorrhoids

External hemorrhoids

Some patients who present with a thrombosed (clotted external hemorrhoids) can be managed with the conservative treatment outlined above (sitz bath, ointment, adequate water intake, pain medication, fiber supplementation or laxative).  Patients who present with a very large painful thrombosed external hemorrhoids of a few day duration can benefit from surgical removal of the clotted hemorrhoids.  This can be done under local anesthesia or light sedation in the procedural room or operating room.  During such procedure, only the clotted hemorrhoid is addressed.

Patients with large or multiple external hemorrhoids that are symptomatic (recurrent clotting, difficulty with anal hygiene, itching) can benefit from excisional hemorrhoidectomy along with the internal hemorrhoids.

Dr. Maher Abbas believes in a personalized approach to each patient.  He will recommend the best treatment for the patient to achieve both short as well as long-term success.  For patients with hemorrhoids and an additional proctologic condition such as fissure or fistula, a combined procedure may be needed for relief of anal symptoms.   During the office visit, Dr. Maher Abbas discusses with his patients any proposed procedure(s), success rate, potential risks, and the recovery period.   Most procedures are performed on an outpatient basis (day case) or with an overnight hospital stay.   Most patients can return to work and go back to daily activities within a week of the procedure.  Complete healing of any anal wounds following hemorrhoidal surgery can take up to 3 months for the final result.  Even when the pain and bleeding improve after surgery, it is important to maintain good bowel habits and eat a high-fiber diet to allow for full healing and prevent recurrence.

What happens if hemorrhoids are left untreated?

Hemorrhoids are a nuisance that negatively impacts a person’s quality of life. They are usually not dangerous and do not cause cancer.  Patients with symptomatic hemorrhoids are advised to undergo treatment to avoid worsening of the symptoms and long-term suffering.

Why is it important to seek expert care with a board certified proctologist and colorectal surgeon?

The anal area is a delicate part of the body.  It is important to seek care to heal and to exclude other more serious causes of anal symptoms.  The expertise of the doctor is critical in order to ensure the best result and minimize the risk of relapse, non-healing, infection, and weakness of the muscle.

Dr. Maher Abbas is an expert in the treatment of diseases of the colon, rectum, and anus.  With over a 30-year career in the USA, he has completed advanced surgical training and is American Board Certified in Colon and Rectal Surgery.  Dr. Maher Abbas is a Fellow of the American Society of Colon and Rectal Surgeons.

If you would like to schedule a consultation with Dr. Maher Abbas to discuss your case, click here.