Patient information: Hemorrhoids

HEMORRHOIDS OVERVIEW

Hemorrhoids are enlarged or swollen veins in the lower rectum. The most common symptoms of hemorrhoids are rectal bleeding, itching, and pain. You may be able to see or feel hemorrhoids around the outside of the anus, or they may be hidden from view, inside the rectum (figure 1A-B).

Hemorrohoids are common, occuring in both men and women. Although hemorrhoids do not usually cause serious health problems, they can be annoying and uncomfortable. Fortunately, treatments for hemorrhoids are available and can usually minimize the bothersome symptoms.

More detailed information about hemorrhoids is available by subscription. (See "Clinical features of hemorrhoids" and "Treatment of hemorrhoids".)

HEMORRHOID SYMPTOMS

Hemorrhoids are more common in people who are older and in those who have diarrhea, pelvic tumors, during or after pregnancy, and in people who sit for prolonged periods of time and/or strain (push hard) to have a bowel movement.

Symptoms of hemorrhoids can include the following:

• Painless rectal bleeding
• Anal itching or pain
• Tissue bulging around the anus
• Leakage of feces or difficulty cleaning after a bowel movement

Rectal bleeding — Many people with hemorrhoids notice bright red blood on the stool, in the toilet, or on the toilet tissue after a bowel movement. The amount of blood is usually small. However, even a small amount of blood in the toilet bowl can cause the water to appear bright red, which can be frightening. Less commonly, bleeding can be heavy.

While hemorrhoids are one of the most common reasons for rectal bleeding, there are other, more serious causes. It is not possible to know what is causing rectal bleeding unless you are examined. If you see bleeding after a bowel movement, call your healthcare provider. (See "Patient information: Blood in the stool (rectal bleeding) in adults".)

Itching — Hemorrhoids commonly cause itching and irritation of skin around the anus.

Pain — Hemorrhoids can become painful. If you develop severe pain, call your healthcare provider immediately because this may be a sign of a serious problem.

HEMORRHOID DIAGNOSIS

To diagnose hemorrhoids, your clinician will examine your rectum and anus, and may insert a gloved finger into the rectum. Further testing may include a procedure that allows your healthcare provider to look inside the anus (called anoscopy) or the lower colon (sigmoidoscopy). (See "Patient information: Flexible sigmoidoscopy".)

INITIAL HEMORRHOID TREATMENT

One of the most important steps in treating hemorrhoids is avoiding constipation (hard or infrequent stools). Hard stools can lead to rectal bleeding and/or a tear in the anus, called an anal fissure. In addition, pushing and straining to move your bowels can worsen existing hemorrhoids and increase the risk of developing new hemorrhoids. (See "Patient information: Anal fissure".)

Fiber supplements — Increasing fiber in your diet is one of the best ways to soften your stools. Fiber is found in fruits and vegetables. The recommended amount of dietary fiber is 20 to 35 grams per day (table 1A-C). (See "Patient information: High fiber diet".)

Several fiber supplements are available, including psyllium (Konsyl®; Metamucil®; Perdiem®), methylcellulose (Citrucel®), calcium polycarbophil (FiberCon®; Fiber-Lax®; Mitrolan®), and wheat dextrin (Benefiber®). Start with a small amount and increase slowly to avoid side effects.

Laxatives — If increasing fiber does not relieve your constipation, or if side effects of fiber are intolerable, you can try a laxative (table 2).

Many people worry about taking laxatives regularly, fearing that they will not be able to have a bowel movement if the laxative is stopped. Laxatives are not "addictive" and using laxatives does not increase your risk of constipation in the future. Instead, using a laxative may actually prevent long-term problems with constipation. (See "Patient information: Constipation in adults".)

Warm sitz baths — During a sitz bath, you soak the rectal area in warm water for 10 to 15 minutes two to three times daily. Sitz baths are available in most drugstores. It is also possible to use a bathtub and sit in 2 to 3 inches of warm water. Do not add soap, bubble bath, or other additives in the water. Sitz baths work by improving blood flow and relaxing the muscle around the anus, called the internal anal sphincter.

Topical treatments — Various creams and suppositories are available to treat hemorrhoids, and many are available without a prescription. Pain-relieving creams and hydrocortisone rectal suppositories may help relieve pain, inflammation, and itching, at least temporarily.

You should not use hemorrhoid creams and suppositories, particularly hydrocortisone, for longer than one week, unless your healthcare provider approves.

MINIMALLY INVASIVE TREATMENT

If you have bothersome hemorrhoids after using conservative measures, you may want to consider a minimally invasive procedure. Most procedures are performed as a day surgery. The following procedures are intended for treatment of internal hemorrhoids.

Rubber band ligation — Rubber band ligation is the most widely used procedure. It is successful in approximately 70 to 80 percent of patients.

Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Many patients report a sense of "tightness" after the procedure, which may improve with warm sitz baths. Patients are encouraged to use fiber supplements to avoid constipation.

Delayed bleeding may occur when the rubber band falls off, usually two to four days after the procedure. In some cases, a raw and sore area develops five to seven days following the procedure. Other less common complications of rubber band ligation include severe pain, thrombosis of other hemorrhoids, and localized infection or pus formation (abscess). Rubber band ligation rarely causes serious complications.

Laser, infrared, or bipolar coagulation — These methods involve the use of laser or infrared light or heat to destroy internal hemorrhoids.

Sclerotherapy — During sclerotherapy, a chemical solution is injected into hemorrhoidal tissue, causing the tissue to break down and form a scar. Sclerotherapy may be less effective than rubber band ligation.

HEMORRHOID SURGERY

If you continue to have hemorrhoids despite conservative or minimally invasive therapies, you may require surgical removal of hemorrhoids (hemorrhoidectomy). Surgery is the treatment of choice for patients with large internal hemorrhoids.

Hemorrhoidectomy involves surgically removing excess hemorrhoidal tissue. It is successful in 95 percent of patients.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Blood in the stool (rectal bleeding) in adults
Patient information: Flexible sigmoidoscopy
Patient information: Anal fissure
Patient information: High fiber diet
Patient information: Constipation in adults

Professional Level Information:
Approach to the patient with anal pruritus
Clinical features of hemorrhoids
Etiology and evaluation of chronic constipation in adults
Etiology of lower gastrointestinal bleeding in adults
Treatment of constipation in adults
Treatment of hemorrhoids

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/hemorrhoids.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/hemorrhoids/)

• American Society of Colon and Rectal Surgeons

      (www.fascrs.org/patients/conditions/hemorrhoids/)

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