More than half of all Americans will develop hemorrhoids at some point in their lives, typically between the ages of 45 and 65. These little clusters of trouble occur when the tissues supporting the “anal cushions”—structures in the anal canal that play a role in controlling defecation—break down and the blood vessels within them enlarge. There are two kinds: Internal hemorrhoids, which are more common, are found inside the anal canal; external ones form on the edge or just outside it; both types may be present.
Also referred to as piles (from the Latin word pila, which means ball), hemorrhoids are not just a scourge of modern times. As discussed in a 2013 review in Clinical Gastroenterology and Hepatology, they were noted in an ancient Egyptian papyrus, which recommended that an ointment of acacia leaves be placed in the anus as a treatment. References to hemorrhoids are also found in the Old Testament. The afflicted even have a patron saint, St. Fiacre, who is said to have healed hemorrhoids in the 7th century.
The most frequent sign is bleeding, with bright red blood visible on toilet paper, on stool, or in the toilet water after a bowel movement. Internal hemorrhoids are rarely painful, but in addition to bleeding they can cause perianal itching and irritation when they “prolapse” and protrude to the outside—and sometimes fecal soiling, since they can impede the sealing of the anal canal opening. Though external hemorrhoids are often asymptomatic, they are the ones that can be particularly painful when they “thrombose”—that is, form a blood clot. Usually the pain diminishes after 24 to 36 hours, with the clot resolving on its own or through surgical evacuation. Skin tags in the perianal area may be left behind.
The debate continues about what causes hemorrhoids; multiple factors are likely involved. They have been associated with irregular bowel habits (chronic constipation or diarrhea), chronic or prolonged straining while defecating, low-fiber diets, lack of exercise, pregnancy, childbirth, and obesity, as well as both erect posture and prolonged sitting. There may be a genetic component. Aging increases the risk because there is a weakening of supporting structures in the anal canal.
Treatment down under
Hemorrhoids are more of a nuisance than a serious risk. Self-care steps can help manage them. Note, however, that if you have bleeding, you should consult your doctor, since it could be a sign of something else, such as an anal fissure or a more serious problem, such as colorectal cancer.
- Avoid constipation. Eat a high-fiber diet (aim for more than 25 grams of fiber a day, from vegetables, fruits, whole grains, and beans) and drink more fluids. This will increase fecal bulk and help prevent the need to strain. Exercising regularly helps promote bowel movements. If you’re chronically constipated, a fiber supplement such as psyllium or methylcellulose (also sold as bulk laxatives) may be of benefit, as may a stool softener. Don’t use harsh laxatives that cause diarrhea. Ask your doctor or pharmacist if any medications you take could cause constipation.
- Develop good toilet habits. Don’t strain or hold your breath when defecating. Go when you feel the urge, when the internal action of peristalsis can be helpful—that is, don’t put it off for a more “convenient” time. Then, do your business and get up: The toilet is not a place to read or meditate.
- Be careful what you wipe with. Dry toilet paper can be irritating. You might try pre-moistened wipes (don’t flush the wipes even if the package says they are flushable or disposable since they can muck up sewage treatment plants). There are also special cleansing lotions (such as Balneol or generic equivalent); some come in convenient lotion packets. Be sure to pat the area dry after.
- Soaking in hot water may help relieve irritation and itching. You can also try cold compresses or ice packs several times a day, particularly if there is swelling.
- Try to identify if any dietary factors cause flare-ups. Though everyone is different, some common triggers include alcohol and spicy foods.
- For temporary relief of pain, irritation, and itching, you can try over-the-counter creams, ointments, and suppositories marketed for hemorrhoids; stronger formulations are available by prescription. They contain anesthetics, antiseptics, astringents, anti-inflammatories, and/or hydro-cortisone. Witch hazel may be soothing, as may simple petroleum jelly or zinc oxide. But it’s questionable how effective these remedies are, and prolonged use can be problematic—for instance, topical steroids can thin the perianal skin.
- Evidence is generally lacking to support the use of dietary supplements promoted for hemorrhoids. A possible exception is horse chestnut (Aesculus hippocastanum), which, when taken orally or applied topically, may reduce inflammation and the permeability and swelling of blood vessels. More studies are needed to confirm benefits, but extracts appear to be safe for most people (avoid if you have kidney, liver, or gastrointestinal problems, and check with your doctor if you take anti-clotting medication).
What your doctor can do
If you have persistent or prolapsed hemorrhoids that are causing symptoms, your doctor can do an examination to determine the best treatment approach. Medical interventions should be done with careful consideration in people who are immunocompromised, because of increased risk of infection and poor healing.
Several nonsurgical, office-based procedures are used for hemorrhoids. All have potential side effects and risks, though serious complications are rare. Rubber band ligation, the most common and effective one, involves placing an elastic ring or band around the base of the hemorrhoid to cut off its blood supply. More than one treatment may be needed, and it’s contraindicated in people who are on anticoagulants or have a clotting disorder. There is also sclerotherapy (which involves injecting substances to shrink the hemorrhoid), infrared coagulation (the use of heat to create scar tissue, which holds the veins in place), and radiofrequency ablation (to coagulate and evaporate hemorrhoidal tissues). Cryotherapy (freezing the hemorrhoid) is no longer an accepted treatment.
Surgery should be considered only as a last resort when more conservative treatments have failed or if hemorrhoids are very large. Hemorrhoidectomy is effective but is the most painful and carries the most risks, including bleeding, infection, and fecal soilage. Newer surgical techniques, including Doppler-guided hemorrhoid artery ligation and stapled hemorrhoidopexy, are less invasive and may result in less pain and faster recovery.