Hemorrhoids

Cause

Hemorrhoids are usually caused by too much pressure on the veins in the pelvic and rectal area. If you sit on the toilet too long (such as taking extra time to read or use your phone) or if you strain to have a bowel movement, the extra pressure causes the veins to swell and stretch, which causes hemorrhoids.

Things that can lead to hemorrhoids include:

• Diarrhea, constipation, and forcing to complete a bowel movement. These may lead to straining and can put more pressure on veins in the anal canal.
• Pregnancy and labor. This is because of greater pressure on the blood vessels in the pelvic area. Straining to push the baby out during labor can make hemorrhoids worse.
• Being overweight. This may put more pressure on the pelvic veins.
• Medical conditions such as severe liver disease, which affects blood flow in the belly and increases pressure on the veins in the anal canal.

Things that make hemorrhoids worse include:

• Sitting or standing for a long time. This may cause blood to pool in the anal area and put more pressure on the veins.
• Frequent heavy lifting or holding your breath when lifting heavy objects. This can suddenly put more pressure on blood vessels.

Prevention

There are things you can do to help prevent hemorrhoids.

• Avoid constipation:
  • Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber.
  • Drink plenty of fluids. If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase the amount of fluids you drink.
  • Get some exercise every day. Build up slowly to 30 to 60 minutes a day on 5 or more days of the week.
  • Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Read and follow all instructions on the label.
  • Schedule time each day for a bowel movement. Having a daily routine may help. Take your time and don't strain when having a bowel movement. Avoid reading or being on your phone while sitting on the toilet. Get off the toilet as soon as you have finished.
• Modify your daily activities.
  • Try not to sit or stand for a long time. If you must sit for a long time, sit on a pillow. Take frequent short walks.
  • Avoid lifting heavy objects, if possible. If you must lift heavy objects, always exhale as you lift the object. Don't hold your breath when you lift.
  • If you are pregnant, sleep on your side. This will lower pressure on the blood vessels in your pelvis. This can help keep hemorrhoids from becoming bigger.
  • If you aren't pregnant, sleep on your stomach with a pillow under your hips to help reduce swelling of hemorrhoids.

Symptoms

Hemorrhoids may cause:

• Rectal bleeding. You may see bright red blood on the toilet paper or in the toilet after a bowel movement. You may see blood on the stool.
• Itching. Hemorrhoids often have some mucus on them. This can irritate the skin near the anus and cause itching.
• Discomfort. You may still feel the urge to pass stool right after having a bowel movement.
• Pain.
  • When a vein within an external hemorrhoid gets irritated, blood may clot under the skin, forming a hard, bluish lump near the anus. This is known as a thrombosed, or clotted, hemorrhoid. Thrombosed hemorrhoids can be very painful.
  • Large internal hemorrhoids that bulge from the anus may be painful if they're squeezed by the anal muscles. They may be very painful if the blood supply to the hemorrhoid is cut off (strangulated hemorrhoid).

What Happens

For some people, hemorrhoids may cause a little discomfort for a short time. Other people have discomfort that comes back when hemorrhoids flare up. Some people struggle with hemorrhoid pain, bleeding, and itching much of their lives. The type of hemorrhoid and amount of discomfort depend on where the hemorrhoids are.

Hemorrhoids often develop during pregnancy because of extra pressure on veins (from the enlarged uterus). During labor, hemorrhoids may start or get worse because of the intense straining and pressure on the anal area while pushing to deliver the baby.

External hemorrhoids

Because external hemorrhoids may not cause any symptoms, you may not be aware that you have hemorrhoids.

When a vein within an external hemorrhoid gets irritated, blood may clot under the skin, forming a hard, bluish lump near the anus. This is known as a thrombosed, or clotted, hemorrhoid. Thrombosed hemorrhoids can be very painful.

Internal hemorrhoids

Small internal hemorrhoids may not grow larger with simple changes to diet and bowel habits to lower the pressure on the veins in the anal canal.

Large internal hemorrhoids may bulge from the anus. After bowel movements, you may have to push them back through the anus. Sometimes large internal hemorrhoids stick out all the time.

In rare cases, hemorrhoids may bulge through the anus and swell. Muscles that control the opening and closing of the anus may cut off a hemorrhoid's blood supply (strangulated hemorrhoid). This may cause the hemorrhoid tissues to die. If this happens, you will feel severe rectal pain and may see blood and pus at the anus. You will need urgent surgery to prevent complications, such as infection.

When to Call a Doctor

If you have hemorrhoids, contact your doctor if:

• Moderate rectal pain has not gone away after 3 to 4 days of home treatment.
• Pain or swelling is severe.
• Tissue from inside the body bulges from the anus and does not return to normal after 3 to 7 days of home treatment.
• A lump inside the anus gets bigger or more painful.

Common symptoms of hemorrhoids may be a sign of other serious health problems. Colon or rectal cancer and other conditions have many of the same symptoms as hemorrhoids. Contact your doctor if you have symptoms like these:

• Stools are black or tarry or change size and shape.
• A lump or bulge that isn't tender and that doesn't go away forms at the anal opening.
• Rectal bleeding becomes heavy or changes color (such as from bright red to dark red).

