Hemorrhoids (or haemorrhoids), also known as piles, are
vascular
The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...
structures in the
anal canal
The anal canal is the part that connects the rectum to the anus, located below the level of the pelvic diaphragm. It is located within the anal triangle of the perineum, between the right and left ischioanal fossa. As the final functional segment ...
.
In their normal state, they are cushions that help with
stool control.
They become a disease when
swollen
Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...
or
inflamed
Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molecu ...
; the unqualified term ''hemorrhoid'' is often used to refer to the disease.
The signs and symptoms of hemorrhoids depend on the type present.
Internal hemorrhoids often result in painless, bright red
rectal bleeding
Rectal bleeding refers to bleeding in the rectum. There are many causes of rectal hemorrhage, including inflamed hemorrhoids (which are dilated vessels in the perianal fat pads), rectal varices, proctitis (of various causes), stercoral ulcers an ...
when
defecating
Defecation (or defaecation) follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus. The act has a variety of names ranging fro ...
.
External hemorrhoids often result in pain and swelling in the area of the
anus
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
.
If bleeding occurs, it is usually darker.
Symptoms frequently get better after a few days.
A
skin tag
A skin tag, or acrochordon (pl. acrochorda), is a small benign tumor that forms primarily in areas where the skin forms creases (or rubs together), such as the neck, armpit and groin. They may also occur on the face, usually on the eyelids. Tho ...
may remain after the healing of an external hemorrhoid.
While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved.
This may include
constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
,
diarrhea
Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
, and sitting on the
toilet
A toilet is a piece of sanitary hardware that collects human urine and feces, and sometimes toilet paper, usually for disposal. Flush toilets use water, while dry or non-flush toilets do not. They can be designed for a sitting position popu ...
for long periods.
Hemorrhoids are also more common during
pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ca ...
.
Diagnosis is made by looking at the area.
Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should not be ruled out.
Colonoscopy
Colonoscopy () or coloscopy () is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (''e. ...
or
sigmoidoscopy
Sigmoidoscopy (from the Greek term for letter " s/ς" + "eidos" + "scopy": namely, to look inside an "s"/"ς"-like object) is the minimally invasive medical examination of the large intestine from the rectum through to the nearest part of the col ...
is reasonable to confirm the diagnosis and rule out more serious causes.
Often, no specific treatment is needed.
Initial measures consist of increasing
fiber
Fiber or fibre (from la, fibra, links=no) is a natural or artificial substance that is significantly longer than it is wide. Fibers are often used in the manufacture of other materials. The strongest engineering materials often incorporate ...
intake, drinking fluids to maintain hydration,
NSAIDs to help with pain, and rest.
Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence.
A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management.
Surgery is reserved for those who fail to improve following these measures.
Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives.
Males and females are both affected with about equal frequency.
Hemorrhoids affect people most often between 45 and 65 years of age,
and they are more common among the wealthy.
Outcomes are usually good.
The first known mention of the disease is from a 1700 BC Egyptian
papyrus
Papyrus ( ) is a material similar to thick paper that was used in ancient times as a writing surface. It was made from the pith of the papyrus plant, '' Cyperus papyrus'', a wetland sedge. ''Papyrus'' (plural: ''papyri'') can also refer to a ...
.
Signs and symptoms
![M 44 anus 22](https://upload.wikimedia.org/wikipedia/commons/0/0a/M_44_anus_22.jpg)
In about 40% of people with pathological hemorrhoids, there are no significant symptoms.
Internal and external hemorrhoids may present differently; however, many people may have a combination of the two.
Bleeding enough to cause
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...
is rare,
and life-threatening bleeding is even more uncommon.
Many people feel embarrassed when facing the problem
and often seek medical care only when the case is advanced.
External
If not
thrombosed
Thrombosis (from Ancient Greek "clotting") is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel (a vein or an artery) is injured, the body uses platelets (thro ...
,
external hemorrhoids
Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''hemo ...
may cause few problems.
However, when thrombosed, hemorrhoids may be very painful.
