Hemorrhoids: what treatments really help?

Top things to know:

• Everybody naturally has hemorrhoids.
• Hemorrhoidal disease occurs when they become enlarged and cause discomfort.
• A medical check-up is then important, as a self-diagnosis may lead to more serious issues.
• There are effective treatment options depending on the stage of hemorrhoidal disease.

What are hemorrhoids?

There are parts of the body that hardly anyone talks because they find them embarrassing. This also includes the lower end of our intestine: the rectum. In the mucosa of the human rectum, there is a ring-shaped, sponge-like vessel cushion, which serves to support continence. This cushion can swell up or shrink like a cavernous body. The medical term is _hemorrhoidal plexus, _or in short: hemorrhoids.

Hemorrhoids can regulate the anus and seal off air and liquid. Strictly speaking, everybody has hemorrhoids over their sphincter. Hemorrhoids themselves are not a disease, even if they are often considered as such by lay people.

Hemorrhoidal disease is a condition in which the vessels become permanently flaccid for various reasons and cause discomfort. This leads to nodular enlargement of the erectile tissue and the hemorrhoids bulge. When passing stool, pressure is exerted on the hemorrhoids, leading to congestion and bleeding. If an inflammatory reaction also occurs, hemorrhoidal disease is present.

In addition to a presumably age-related weakness of the connective tissue around hemorrhoids, which causes them to fall, a pathologically increased muscular tension (tone) of the sphincter muscle is often to blame for hemorrhoidal disease.

How common are hemorrhoids?

Hemorrhoidal disease is common in the western world. In developed countries, about 70 percent of adults experience hemorrhoid disease at least once during their lifetime.

Worldwide, about 4 percent of the population has hemorrhoidal disease. However, the number of unreported cases is high, as the taboo related to the topic and a sense of shame prevents many people from visiting the doctor.

Hemorrhoids increase with age. The number of new cases is highest between the ages of 45 and 65. Gender plays no role in terms of disease frequency.

What are risk factors and causes for the occurrence of hemorrhoids?

Many risk factors for the occurrence of hemorrhoidal disease are discussed in science, but there is no conclusive explanation yet. Many studies on individual risk factors are also contradictory.

Some things that are discussed in particular include the type of diet (high in fiber or low in fiber), disturbed habits in bowel movements, malfunction of the rectum or anus, genetic predisposition, and an increase in pressure in the abdomen.

Some studies have shown that a low-fiber diet contributes to the development of hemorrhoidal disease. However, too much fiber may be just as unfavorable, as it increases the frequency of bowel movements and promotes increased pressing when passing stool. For example, increased stool frequency may also occur with irritable bowel syndrome of the diarrheal (IBS-D) type.

Furthermore, many of the risk factors have in common that they generally increase abdominal pressure. This includes pressing during bowel movements, as occurs with chronic constipation or irritable bowel syndrome of the constipation (IBS-C) type. But also diarrhea, being overweight or obesity, standing for several hours, and chronic coughing are among the risk factors.

Are there any peculiarities with hemorrhoids in pregnancy?

Even with a pregnancy, an increased incidence of hemorrhoids is controversial.

Reasons for a higher risk may be hormonal changes as well as permanently increased pressure in the mother's abdomen, which could lead to a reduced outflow of blood from the rectal area, on the one hand, and to an increased risk of rectal muscle damage, on the other.

However, some doctors suspect that the symptoms described in the anal area in the context of pregnancy are more due to blood clots of the superficial veins (anal venous thrombosis) or to tears of the skin or mucous membrane of the anus (anal fissures). Some pregnant women may therefore be affected by an incorrect diagnosis.

To alleviate symptoms, pregnant women with hemorrhoids should increase the content of fiber-rich foods and their fluid intake. In addition, training certain habits during bowel movements is helpful. In severe cases, local analgesics, anti-inflammatory drugs, or steroid-containing ointments may be used. Glycerine suppositories, applied 20 minutes before defecation, can help ease bowel movements.