Watchful waiting

Watchful waiting is a wait-and-see approach. And in most cases, bleeding caused by hemorrhoids should stop after 2 to 3 days. Continue home treatment to prevent bleeding from starting again. Contact your doctor if bleeding:

• Occurs for more than 1 week without improvement.
• Starts again.
• Occurs when there is no reason to expect it.

Exams and Tests

Your doctor can tell if you have hemorrhoids by asking about your past health and doing a physical exam.

You may not need many tests at first if your doctor thinks that your rectal bleeding is caused by hemorrhoids. Your doctor may just examine your rectum with a gloved finger. Or your doctor may use a short, lighted scope to look inside the rectum.

Rectal bleeding can be a sign of a more serious problem, such as colon, rectal, or anal cancer. So if the first exam doesn't show a clear cause of your problems, your doctor may do tests to check for other causes of bleeding. The doctor may use a lighted scope to look at the lower third of your colon. This is called sigmoidoscopy. Or your doctor may use another kind of scope to look at the entire colon. This is called colonoscopy.

Treatment Overview

Most hemorrhoids can be treated with simple changes to diet and bowel habits. Most don't require surgery or other treatment unless the hemorrhoids are very large and painful.

Home treatment

For most external hemorrhoids, home treatment is all you need. The same home treatment can be used for most internal hemorrhoids.

• Slowly add fiber to your meals. Eat foods that have lots of fiber, such as fruits, vegetables, beans, and whole grains.
• Drink plenty of water.
• Get some exercise every day.
• Try over-the-counter medicines. Be safe with medicines. Read and follow all instructions on the label.
  • Use an ointment for a short time to stop itching. You also may use a stool softener.
  • Try suppositories. They can help relieve irritation and lubricate the anal canal during bowel movements.

Nonsurgical procedures

The goal of these procedures is to reduce the blood supply to the hemorrhoid so it shrinks or goes away. The scar tissue left in its place helps support the anal tissue and helps reduce the risk of more hemorrhoids.

These procedures can only be done on internal hemorrhoids. They include:

• Tying off the hemorrhoids with a rubber band. This is called rubber band ligation.
• Using heat, lasers, or electric current to create scar tissue. This is called coagulation therapy.
• Injecting a solution into the hemorrhoid that creates scar tissue. This is called injection sclerotherapy.

Surgery

Surgery to remove hemorrhoids is called hemorrhoidectomy. It can be used:

• For large internal hemorrhoids.
• When you have several small hemorrhoids.
• When other treatments don't help.

Sometimes a combination of treatments (for example, a nonsurgical procedure and surgery) is the best way to treat hemorrhoids.

External hemorrhoids usually aren't removed with surgery unless they are very large and uncomfortable. Or they may be removed if you are having surgery on the anal area for another reason, such as for internal hemorrhoids or a tear (anal fissure). If a blood clot forms in the external hemorrhoid, the clot may need to be removed to relieve pain.

Self-Care

• Keep the anal area clean, but be gentle. Use water and a fragrance-free soap, or use baby wipes or medicated pads such as Tucks.
• Wear cotton underwear and loose clothing to decrease moisture in the anal area.
• Sit in a few inches of warm water (sitz bath) 3 times a day and after bowel movements. The warm water helps with pain and itching. You can also use a sitz bath that fits on the toilet seat.
• Put ice on your anal area several times a day for 10 minutes at a time. Put a thin cloth between the ice and your skin. Follow this by placing a warm, wet towel on the area for another 10 to 20 minutes.
• Avoid constipation:
  • Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber.
  • Drink plenty of fluids. If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase the amount of fluids you drink.
  • Get some exercise every day. Build up slowly to 30 to 60 minutes a day on 5 or more days of the week.
  • Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Read and follow all instructions on the label.
  • Schedule time each day for a bowel movement. Having a daily routine may help. Take your time and do not strain when having a bowel movement. Avoid reading or being on your phone while sitting on the toilet. Get off the toilet as soon as you've finished.
• Be safe with medicines. Read and follow all instructions on the label.
  • If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
  • If the doctor gave you a prescription medicine for pain, take it as prescribed.
  • Store your prescription pain medicines where no one else can get to them. When you are done using them, dispose of them quickly and safely. Your local pharmacy or hospital may have a drop-off site.
  • Take your medicines exactly as prescribed. Contact your doctor if you think you are having a problem with your medicine.

Medicines

Medicines can help relieve symptoms of hemorrhoids. Be safe with medicines. Read and follow all instructions on the label. Over-the-counter (OTC) treatments you can try include:

• Ointments that protect the skin. They form a barrier over hemorrhoids. This can prevent more injury and reduce itching. Examples include zinc oxide and petroleum jelly.
• Suppositories. These can help relieve irritation. They can also lubricate the anal canal during bowel movements. They include Preparation H and Tucks.
• 1% hydrocortisone ointment. This is a type of steroid medicine. It may relieve inflammation and itching.
• Products that numb an area. Although these products help some people, others become allergic to them. Ask your doctor before you use them. These products often have "-caine" in the name or the ingredients.
• OTC pain relievers. Acetaminophen (Tylenol) can help with pain. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve) can help with pain and swelling.