Nevertheless, this pain typically resolves in two to three days.
The swelling may, however, take a few weeks to disappear.
A
skin tag
A skin tag, or acrochordon (pl. acrochorda), is a small benign tumor that forms primarily in areas where the skin forms creases (or rubs together), such as the neck, armpit and groin. They may also occur on the face, usually on the eyelids. Tho ...
may remain after healing.
If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.
Lidocaine is a local anesthetic that blocks the calcium channel by blocking the transmission of nerve messages before reaching the central nervous system. As a result, the patient does not feel any pain. In addition, this drug is anti-inflammatory and is effective in treating hemorrhoids. Lidocaine is not recommended if you are pregnant or have a local allergy.
Internal
Internal hemorrhoids usually present with painless, bright red
rectal bleeding
Rectal bleeding refers to bleeding in the rectum. There are many causes of rectal hemorrhage, including inflamed hemorrhoids (which are dilated vessels in the perianal fat pads), rectal varices, proctitis (of various causes), stercoral ulcers an ...
during or following a bowel movement.
The blood typically covers the stool (a condition known as
hematochezia
Haematochezia is the passage of fresh blood through the anus path, usually in or with stools (contrast with melena). The term is from Greek αἷμα ("blood") and χέζειν ("to defaecate"). Hematochezia is commonly associated with lower gastro ...
), is on the toilet paper, or drips into the toilet bowl.
The stool itself is usually normally coloured.
Other symptoms may include mucous discharge, a perianal mass if they
prolapse
In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes call ...
through the anus,
itchiness
Itch (also known as pruritus) is a sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of sensory experience. Itch has many similarities to pain, and while both are unpleasant ...
, and
fecal incontinence
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred ...
.
Internal hemorrhoids are usually painful only if they become thrombosed or
necrotic
Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
.
Causes
The exact cause of symptomatic hemorrhoids is unknown.
A number of factors are believed to play a role, including irregular bowel habits (
constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
or
diarrhea
Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining,
ascites
Ascites is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdominal size, increased weight, ab ...
, an intra-abdominal mass, or
pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ca ...
), genetics, an absence of valves within the hemorrhoidal veins, and aging.
Other factors believed to increase risk include
obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
, prolonged sitting,
a
chronic cough
A cough is a sudden expulsion of air through the large breathing passages that can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three pha ...
, and
pelvic floor dysfunction
Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects ...
.
Squatting while defecating may also increase the risk of severe hemorrhoids. Evidence for these associations, however, is poor.
During pregnancy, pressure from the
fetus
A fetus or foetus (; plural fetuses, feti, foetuses, or foeti) is the unborn offspring that develops from an animal embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal deve ...
on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.
Pathophysiology
![Gross pathology of hemorrhoids](https://upload.wikimedia.org/wikipedia/commons/5/59/Gross_pathology_of_hemorrhoids.jpg)
Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes.
There are three main cushions present in the normal
anal canal
The anal canal is the part that connects the rectum to the anus, located below the level of the pelvic diaphragm. It is located within the anal triangle of the perineum, between the right and left ischioanal fossa. As the final functional segment ...
.
These are located classically at left lateral, right anterior, and right posterior positions.
They are composed of neither
arteries
An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pul ...
nor
veins
Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
, but blood vessels called
sinusoids
A capillary is a small blood vessel from 5 to 10 micrometres (μm) in diameter. Capillaries are composed of only the tunica intima, consisting of a thin wall of simple squamous endothelial cells. They are the smallest blood vessels in the body: ...
,
connective tissue
Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...
, and
smooth muscle
Smooth muscle is an involuntary non-striated muscle, so-called because it has no sarcomeres and therefore no striations (''bands'' or ''stripes''). It is divided into two subgroups, single-unit and multiunit smooth muscle. Within single-unit mus ...
.
Sinusoids do not have
muscle tissue
Muscle tissue (or muscular tissue) is soft tissue that makes up the different types of muscles in most animals, and give the ability of muscles to contract. Muscle tissue is formed during embryonic development, in a process known as myogenesis. Mu ...
in their walls, as veins do.
