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Look Up > Conditions > Hemorrhoids
Hemorrhoids
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Imaging
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Surgical Procedures
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
Definition

Hemorrhoids are a varicosity of the rectal venous plexus, classified as either internal or external to the anal verge.

  • External skin tags at the anal verge
  • External hemorrhoids, possibly thrombosed
  • Internal hemorrhoids: first degree—bulging into anal canal and causing bleeding; second degree—prolapsing during defecation and reducing spontaneously; third degree—prolapsing and requiring manual reduction; thrombosed—prolapsing and may be strangulated

Hemorrhoids are uncommon before age 25 (except in women who have been pregnant) and thereafter increase in prevalence by age. After age 50, about 50% of the population have asymptomatic hemorrhoids and 5% have symptomatic hemorrhoids.


Etiology

Hemorrhoids are caused by dilation of veins within the rectal venous plexus. Prolapse in internal hemorrhoids may be caused by shearing forces from passage of large, firm stool or urgent defecation; the prolapse may become entrapped by the internal anal sphincter.


Risk Factors

In most cases, there is no obvious predisposing factor. The following factors increase a patient's risk.

  • Family history
  • Age
  • Irritable bowel syndrome
  • Portal hypertension
  • Pregnancy
  • Constipation
  • Obesity
  • Regular prolonged sitting
  • Congestive heart failure
  • Pelvic inflammatory disease or neoplasms
  • Carcinoma of the rectum

Signs and Symptoms
  • Constipation
  • Straining while defecating
  • Anal fissures
  • Stool mucus

External hemorrhoids:

  • Discomfort, pain
  • Tender perianal lump
  • Possible bleeding
  • Pruritus

Internal hemorrhoids:

  • Intermittent or sustained bleeding
  • Pain (if thrombosed or strangulated)
  • Sensation of fullness (if prolapsed)

Differential Diagnosis
  • Hypertrophied anal papillae from anal fissure, Crohn's disease, or other cause
  • Anal skin tags from previous hemorrhoids or Crohn's disease
  • Prolapsed rectal mucosa
  • Rectal or anal tumors, polyps
  • Endometriosis
  • Condyloma

Diagnosis
Physical Examination

External hemorrhoids appear as a mass outside the anal verge, which may be soft and painless or, if thrombosed, firm and tender with blue coloration. Internal hemorrhoids may be visualized with buttocks retracted and the patient straining. Sigmoidoscopy or colonoscopy may be performed when there is bleeding or if carcinoma is suspected as a cause of the hemorrhoids.


Imaging

In cases of significant or repeated bleeding, barium enema may be performed.


Other Diagnostic Procedures

Since hemorrhoids usually do not produce significant bleeding, question the patient carefully about any bleeding as well as about any constipation experienced. Assess the level of pain, as severe pain may indicate strangulation and the need for immediate surgical referral. Rectal examination. Sigmoidoscopy.


Treatment Options
Treatment Strategy

The goal is to alleviate symptoms and promote healing. Surgery may be needed in severe cases, but most cases respond well to other measures.

  • Treating any underlying condition
  • Preventing direct pressure (positional changes, sitting on an inflatable ring)
  • Avoiding straining on defecation
  • Limiting the amount of time sitting on the toilet
  • Sitz baths with soapy water or Epsom salts 2 to 3 times daily for 15 to 20 minutes
  • Stool softeners and high-fiber foods reduce straining and prolapse
  • Topical preparations for pain or pruritus
  • Analgesics (rectal or systemic) for pain

Drug Therapies
  • Stool softeners, such as docusate sodium (Colace, 200 mg) help reduce straining and prevent hard stools; side effects include nausea, cramps, diarrhea; contraindicated in obstruction and fecal impaction.
  • Bulk laxatives, such as psyllium (Effer-Syllium, Metamucil, 1 to 2 tsp. in water bid to tid, or premeasured packets), help prevent hard stools; side effects include nausea, vomiting, diarrhea; contraindicated in obstruction, abdominal pain, and fecal impaction.
  • Rectal preparations, such as hydrocortisone (Anusol-HC cream, ProctoFoam-HC aerosol, or Wyanoids-HC ointment), relieve itching and discomfort; side effects include local irritation, burning, blistering.
  • Topical anesthetics, such as dibucaine hydrochloride (Nupercainal, applied topically qid as needed) or lidocaine 2.5% (Xylocaine, applied topically tid to qid), relieve rectal discomfort; side effects include contact allergy symptoms.
  • Systemic analgesics, such as oxycodone (Tylox, 5 to 10 mg every 6 hours), for severe pain of thrombosed hemorrhoids; side effects include drowsiness, dizziness, sedation, nausea, vomiting, constipation; contraindicated in addictive personality.

Surgical Procedures

Surgery is indicated if conservative measures fail or for persistent bleeding, severe pain with thrombosis, prolapse, strangulation, ulceration, or perianal infection. Surgical methods include the following.

