Hemorrhoids are the most common ailment of the lower digestive tract: About half of people over 50 have them at one time or another, with the risk for hemorrhoids peaking at around age 65. The American Society of Colon and Rectal Surgeons (ASCRS) updated its guidelines last year on the management of hemorrhoids, and the good news is that dependable treatments are available.
What are hemorrhoids?
Hemorrhoids are clusters of swollen and inflamed veins and small arteries around the anus or lower rectum. They appear to form as a result of increased pressure on the blood vessels, such as when straining during bowel movements. Multiple factors can cause the elevated pressure, and all are associated with the development of hemorrhoids. These include chronic constipation or diarrhea, obesity, pregnancy, lack of exercise, liver disease, prostate enlargement, chronic cough, and anal intercourse. Prolonged sitting, including on the toilet, may also increase the risk.
Hemorrhoids come in two forms:
- Internal hemorrhoids form in the lining of the anus and lower rectum and are the most common type. They usually don’t hurt because membranes inside the rectum lack pain-sensitive nerves. Rectal bleeding is the most common symptom. You may see bright red blood on toilet paper after a bowel movement or some blood in the toilet bowl or on the outside of the stool. An internal hemorrhoid that prolapses, or protrudes out of the anal canal, can cause irritation and itching. You might also have fecal incontinence or feel as though you can’t adequately pass a stool.
- External hemorrhoids form near the anus, and you can see and feel them. They are hard lumps that can ache, itch, and bleed. They can be painful because they form in nerve-rich tissue outside the anal canal. The discomfort may become severe enough to make sitting uncomfortable.
Self-care and prevention
Hemorrhoids that aren’t bothersome or cause no symptoms don’t require treatment, but if you’re constipated or straining during bowel movements, increase your fiber and water intake. Most hemorrhoids disappear on their own in 10 to 14 days. If you develop a hemorrhoid, the following steps can help alleviate symptoms-and most of these measures can help prevent hemorrhoids, too. Note that the first three tips apply to external hemorrhoids only:
- Sit in a tub of warm water two or three times a day for 20 minutes, or take a sitz bath, using a special plastic basin that fits over the toilet seat, for 10 minutes.
- Try OTC hemorrhoid treatments, which may provide temporary relief of symptoms. The ASCRS notes that there’s not much evidence that these products work, but some users find they relieve pain and itching. Don’t use topical treatments for more than a week without consulting your doctor; they can cause dry skin, rashes, and in the case of products containing hydrocortisone, thinning of delicate skin.
- Use wet toilet paper or pre-moistened wipes, such as unscented baby wipes or witch hazel wipes, and pat the area dry.
- Add fiber to your diet. Aim for 20 to 30 grams of fiber daily from fruits, vegetables, beans, and whole grains.
- Drink more water-which is essential when you add fiber-to soften stools.
- If you’re chronically constipated, use a bulk-forming laxative, such as psyllium (Metamucil, Konsyl, others), methylcellulose (Citrucel, others), polycarbophil (FiberCon, others), and wheat dextrin (Benefiber, others).
- Ask your doctor whether any medications you take could cause constipation.
- Take a stool softener, such as docusate sodium (Colace, DulcoEase, others).
- Avoid straining during bowel movements and don’t linger longer than necessary on the toilet.
- Exercise regularly, which will help promote bowel movements. If symptoms persist beyond a week, see your doctor. If you’re bleeding from the rectum or have severe pain, see a doctor as soon as possible to rule out other conditions. Never assume that persistent or recurrent rectal bleeding is from hemorrhoids.
In-office and surgical treatments
If conservative measures don’t help, your doctor may suggest an in-office nonsurgical procedure. The most effective and widely used treatment for internal hemorrhoids is rubber band ligation (RBL), which has a cure rate of better than 90 percent, according to the ASCRS. The doctor slips a tiny rubber band around a hemorrhoid to cut off its blood supply. The tissue dies within three to five days and the hemorrhoid drops off. RBL is considered safe for most people, although there’s a rare risk of infection. If you take warfarin, dabigatran, or another anticoagulant, significant bleeding can occur when the hemorrhoid drops off.
Other procedures for internal hemorrhoids include sclerotherapy, during which the doctor injects a chemical solution that shrinks swollen blood vessels into the hemorrhoid. Infrared coagulation and electrocoagulation use heat or an electrical current to cause the hemorrhoid to wither. These techniques are usually painless but may require several sessions and are more expensive than RBL.
A few people have hemorrhoids that don’t respond to conservative therapies. They may need a surgical procedure called hemorrhoidectomy to remove excess tissue. It’s highly effective, but some patients report significant postoperative pain. Other complications may include infection and fecal incontinence.
Less painful alternatives include hemorrhoidopexy, which uses staples to push prolapsed hemorrhoids back into the anus, and Doppler-assisted hemorrhoidal artery ligation, which uses ultrasound to locate hemorrhoids, which are then tied off to stop the blood supply. Neither procedure appears to be as effective as hemorrhoidectomy.