This set of blood vessels is known as the
hemorrhoidal plexus
The rectal venous plexus (or hemorrhoidal plexus) surrounds the rectum, and communicates in front with the vesical venous plexus in the male, and the vaginal venous plexus in the female.
A free communication between the portal and systemic venous ...
.
Hemorrhoid cushions are important for
continence
Continence may refer to:
*Fecal continence, the ability to control defecation, see Fecal incontinence
*Urinary continence, the ability to control urination, see Urinary incontinence, the involuntary excretion of urine
*Sexual continence, a synony ...
. They contribute to 15–20% of anal closure pressure at rest and protect the
internal
Internal may refer to:
*Internality as a concept in behavioural economics
*Neijia, internal styles of Chinese martial arts
*Neigong or "internal skills", a type of exercise in meditation associated with Daoism
*''Internal (album)'' by Safia, 2016
...
and
external anal sphincter
The external anal sphincter (or sphincter ani externus ) is a flat plane of skeletal muscle fibers, elliptical in shape and intimately adherent to the skin surrounding the margin of the anus.
Anatomy
The external anal sphincter measures about 8 ...
muscles during the passage of stool.
When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure.
Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased.
Increased
internal
Internal may refer to:
*Internality as a concept in behavioural economics
*Neijia, internal styles of Chinese martial arts
*Neigong or "internal skills", a type of exercise in meditation associated with Daoism
*''Internal (album)'' by Safia, 2016
...
and
external anal sphincter
The external anal sphincter (or sphincter ani externus ) is a flat plane of skeletal muscle fibers, elliptical in shape and intimately adherent to the skin surrounding the margin of the anus.
Anatomy
The external anal sphincter measures about 8 ...
pressure may also be involved in hemorrhoid symptoms.
Two types of hemorrhoids occur: internals from the
superior hemorrhoidal plexus
The superior rectal plexus (or superior hemorrhoidal plexus) supplies the rectum and joins in the pelvis with branches from the pelvic plexuses.
The superior rectal plexus is a division of the inferior mesenteric plexus
The inferior mesenteric pl ...
and externals from the inferior hemorrhoidal plexus.
The
pectinate line
The pectinate line (dentate line) is a line which divides the upper two-thirds and lower third of the anal canal. Developmentally, this line represents the hindgut-proctodeum
A proctodeum is the back ectodermal part of an alimentary canal. It ...
divides the two regions.
Diagnosis
Hemorrhoids are typically diagnosed by physical examination.
A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.
A
rectal exam may be performed to detect possible rectal
tumor
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s,
polyps
A polyp in zoology is one of two forms found in the phylum Cnidaria, the other being the medusa. Polyps are roughly cylindrical in shape and elongated at the axis of the vase-shaped body. In solitary polyps, the aboral (opposite to oral) end is ...
, an enlarged
prostate
The prostate is both an Male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found only in some mammals. It differs between species anatomically, ...
, or
abscess
An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...
es.
This examination may not be possible without appropriate
sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
because of pain, although most internal hemorrhoids are not associated with pain.
Visual confirmation of internal hemorrhoids may require
anoscopy
An anoscopy is an examination using a small, rigid, tubular instrument called an anoscope (also called an anal speculum). This is inserted a few inches into the anus in order to evaluate problems of the anal canal. Anoscopy is used to diagnose h ...
, insertion of a hollow tube device with a light attached at one end.
The two types of hemorrhoids are external and internal. These are differentiated by their position with respect to the pectinate line.
Some persons may concurrently have symptomatic versions of both.
If pain is present, the condition is more likely to be an
anal fissure
An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they are painful after defecation, but with chronic ...
or external hemorrhoid rather than internal hemorrhoid.
Internal
Internal hemorrhoids originate above the pectinate line.
They are covered by
columnar epithelium
Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellular ...
, which lacks pain
receptors
Receptor may refer to:
*Sensory receptor, in physiology, any structure which, on receiving environmental stimuli, produces an informative nerve impulse
*Receptor (biochemistry), in biochemistry, a protein molecule that receives and responds to a n ...