  • Excision hemorrhoidectomy
  • Rubber band ligation
  • Cryosurgery
  • Injection of sclerosing agents
  • Laser therapy
  • Infrared photocoagulation

Complementary and Alternative Therapies

Nutritional support, topical preparations, and sitz baths may be effective in restoring the integrity of the vasculature, reducing hemorrhoids, and minimizing recurrence.


Nutrition
  • Take time to eat in a relaxed atmosphere, breathing and chewing food thoroughly.
  • Eat smaller, more frequent meals and avoid overeating at one sitting.
  • Decrease low-fiber foods and foods and drinks that cause excess urination (refined foods, sugars, caffeine, alcohol, meat, and dairy products), which leads to harder stools. Increase foods that are high in fiber (fresh fruits and vegetables, whole grains) to soften stools. Increase water intake.
  • Decrease saturated fats (animal products) and increase polyunsaturated fats (cold-water fish, nuts, and seeds).
  • Stewed or soaked prunes, one to three/day have a slightly laxative effect and may help soften stools.
  • Flaxmeal, 1 heaping tsp. in 8 oz. of apple juice, provides fiber and essential fatty acids to help relieve constipation and soothe the digestive tract. Follow with an additional 8 oz. of water. Flaxmeal can be made by grinding flaxseeds in a blender.
  • Vitamin C (1,000 mg bid to tid) supports the integrity of connective tissue.
  • Vitamin E (400 to 800 IU/day) promotes normal clotting and healing.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Flavonoids, a constituent found in dark berries and some plants, help restore the integrity of the vasculature. The following are flavonoids that may be taken in dried extract form as noted.

  • Catechin (150 mg bid to tid), quercetin (250 mg tid to qid), hesperidin (250 mg tid to qid), and rutin (250 mg tid to qid).
  • Rose hips (Rosa canina) and green tea (Camellia sinensis) are also high in flavonoids and either one may be used as a tea. Drink 3 to 4 cups/day.
  • Stone root (Collinsonia canadensis) and horse chestnut (Aesculus hippocastanum) can be used to strengthen blood vessel walls (60 drops tincture bid).

Topical applications may relieve itching and burning, as well as promote healing. Apply one of the following bid to qid.

  • Witch hazel (Hamamelis virginiana) is an astringent that may reduce swelling (commercially available as Tuck's pads).
  • A salve containing comfrey (Symphytum officinale) and/or marigold (Calendula officinalis) soothes and promotes healing.
  • A poultice made from grated potato is astringent and soothing.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

  • Aesculus for burning hemorrhoids with a sensation of a lump in anus and aggravations from walking
  • Aloe for a sensation of pulsation in the rectum with large, external hemorrhoids
  • Collinsonia for chronic, itchy hemorrhoids with obstinate constipation
  • Hamamelis for large bleeding hemorrhoids with raw feeling in the anus

Physical Medicine

Contrast hydrotherapy: Contrast sitz baths may relieve symptoms and promote circulation, relieving pelvic vascular congestion. You will need two basins that can be comfortably sat in. Fill one basin with hot water, one with cold water. Sit in hot water for three minutes, then in cold water for one minute. Repeat this three times to complete one set. Do one to two sets per day three to four days per week.


Acupuncture

Acupuncture may be effective in resolving stagnant, congestive conditions.


Patient Monitoring

If the hemorrhoids do not resolve in one to two weeks, reevaluate the patient's condition and consider additional therapy.


Other Considerations

Patients with severe congestive heart failure, portal hypertension, or debilitating disease should consider options outside of surgery and be treated with general measures.


Prevention

A high-fiber diet and avoiding prolonged sitting may help prevent hemorrhoids in susceptible individuals.


Complications/Sequelae
  • Secondary infection
  • Ulceration
  • Thrombosis

Prognosis

Untreated, the symptoms of hemorrhoids often resolve within days to weeks, though they are likely to recur. If a thrombosed hemorrhoid strangulates, however, it may ulcerate and cause infection.


Pregnancy

Nutritional support, topical herbal applications, and homeopathic remedies for hemorrhoids are safe in pregnancy. Hemorrhoids often resolve after childbirth.


References

Balch JF. Prescription for Nutritional Healing. 2nd ed. Garden City Park, NY: Avery Publishing, 1997.

Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:1347-1361.

Duke JA. The Green Pharmacy. Emmaus, Pa: Rodale Press; 1997.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:181-183.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998.

Olshevsky M, Noy S, Zwang M. Manual of Natural Therapy: A Succinct Catalog of Complementary Treatments. New York, NY: Facts on File; 1989.

Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book; 1994:486-492.

United States Pharmacopeial Convention, Inc. Advice for the Patient. 15th ed. USPDI; 1995:2.


Copyright © 2000 Integrative Medicine Communications

This publication contains information relating to general principles of medical care that should not in any event be construed as specific instructions for individual patients. The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. The reader is advised to check product information (including package inserts) for changes and new information regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.