A study showed that warm sitz baths with a saline solution could cure hemorrhoidal disease in 100 percent of all pregnant women. A locally applied ointment only managed this in just under 85 percent of all patients.

What are the symptoms of hemorrhoidal disease?

The symptoms of hemorrhoidal disease depend on the severity and development of the disease. In about 60 percent of those affected, bright blood is found in the stool. Those affected can also notice blood on the toilet paper, in the toilet water and sometimes but rarely in their underwear.

An itch in the area of the anus is also typical (about 55 percent affected). Furthermore, in about 10 percent so-called “stool smearing” occurs, i.e. stool residue in the underwear, which is caused by the anus not sealing completely. This, as well as a moist anus, can lead to an eczema in the anal area. Sometimes there is also a feeling of pressure or the feeling of incomplete evacuation.

On the other hand, pain is atypical for “classic” hemorrhoidal disease. The vascular cushion in the rectum itself has no nerve fibers that could convey pain. Pain develops only when hemorrhoids are pinched or in those in which a blood clot has formed. This happens very rarely.

If such a blood clot occurs in the so-called “outer” hemorrhoids, the medical term for this is a perianal thrombosis. These “outer” hemorrhoids differ from the inner ones in that they consist of veins. Perianal thrombosis is a separate disease that is treated differently than hemorrhoidal disease.

Other causes of anal pain are anal fissures, infections, venereal diseases, abscesses, inflammatory bowel disease, diverticular disease, anal polyps, and anal tumors.

This multitude of possible alternative diagnoses explains why complaints in this area should be clarified by a doctor. If blood is detected in or on the stool, a colonoscopy should always be performed to exclude colon cancer. Self-diagnosis can be dangerous because serious illnesses could be overlooked.

Hemorrhoidal disease itself very rarely causes death. Only one death has been reported so far, which involved a severe bacterial infection.

How are hemorrhoids diagnosed?

As with any other diagnosis, suspicion of hemorrhoids should begin with a doctor's assessment of the condition.

Examination both while resting and during pressing is especially important for the diagnosis of hemorrhoids. Only then can an assessment of the function of the sphincter take place, and the stage of the disease can be determined. Anyone who suspects hemorrhoidal disease should consult a proctologist.

The next steps are the inspection and the palpation of the findings. For this, the patient should either lie on the left side of the body (left lateral position) or in the classic so-called “lithotomy position” for examination of the anus. In the lithotomy position, the patient lies on their back while their legs are spread apart so that the examiner has a good view of the anus.

Finally, a proctoscopy with an endoscope is an integral part of the diagnosis of hemorrhoids. Here, the doctor can especially assess hemorrhoids that are not yet advanced. Other diseases with similar symptoms can be excluded by a proctoscopy.

What are the different degrees of severity and how are they classified?

Classically, hemorrhoids are divided into four different stages. The higher the stage, the more serious the disease. This division is important not only for the diagnostic description, but above all for the choice of the right treatment.

Which treatment options are available for hemorrhoids?

There are many different options for treating hemorrhoids. Depending on the stage and individual characteristics, the correct treatment must be agreed with the attending physician. A distinction is made between treatment methods based on general measures and medication (conservative methods) and those involving surgery (operative methods).

When do hemorrhoids have to be operated on?

Hemorrhoids (stage I) that are not visible from the outside or those that only appear during the stool during pressing and then retreat by themselves (stage II) can be treated conservatively with medication and behavioral changes or with minor surgical interventions.

Generally, vascular nodules visible from the outside, which can be pushed back into the intestine after stool passage (stage III) or those in which manual return is no longer possible (stage IV) usually require surgery.

The discomfort experienced by those affected does not necessarily match what the proctologist sees in the examination. For example, some people can live with stage IV without further restrictions.