.
They were classified in 1985 into four grades based on the degree of
prolapse
In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes call ...
:
* Grade I: No prolapse, just prominent blood vessels
* Grade II: Prolapse upon bearing down, but spontaneous reduction
* Grade III: Prolapse upon bearing down requiring manual reduction
* Grade IV: Prolapse with inability to be manually reduced.
External
External hemorrhoids
Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''hemo ...
occur below the dentate (or pectinate) line.
They are covered proximally by
anoderm
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
and distally by skin, both of which are sensitive to pain and temperature.
Differential
Many anorectal problems, including
fissures
A fissure is a long, narrow crack opening along the surface of Earth. The term is derived from the Latin word , which means 'cleft' or 'crack'. Fissures emerge in Earth's crust, on ice sheets and glaciers, and on volcanoes.
Ground fissure
A ...
,
fistulae
A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow or ...
, abscesses,
colorectal cancer
Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel m ...
,
rectal varices
Anorectal varices are the dilation of collateral submucosal vessels due to backflow in the veins of the rectum. Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anastomosi ...
, and
itching
Itch (also known as pruritus) is a sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of sensory experience. Itch has many similarities to pain, and while both are unpleasan ...
have similar symptoms and may be incorrectly referred to as hemorrhoids.
Rectal bleeding
Rectal bleeding refers to bleeding in the rectum. There are many causes of rectal hemorrhage, including inflamed hemorrhoids (which are dilated vessels in the perianal fat pads), rectal varices, proctitis (of various causes), stercoral ulcers an ...
may also occur owing to colorectal cancer,
colitis
Colitis is swelling or inflammation of the large intestine ( colon). Colitis may be acute and self-limited or long-term. It broadly fits into the category of digestive diseases.
In a medical context, the label ''colitis'' (without qualification) ...
including
inflammatory bowel disease
Inflammatory bowel disease (IBD) is a group of inflammation, inflammatory conditions of the colon (anatomy), colon and small intestine, Crohn's disease and ulcerative colitis being the principal types. Crohn's disease affects the small intestine a ...
,
diverticular disease
Diverticular disease is when problems occur due to diverticulosis, a condition defined by the presence of pouches in the wall of the large intestine (diverticula). This includes diverticula becoming inflamed ( diverticulitis) or bleeding. Colonic ...
, and
angiodysplasia
In medicine (gastroenterology), angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or asce ...
.
If
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...
is present, other potential causes should be considered.
Other conditions that produce an anal mass include
skin tags
A skin tag, or acrochordon (pl. acrochorda), is a small benign tumor that forms primarily in areas where the skin forms creases (or rubs together), such as the neck, armpit and groin. They may also occur on the face, usually on the eyelids. Th ...
,
anal warts
Genital warts are a sexually transmitted infection caused by certain types of human papillomavirus (HPV). They are generally pink in color and project out from the surface of the skin. Usually they cause few symptoms, but can occasionally be pa ...
,
rectal prolapse
A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depend ...
,
polyps
A polyp in zoology is one of two forms found in the phylum Cnidaria, the other being the medusa. Polyps are roughly cylindrical in shape and elongated at the axis of the vase-shaped body. In solitary polyps, the aboral (opposite to oral) end is ...
, and enlarged anal papillae.
Anorectal varices
Anorectal varices are the dilation of collateral submucosal vessels due to backflow in the veins of the rectum. Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anastomosi ...
due to
portal hypertension
Portal hypertension is abnormally increased portal venous pressure – blood pressure in the portal vein and its branches, that drain from most of the intestine to the liver. Portal hypertension is defined as a hepatic venous pressure gradient gr ...
(blood pressure in the
portal venous system
In the circulatory system of animals, a portal venous system occurs when a capillary bed pools into another capillary bed through veins, without first going through the heart. Both capillary beds and the blood vessels that connect them are co ...
) may present similar to hemorrhoids but are a different condition.
Portal hypertension does not increase the risk of hemorrhoids.
