Hemorrhoids - Identification, Treatment, Prevention

Almost everyone suffers from hemorrhoids (hemorrhoid disease) at some point in their lives. Many people are embarrassed about pain in the anal area and avoid asking their doctor for help. Read on to find out what hemorrhoids actually are, how you can prevent hemorrhoids, and what you should do if you notice the signs associated with hemorrhoids.

Our digestive system

Our digestive system and bowels are made up of different parts, each of which (stomach - small intestine - large intestine - rectum - anus) assumes specific tasks in breaking down the food we eat. The rectum is located in the lower part of our digestive system. Indigestible food waste is held in the rectal tract until it is eliminated through the anus. The anus has two important ring muscles which control the elimination of waste. These ring muscles’ functions are supported by hemorrhoidal tissue. Hemorrhoidal tissue is a cushion made up of blood vessels located between the rectum and the anus, and which also closes it off. The medical term for this tissue is the hemorrhoidal plexus, commonly referred to as “hemorrhoids”.

That means that everybody has hemorrhoids. Medically, the disease also referred to as “hemorrhoids” or “hemorrhoid disease” occurs when this hemorrhoidal tissue expands and is displaced downward.

Symptoms - Identifying hemorrhoids

Hemorrhoids occur when the interaction between the ring muscles of the anus and the hemorrhoidal tissue is disrupted, or when the cushion of blood vessels is no longer properly irrigated and becomes enlarged. Patients with hemorrhoids mainly present the following symptoms:

bleeding from the anus
itchy anus
a feeling of pressure at the anus
burning anus
pain in the anus

Bleeding from the anus mainly refers to the passage of fresh, bright red blood, which most patients notice directly in their stool or on their toilet paper. Most people are frightened when they see blood in their stool. Bleeding from the anus should be examined by a doctor, but is no cause for premature panic. Patients in the early phase of hemorrhoid disease generally notice general discomfort in the area of the anus. The area is also more sensitive than usual and even reacts to light external irritation. The four stages of hemorrhoids In medicine, hemorrhoid disease is divided into four stages:

Stage 1: In this stage, the swelling of the hemorrhoidal tissue is limited to the internal part of the anus. One of the first signs is bright red blood in the stool or on toilet paper. Itching may also occur. Since there isn't often much pain at this point, these hemorrhoids are generally discovered by chance, during other examinations.

Stage 2: In the second stage of hemorrhoid disease, the hemorrhoidal tissue is even more enlarged. At this point, the hemorrhoids can burn, itch uncomfortably, and ooze. During bowel movement, the blood vessel nodules exit the anus and are pulled back inside the anus automatically after the bowel movement.

Stage 3: In this stage, fingers are required to re-insert the small blood vessel nodules into the anus following bowel movement. The third stage is also characterised by strong itching, burning, and oozing, as well as increased bleeding from the anus.

Stage 4: The hemorrhoidal tissue is now so enlarged that it protrudes out of the internal anal area. The blood vessels no longer retract themselves after bowel movement, and cannot be reinserted with a finger. The hemorrhoids ooze and the patient suffers from uncomfortable itching, a strong burning sensation, as well as a general sensitivity in the anal area. Bleeding after bowel movement also increases.

Treating hemorrhoids correctly

Hemorrhoidal disease is curable and can generally be treated effectively. The earlier the appropriate treatment starts, the faster and more easily hemorrhoid disease can be cured. When taking the patient’s medical history, the doctor will first ask about current symptoms. Next, two different examinations (digital examination and anal endoscopy) can determine if hemorrhoid disease is present, and if so, how far it has progressed. In a digital examination, the anal area is probed using fingers, while during anal endoscopy a special tool is inserted into the anal area to observe any possible changes. Depending on the characteristics, progression, and the patient's individual medical history, the doctor may begin the necessary treatment.

Stage 1 treatment

At this point, the itching can be treated with a special hemorrhoid ointment. New hemorrhoid ointments made from natural ingredients soothe the mucus membranes of the anal area, are antispasmodic, and reduce inflammation. Minor swelling of the hemorrhoidal tissue can be treated with suppositories and creams. Another option is outpatient injections (sclerotherapy). In this process, the doctor injects the hemorrhoids with a special substance, which causes them to shrink back to their original size. Sclerotherapy is painless and only takes a few minutes.

Stage 2 treatment

In this stage, injections can still be used to get hemorrhoids under control. Another form of treatment is rubber band ligation. In this procedure, small rubber bands are tied around part of the hemorrhoidal tissue, which then falls off and is expelled naturally together with the rubber band. This is an outpatient procedure that can be done by the doctor.

Stage 3 treatment

In the third stage, hemorrhoids can either be treated with rubber band ligation or by using what is known as HAL-RAR method. The hemorrhoids can also be surgically treated. The HAL-RAR method is a process that shrinks the blood vessels and pulls the anal tissue around the anus back into place. This intervention is painless and the patient can normally leave the hospital the next day.