When deciding together with the doctor, therefore, subjective and objective aspects of the condition must be taken into account. If the symptoms are tolerable (usually stages I and II), conservative or small outpatient treatments can be tried. As a rule, surgery is necessary only at the transition to grade III. In stage I to III, the patient’s subjective symptoms can be the indicator for an operation.

Conservative treatment of inflamed hemorrhoids

A conservative treatment attempt is always possible, as there are no circumstances in which hemorrhoids need urgent and emergency surgery. Once a patient is diagnosed with hemorrhoidal disease, basic therapy is useful.

This should include the following measures:

• Training in the general habits of bowel movements, in particular avoiding long and intense pressing
• Enough fluid intake
• Sports activity
• High-fiber diet (25 - 30 g per day)
• Warm sitz baths

Sufficient intake of fiber reduces the risk of hemorrhages by half and generally improves the symptoms.

In one study, an increased intake of fiber (psyllium husks) and compliance with simple rules on bowel movement (e.g., no pressing, no more than 3 minutes on the toilet) prevented the need for surgical treatment, even in more advanced stages.

Medicines and ointments for hemorrhoidal disease

Medications are the second component of conservative treatment. These include ointments, creams, pastes, suppositories, and tampons. Various forms of application, especially pain-relieving and anti-inflammatory agents, are included. However, according to current scientific knowledge, these locally effective drugs are only suitable for alleviating the symptoms and do not lead to a permanent cure.

The situation is somewhat different with a drug taken in tablet form: diosmin. According to various studies, in combination with hesperidin from orange and lemon peel, diosmin demonstrably leads to less pain, bleeding and itching.

If all conservative treatment attempts fail, operative treatment of hemorrhoidal disease must be considered.

What methods are available if conservative treatment is not enough?

For non-conservative treatment, various treatment alternatives are available in the form of operative and semi-operative procedures. Basically, the treatment is based on the stage of hemorrhoidal disease. Patients with complaints should be examined individually and provided with a treatment tailored to their case.

Semi-operative methods include sclerotherapy treatment and rubber band ligation, which can be performed on an outpatient basis:

Sclerotherapy: Hemorrhoids in stages I and II can be sclerosed (i.e., hardened). This means that an oily solution (for example, phenol oil) is sprayed three times in three sessions close to the hemorrhoidal blood vessels to restrict blood flow to the vascular cushion (Blanchard’s method). Alternatively, the more strongly sclerosing aethoxysklerol can be injected into the tissue itself, so that it shrinks in the process (Bold method). Sclerotherapy has not been successful in just over 20 percent of cases, according to several studies.

Rubber band ligation: If the hemorrhoids are in stage II or III, they can be treated with a low rate of side effects using rubber band ligation. In this process, enlarged progenitor hemorrhoids are pinched off with small rubber bands. The constricted vascular tissue dies and falls off within a few days.

How are hemorrhoids operated on?

If symptoms progress, and if the hemorrhoids can no longer be pushed into the anal canal, an operation is necessary. The surgical removal of hemorrhoids is referred to as hemorrhoidectomy. Classically, the following procedures are available, following the name of the surgeons who invented them:

• Hemorrhoidectomy following Milligan and Morgan/Ferguson
• Hemorrhoidectomy following Parks
• Stapled hemorrhoidopexy
• Hemorrhoidal artery ligation

What complications can occur with hemorrhoid surgery?

Regardless of which procedure is used to treat hemorrhoids, most patients experience anal pain after surgery. Emptying of the bowels can be painful and cause problems sitting. These complaints can usually be treated with painkillers (analgesics).

It may also happen that the bladder cannot empty itself for some time after the operation, so a bladder catheter must be placed. Subsequent bleeding or infection of the wound may also occur.

Although surgery is carried out with the intent to heal, hemorrhoidal disease may still recur. In addition, the sphincter may be injured in the surgery, resulting in fecal incontinence. The rectum can also become narrowed (rectal stenosis, anal stenosis).