Prevention
A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements and getting sufficient exercise.
Spending less time attempting to
defecate
Defecation (or defaecation) follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus. The act has a variety of names ranging fro ...
, avoiding reading while on the toilet,
and losing weight for overweight persons and avoiding heavy lifting are also recommended.
Management
Conservative
Conservative treatment typically consists of foods rich in
dietary fiber
Dietary fiber (in British English fibre) or roughage is the portion of plant-derived food that cannot be completely broken down by human digestive enzymes. Dietary fibers are diverse in chemical composition, and can be grouped generally by the ...
, intake of oral fluids to maintain hydration,
nonsteroidal anti-inflammatory drug
Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
s,
sitz bath
A sitz bath or hip bath is a bath in which a person sits in water up to the hips. It is used to relieve discomfort and pain in the lower part of the body, for example, due to hemorrhoids (piles), anal fissures, perianal fistulas, rectal surgery, ...
s, and rest.
Increased fiber intake has been shown to improve outcomes
and may be achieved by dietary alterations or the consumption of
fiber supplements.
Evidence for benefits from sitz baths during any point in treatment, however, is lacking. If they are used, they should be limited to 15 minutes at a time.
Decreasing time spent on the toilet and not straining is also recommended.
While many
topical agent
A topical medication is a medication that is applied to a particular place on or in the body. Most often topical medication means application to body surfaces such as the skin or mucous membranes to treat ailments via a large range of classes ...
s and
suppositories
A suppository is a dosage form used to deliver medications by insertion into a body orifice where it dissolves or melts to exert local or systemic effects. There are three types of suppositories, each to insert into a different sections: rectal su ...
are available for the treatment of hemorrhoids, little evidence supports their use.
As such, they are not recommended by the
American Society of Colon and Rectal Surgeons The American Society of Colon and Rectal Surgeons (ASCRS), formerly the American Proctologic Society, is a professional society for surgeons specializing in colorectal surgery. It is one of the oldest surgical societies, having been established in ...
.
Steroid
A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
-containing agents should not be used for more than 14 days, as they may cause thinning of the skin.
Most agents include a combination of active ingredients.
These may include a barrier cream such as
petroleum jelly
Petroleum jelly, petrolatum, white petrolatum, soft paraffin, or multi-hydrocarbon, CAS number 8009-03-8, is a semi-solid mixture of hydrocarbons (with carbon numbers mainly higher than 25), originally promoted as a topical ointment for its h ...
or
zinc oxide
Zinc oxide is an inorganic compound with the formula . It is a white powder that is insoluble in water. ZnO is used as an additive in numerous materials and products including cosmetics, food supplements, rubbers, plastics, ceramics, glass, cemen ...
, an analgesic agent such as
lidocaine
Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...
, and a
vasoconstrictor
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vessel ...
such as
epinephrine
Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
.
Some contain
Balsam of Peru
Balsam of Peru or Peru balsam, also known and marketed by many other names, is a balsam derived from a tree known as ''Myroxylon balsamum'' var. ''pereirae''; it is found in El Salvador, where it is an endemic species.
Balsam of Peru is used i ...
to which certain people may be allergic.
Flavonoids
Flavonoids (or bioflavonoids; from the Latin word ''flavus'', meaning yellow, their color in nature) are a class of polyphenolic secondary metabolites found in plants, and thus commonly consumed in the diets of humans.
Chemically, flavonoids ...
are of questionable benefit, with potential side effects.
Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery. Evidence does not support the use of
traditional Chinese herbal treatment.
Several professional organizations weakly recommend the use of
phlebotonics
Diosmin (diosmetin 7-O-rutinoside), a flavone glycoside of diosmetin, is manufactured from citrus fruit peels as a phlebotonic non-prescription dietary supplement used to aid treatment of hemorrhoids or chronic venous diseases, mainly of the le ...
in the treatment of the symptoms of haemorrhoids grade I to II,
although these drugs are not approved in the United States and in Germany,
and restricted in Spain for the treatment of chronic venous diseases.
