"I have avoided going to the
doctor for my hemorrhoids by using over the counter
remedies, but it is becoming unbearable. I eat a high-fiber
diet but that has not helped either. Is there anything
else I can do before I make that embarrassing doctor's
appointment?"
Hemorrhoids are swollen veins just inside the anus.
They produce pain if they come out of the anus with
a bowel movement because they are constricted. Once
they come out, the skin around them and the veins
themselves can become inflamed.
It sounds as if you have tried diet modification
to prevent constipation. What other creams or rectally
applied compounds have you used? It would also be
good to know what your occupation is and what your
weight is. These can be factors that contribute to
development of hemorrhoids.
What causes hemorrhoids and their symptoms?
Sometimes the veins just inside the anus become swollen
if there is pressure on the vein itself to prevent
blood flow from returning to the heart. The veins
may become constricted by a large amount of stool
that stays in the rectum just above the anus in someone
who has constipation. A job in which a person sits
all of the time can produce hemorrhoids just as a
person who is on their feet may get varicose veins
of the leg. Straining and sitting a long time on the
toilet trying to have a bowel movement is also thought
to produce hemorrhoids. Chronic diarrhea causes hemorrhoids
by the same mechanism.
Heavy lifting or a chronic cough from asthma, smoking
or any chronic lung disease causes hemorrhoids because
of increased intraabdominal pressure. This increased
pressure is just like straining at stool in that the
pressure obstructs the flow of blood through the veins
causing them to swell. Obesity can also cause an increased
intraabdominal pressure just by the weight of the
abdominal wall. It is associated also with hemorrhoids.
Pregnancy produces swollen veins and hemorrhoids due
to a moderately increased blood volume, and also because
the pregnancy itself may slightly block some of the
return venous blood flow from the lower pelvis and
rectum. Rectoceles can also be associated with hemorrhoids
when the rectal wall protrudes out of the vagina and
obstructs the veins in the wall of the rectum below.
If one or more of the swollen veins becomes "scratched"
by hard stool, it may cause bright red bleeding. Often
this is painless bleeding and comes out in the toilet
bowl water or on toilet paper. Most bright red rectal
bleeding is due to hemorrhoids but there is always
concern that a rectal cancer could be present so a
rectal exam by a physician needs to be performed if
there is bleeding.
Two sets of anorectal veins can become dilated. Internal
and external hemorrhoidal veins. The external veins
are just inside the anal sphincter while the internal
veins are slightly higher up in the rectum. If a large
internal rectal vein prolapses and falls through the
anal sphincter muscle, the vein becomes even more
distended and then very painful. Most of the pain
of hemorrhoids is due to prolapsed internal hemorrhoid
veins or external veins that are swollen.
How can I treat the itching and pain of hemorrhoids?
Anal itching occurs because the surrounding skin tissue
is traumatized due to excessive use of harsh toilet
paper, a secondary irritant or allergic dermatitis
due to soaps and creams used around the anus, and/or
secondary yeast or parasite infections of the surrounding
anal skin. The best treatment for this is avoidance
of any substance touching the perianal skin other
than water from a shower or bath. Soap does not need
to be used to wash bacteria away; water is sufficient.
An exception to this rule is that perhaps a non scented
petrolatum gel or hemorrhoidal cream can be applied
to the skin around the anus to protect from irritation.
This is especially important if chronic diarrhea or
loose stools result in greater soiling of the anal
skin.
Almost always, a painful hemorrhoid is one that has
prolapsed out of the anus. The treatment is:
prevent the prolapse of the hemorrhoid
replace the prolapsed hemorrhoid inside the anus
Preventing the prolapse of a hemorrhoid is aided
by avoiding any constipation and also lubricating
the stool. Glycerin rectal suppositories can provide
lubrication that prevents hemorrhoid friction and
irritation . Agar agar, a sea plant, can be used as
a nutritional supplement both as a bulking agent as
well as lubricating the stool. Cod liver oil, Senekot
S ® and flaxseed are other supplements that can
help provide a lubricated stool.
If the hemorrhoids prolapse only with a bowel movement,
replacement of the hemorrhoid can be done manually
by lubricating your finger with petrolatum gel and
using it to push the vein or veins back inside the
anal sphincter. If you are squeamish about using your
finger inside the rectum without a covering, you can
use a disposable glove or finger cot coated with the
petrolatum gel. While it is slightly painful to push
the veins back in, the relief is almost instantaneous
and lasts until the next bowel movement. If the veins
stay out all of the time or they come back out even
without a bowel movement, then you must see your physician
about further treatment.
Is high fiber diet enough or are there any other
ways to keep the stool soft?
Once the rectal veins have been stretched out and
hemorrhoids created, they are very difficult to get
rid of completely. They tend to recur with less and
straining than it took to produce them initially.
If chronic constipation has a role in creating or
maintaining the hemorrhoids, then diet to avoid constipation
is essential in treating them. See our article for
further discussion on treatment and avoidance of constipation.
If you have a job involving sitting for long periods
of time, make sure you get up and walk around for
a short time at least every 45-60 minutes. If your
job involves heavy lifting, practice breathing in
and out slowly while lifting. This prevents you from
holding your breath and causing a rise in intraabdominal
pressure when you lift. If a chronic cough is part
of your cause, do your best to get your lung disease
in the best shape possible. Also practice Kegel exercises
that emphasize the rectal sphincter rather than the
perivaginal muscles. This will help protect the hemorrhoids
from prolapsing during a cough.
If pregnancy is the main etiology of the hemorrhoids,
there is not much you can do beyond avoiding constipation,
until the pregnancy ends. Almost always they go away
then. When rectoceles are associated with hemorrhoids,
surgical repair often (but not always) results in
resolution of the dilated veins.
Can any of the salves, suppositories or creams
applied to the rectum make the hemorrhoids go away?
Most creams or suppositories used in the treatment
of hemorrhoids are directed at reducing the pain and
itching symptoms. They do not make the dilated veins
go away but merely give you relief until the precipitating
cause is eliminated and the body heals them itself.
The most effective creams contain hydrocortisone (e.g.,
Anusol-HC®[2.5%]) or some other steroid. These
are only available by prescription although there
are preparations with low doses of steroids (1% hydrocortisone)
that do not require prescription.
Medicated pads containing witch hazel (Tucks®)
is a popular over-the-counter treatment especially
for the itching, burning and skin irritation. Another
popular non prescription medication is Preparation
H® which contains phenylephrine, 0.25%, a vasoconstrictor
that makes the veins smaller.
There are some natural, herbal creams that may also
be effective.
How does a doctor treat hemorrhoids?
Physician's will advise you of all of the preventive
and home treatment modalities as listed above. In
addition, they may prescribe various creams or suppositories
containing pharmaceutical ingredients that not only
relieve the pain (usually using steroids), but also
that have direct action on the dilated veins. Various
components have been reported such as nitroglycerin
paste , calcium dobesilate with steroid and local
anesthetic and even a standardized leech extract .
The mainstay of treatment however is a topical preparation
usually containing steroid and local anesthetic.
Surgical treatment is usually reserved for large
hemorrhoids, chronic anal fissures or perirectal abscesses.
Surgical treatment can include banding of the veins,
surgical excision, laser or electrocautery and even
injection of the veins with sclerosing agents that
scar shut the hemorrhoid.
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