Stage 4 treatment

In the fourth stage, surgery is usually required to treat the hemorrhoids. Depending on the patient's symptoms and pain, they can usually be discharged within four days after the intervention. There are a few surgical options, depending on the characteristics and severity of the hemorrhoid disease, that can offer long-term relief from these symptoms. Basically, each operation involves cutting away the prolapsed blood vessels under general anesthesia. The processes differ depending on how the incisions are made and whether the resulting wound is sutured or left open. No-one should feel ashamed about hemorrhoid disease. It is a very common medical problem, which should be identified and, if necessary, treated by a doctor.

Causes of hemorrhoids

There are many possible causes of hemorrhoids. The following factors are amongst the most common causes of pain around the anus:

Low-fibre diets: an unbalanced diet or low-fibre diet can lead to constipation and hard stool. Prolonged periods of excreting hard waste can irritate the hemorrhoidal tissue.
Too little stool: too little stool does not fill the rectal tract properly, which does not allow the intestinal wall to stretch sufficiently. This leads to pushing too hard during bowel movement.
Pushing too hard: pushing too hard during bowel movement increases the pressure on the intestine's blood vessels. This causes blood congestion, which leads the hemorrhoidal tissue to form nodules and bulge forward.
Increased pressure on the blood vessels in the hemorrhoidal tissue through lack of exercise, sitting too long, or excess weight.
Genetic predisposition
Weak connective tissue (due to old age or congenital)
Prolonged use of laxatives
Pregnancy: pregnancy increases pressure in the abdomen, which can obstruct the blood that drains out of the hemorrhoidal tissue. Hormonal changes during pregnancy can also be a cause of hemorrhoid disease.

How to prevent hemorrhoids

The longer hemorrhoids remain undetected, the more difficult and unpleasant treatment becomes. This is why you should consult a doctor as soon as you notice the first signs of hemorrhoid disease. If the initial symptoms are treated appropriately, most patients can avoid a painful operation. However, everyone can take targeted steps to prevent hemorrhoids, and even those with a genetic predisposition can take precautions to avoid (recurring) unpleasant discomfort around the anus.

A healthy lifestyle supports digestion and elimination

A healthy lifestyle not only has long-term positive effects on health, it also supports normal and healthy digestion and elimination. High-fibre diets help maintain the right stool consistency, preventing problems during elimination. Fibre absorbs a lot of water, which then swells up. This creates positive stimuli for intestinal activity and stool production. Fibre-rich foods include fruits, vegetables, whole grain products (wholemeal bread, wheat bran, oat bran, whole grain noodles), legumes (beans, lentils), nuts, cereal flakes (rolled oats, spelt), brown rice, and much more. Just 30 grams of fibre per day is enough, on average, to provide the body with an adequate amount of fibre.

Another preventative measure is to drink enough water. Drinking enough liquids, especially water and unsweetened tea, supports the body's production of normal, soft stool. Movement is also a crucial part of a healthy lifestyle. People who have already developed hemorrhoid disease, however, should avoid sports that strain the pelvic floor (e.g. tennis, aerobics, squash). Good toilet hygiene is another step that can help prevent hemorrhoids. Void your bowels as soon as you feel pressure from the stool. If waste is kept in the rectal tract for too long, the body starts to draw water from it, which can cause it to harden and impede comfortable elimination. Furthermore, don't hurry bowel movement, which could cause you to push excessively. The anus should be thoroughly cleaned after each bowel movement, ideally with soft toilet paper or damp wipes. Regular pelvic floor exercises can help pregnant women avoid hemorrhoid disease. These exercises lighten the load borne by the pelvic floor and reduce the pressure on hemorrhoidal tissue.

Sources:
Dr. M. Wunderlich, Vienna Centre for Intestinal Diseases; Update Hämorrhoidalleiden, Phlebologie & Proktologie 1/2015, MedMedia Verlag und Mediaservice GmbH

Dr. S. Roka, Vienna Medical University Clinic for Surgery; Systemorientierte Therapiekonzepte, Medizin & Wissenschaft 4/2013, MedMedia Verlag und Mediaservice GmbH

Ao. Dr. A. Salat, Vienna Medical University Clinic for Surgery; Nichtvenerische anale, perianale und perineale Erkrankungen, Spektrum Dermatologie 1/2013, MedMedia Verlag und Mediaservice GmbH

Kirsch J. et al., Mannheim Rectal Centre; Die konservative Hämmorhoidalbehandlung, Wiener Medizinische Wochenschrift 2004 (154/3-4: 50:55), Springer Verlag

H.-P. Bruch et al., Lübeck University Clinic; Pathophysiologie des Hämorrhoidalleidens, Chirurg 2001 (72:656-659), Springer Verlag

Autor: Katharina Miedzinska, MSc