Procedures
A number of office-based procedures may be performed. While generally safe, rare serious side effects such as
perianal sepsis may occur.
#
Rubber band ligation
Rubber band ligation (RBL) is an outpatient treatment procedure for internal hemorrhoids of any grade. There are several different devices a physician may use to perform the procedure, including the traditional metal devices, endoscopic banding ...
is typically recommended as the first-line treatment in those with grade I to III disease.
It is a procedure in which elastic bands are applied onto internal hemorrhoid at least 1 cm above the pectinate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the pectinate line, intense pain results immediately afterwards.
The cure rate has been found to be about 87%,
with a complication rate of up to 3%.
#
Sclerotherapy
Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'')
is a procedure used to treat blood vessel malformations (vascular malformations) and also malformations of the lymphatic system. A medicine is injected into the vessels, wh ...
involves the injection of a
sclerosing
Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'')
is a procedure used to treat blood vessel malformations ( vascular malformations) and also malformations of the lymphatic system. A medicine is injected into the vessels, ...
agent, such as
phenol
Phenol (also called carbolic acid) is an aromatic organic compound with the molecular formula . It is a white crystalline solid that is volatile. The molecule consists of a phenyl group () bonded to a hydroxy group (). Mildly acidic, it req ...
, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is about 70%.
# A number of
cauterization
Cauterization (or cauterisation, or cautery) is a medical practice or technique of burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, or ...
methods have been shown to be effective for hemorrhoids, but are usually used only when other methods fail. This procedure can be done using
electrocautery
Cauterization (or cauterisation, or cautery) is a medical practice or technique of burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, or ...
,
infrared radiation
Infrared (IR), sometimes called infrared light, is electromagnetic radiation (EMR) with wavelengths longer than those of visible light. It is therefore invisible to the human eye. IR is generally understood to encompass wavelengths from around ...
,
laser surgery
Laser surgery is a type of surgery that uses a laser (in contrast to using a scalpel) to cut tissue.
Examples include the use of a laser scalpel in otherwise conventional surgery, and soft-tissue laser surgery, in which the laser beam vapori ...
,
or
cryosurgery
Cryosurgery is the use of extreme cold in surgery to destroy abnormal or diseased tissue; thus, it is the surgical application of cryoablation. The term comes from the Greek words cryo (κρύο) ("icy cold") and surgery (''cheirourgiki'' – χ ...
. Infrared cauterization may be an option for grade I or II disease.
In those with grade III or IV disease, reoccurrence rates are high.
Surgery
A number of surgical techniques may be used if conservative management and simple procedures fail.
All surgical treatments are associated with some degree of complications, including bleeding, infection,
anal stricture
Anal stricture or anal stenosis is a narrowing of the anal canal. It can be caused by a number of surgical procedures including: hemorrhoid removal and following anorectal wart
Genital warts are a sexually transmitted infection caused by certai ...
s, and
urinary retention
Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladd ...
, due to the close proximity of the rectum to the nerves that supply the bladder.
Also, a small risk of
fecal incontinence
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred ...
occurs, particularly of liquid,
with rates reported between 0% and 28%. Mucosal
ectropion
Ectropion is a medical condition in which the lower eyelid turns outwards. It is one of the notable aspects of newborns exhibiting congenital Harlequin-type ichthyosis, but ectropion can occur due to any weakening of tissue of the lower eyelid. ...
is another condition which may occur after hemorrhoidectomy (often together with anal stenosis).
This is where the anal mucosa becomes everted from the anus, similar to a very mild form of
rectal prolapse
A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depend ...
.
# Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases.
It is associated with significant postoperative pain and usually requires two to four weeks for recovery.
However, the long-term benefit is greater in those with grade III hemorrhoids as compared to rubber band ligation. It is the recommended treatment in those with a
thrombosed external hemorrhoid if carried out within 24–72 hours.
Evidence to support this is weak, however.
Glyceryl trinitrate
Nitroglycerin (NG), (alternative spelling of nitroglycerine) also known as trinitroglycerin (TNG), nitro, glyceryl trinitrate (GTN), or 1,2,3-trinitroxypropane, is a dense, colorless, oily, explosive liquid most commonly produced by nitrating ...
ointment after the procedure helps both with pain and with healing.
# Doppler-guided
transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy.
# Stapled hemorrhoidectomy, also known as
stapled hemorrhoidopexy, involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids.
However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy,
so it is typically recommended only for grade II or III disease.
Epidemiology
It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider.
However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time.
Both sexes experience about the same incidence of the condition,
with rates peaking between 45 and 65 years.
They are more common in
Caucasians and those of higher socioeconomic status.
Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes.
Only a small proportion of persons end up needing surgery.
History
![11th century English surgery](https://upload.wikimedia.org/wikipedia/commons/6/63/11th_century_English_surgery.jpg)
The first known mention of this disease is from a 1700 BCE Egyptian
papyrus
Papyrus ( ) is a material similar to thick paper that was used in ancient times as a writing surface. It was made from the pith of the papyrus plant, '' Cyperus papyrus'', a wetland sedge. ''Papyrus'' (plural: ''papyri'') can also refer to a ...
, which advises: "... Thou shouldest give a recipe, an ointment of great protection;
acacia
''Acacia'', commonly known as the wattles or acacias, is a large genus of shrubs and trees in the subfamily Mimosoideae of the pea family Fabaceae. Initially, it comprised a group of plant species native to Africa and Australasia. The genus na ...
leaves, ground, titurated and cooked together. Smear a strip of fine linen there-with and place in the anus, that he recovers immediately."
In 460 BCE, the
Hippocratic corpus
The Hippocratic Corpus (Latin: ''Corpus Hippocraticum''), or Hippocratic Collection, is a collection of around 60 early Ancient Greek medical works strongly associated with the physician Hippocrates and his teachings. The Hippocratic Corpus cove ...
discusses a treatment similar to modern rubber band ligation: "And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not foment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of
Hellebore
Commonly known as hellebores (), the Eurasian genus ''Helleborus'' consists of approximately 20 species of herbaceous or evergreen perennial flowering plants in the family Ranunculaceae, within which it gave its name to the tribe of Helleboreae. ...
."
Hemorrhoids may have been described in the
Bible
The Bible (from Koine Greek , , 'the books') is a collection of religious texts or scriptures that are held to be sacred in Christianity, Judaism, Samaritanism, and many other religions. The Bible is an anthologya compilation of texts of a ...
, with earlier English translations using the now-obsolete spelling "
emerods".
Celsus
Celsus (; grc-x-hellen, Κέλσος, ''Kélsos''; ) was a 2nd-century Greek philosopher and opponent of early Christianity. His literary work, ''The True Word'' (also ''Account'', ''Doctrine'' or ''Discourse''; Greek: grc-x-hellen, Λόγ ...
(25 BCE – 14 CE) described ligation and excision procedures and discussed the possible complications.
Galen
Aelius Galenus or Claudius Galenus ( el, Κλαύδιος Γαληνός; September 129 – c. AD 216), often Anglicized as Galen () or Galen of Pergamon, was a Greek physician, surgeon and philosopher in the Roman Empire. Considered to be one of ...
advocated severing the connection of the arteries to veins, claiming it reduced both pain and the spread of gangrene.
The
Susruta Samhita
The ''Sushruta Samhita'' (सुश्रुतसंहिता, IAST: ''Suśrutasaṃhitā'', literally "Suśruta's Compendium") is an ancient Sanskrit text on medicine and surgery, and one of the most important such treatises on this subje ...
(4th–5th century BCE) is similar to the words of Hippocrates, but emphasizes wound cleanliness.
In the 13th century, European surgeons such as
Lanfranc of Milan
Lanfranc of Milan (–1315), variously called , or , was an Italian cleric, surgeon who set up practice in France. Lanfranc was appointed personal physician to Philip IV of France and in 1296 published a thesis on surgery under the title Chirurg ...
,
Guy de Chauliac
Guy de Chauliac (), also called Guido or Guigo de Cauliaco ( 1300 – 25 July 1368), was a French physician and surgeon who wrote a lengthy and influential treatise on surgery in Latin, titled '' Chirurgia Magna''. It was translated into many othe ...
,
Henri de Mondeville
Henri de Mondeville (1320) was a medieval French surgeon who made a significant number of contributions to anatomy and surgery, and was the first Frenchman to author a surgical treatise, ''La Chirurgie'' (1306-1320). Very little is known about the ...
, and John of Ardene made great progress and development of the surgical techniques.
In medieval times, hemorrhoids were also known as
Saint Fiacre
Saint Fiacre ( ga, Fiachra, la, Fiacrius) is the name of three different Irish saints, the most famous of which is Saint Fiacre of Breuil (c. AD 600 – 18 August 670), the Catholic priest, abbot, hermit, and gardener of the seventh century w ...
's curse after a sixth-century saint who developed them following tilling the soil.
The first use of the word "hemorrhoid" in English occurs in 1398, derived from the
Old French
Old French (, , ; Modern French: ) was the language spoken in most of the northern half of France from approximately the 8th to the 14th centuries. Rather than a unified language, Old French was a linkage of Romance dialects, mutually intelligib ...
"emorroides", from
Latin
Latin (, or , ) is a classical language belonging to the Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through the power of the ...
''hæmorrhoida'', in turn from the Greek αἱμορροΐς (''haimorrhois''), "liable to discharge blood", from αἷμα (''haima''), "blood" and ῥόος (''rhoos''), "stream, flow, current", itself from ῥέω (''rheo''), "to flow, to stream".
Notable cases
Hall-of-Fame baseball player
George Brett
George Howard Brett (born May 15, 1953) is an American former professional baseball player who played all of his 21 seasons in Major League Baseball (MLB) as a third baseman for the Kansas City Royals.
Brett's 3,154 career hits are second-mos ...
was removed from a game in the
1980 World Series
The 1980 World Series was the World Series, championship series of Major League Baseball's (MLB) season. The 77th edition of the World Series, it was a best-of-seven playoff played between the National League (NL) champion 1980 Philadelphia Phill ...
due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping, "My problems are all behind me". Brett underwent further hemorrhoid surgery the following spring. Conservative political commentator
Glenn Beck
Glenn Lee Beck (born February 10, 1964) is an American conservative political commentator, radio host, entrepreneur, and television producer. He is the CEO, founder, and owner of Mercury Radio Arts, the parent company of his television and rad ...
underwent surgery for hemorrhoids, subsequently describing his unpleasant experience in a widely viewed 2008
YouTube
YouTube is a global online video platform, online video sharing and social media, social media platform headquartered in San Bruno, California. It was launched on February 14, 2005, by Steve Chen, Chad Hurley, and Jawed Karim. It is owned by ...
video. Former U.S. President
Jimmy Carter
James Earl Carter Jr. (born October 1, 1924) is an American politician who served as the 39th president of the United States from 1977 to 1981. A member of the Democratic Party (United States), Democratic Party, he previously served as th ...
had surgery for hemorrhoids in 1984. Cricketers
Matthew Hayden
Matthew Lawrence Hayden (born 29 October 1971) is an Australian cricket commentator and former cricketer. His career spanned fifteen years. Hayden was a powerful and aggressive left-handed batting order (cricket)#opening batsman, opening batsm ...
and
Viv Richards
Sir Isaac Vivian Alexander Richards (born 7 March 1952) is an Antiguan retired cricketer who represented the West Indies cricket team between 1974 and 1991. Batting generally at number three in a dominant West Indies side, Richards is widely ...
have also had the condition.
References
External links
*
*
{{Authority control
Diseases of veins, lymphatic vessels and lymph nodes
Digestive diseases
Medical conditions related to obesity
Colorectal surgery
Rectum
Anus
Wikipedia medicine articles ready to translate (full)
Acute pain
Wikipedia emergency medicine articles ready to translate