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Proctology

Hemorrhoids

Hemorrhoids

What Are Hemorrhoids?

Hemorrhoids, also known as piles, are vascular cushions contained within the submucosal space of the anal canal. They are swollen veins in the anus that can cause discomfort, itching, bleeding, and pain.

The psychological role of these cushions: help to maintain fecal continence by ensuring airtight closure of anal canal.

Pathophysiology: chronic venous engorgement (overflow) + loss of connective tissue support -> causing displacement, prolapse, bleeding, and symptomatic hemorrhoids.

They are very common, especially among adults, and can develop inside the anal canal (internal hemorrhoids) or outside at the anal verge (external hemorrhoids).

Internal hemorrhoids are usually not visible, while external ones can often be seen or felt as small lumps near the anal opening.

Common Symptoms of Hemorrhoids

Not everyone with hemorrhoids will have symptoms. When they do appear, they may include:

  • Itching or irritation around the anus and inside the anorectal canal
  • Bleeding during or after bowel movements
  • Burning sensation
  • Pain or discomfort, especially when sitting
  • Swelling or lumps (prolapse) near the anus that may feel tender
  • Swollen hemorrhoids may cause the patient to feel as if they are sitting on a foreign object
  • A feeling of fullness or incomplete emptying after a bowel movement
  • Mucus discharge
  • Difficulty with perineal hygiene
  • Prolapsed hemorrhoid may cause wetness, itching, and soiling of the undergarments
  • Palpable mass in the anal area (thrombosed or strangulated hemorrhoid)

If you notice bleeding, pain, or dark, tarry stools, it’s important to see a doctor rule out other causes such as fissures, infections, tumors or more serious conditions.

What Causes Symptomatic Hemorrhoids?

Hemorrhoids can develop due to increased pressure in the lower rectum, which can cause dilatation, congestion, and weakening of supporting tissues. Also, when the venous blood outflow is impeded (by straining, constipation, pregnancy, or portal hypertension), the pressure will rise.

Common causes include:

  • Chronic constipation
  • Diarrhea
  • Hard dry stools
  • Excessive straining during bowel movements
  • Sitting for long periods (on the toilet)
  • Pregnancy and childbirth
  • Obesity
  • Heavy weightlifting
  • Chronic cough
  • Low-fiber diet
  • Dietary and behavioral features
  • Pelvic mass
  • Pelvic floor dysfunction
  • Ascites

Classification of hemorrhoids:

Grade I.: Internal hemorrhoids bulge into the anus without prolapse

Grade II.: Internal hemorrhoids prolapse during defecation, spontaneously reduce

Grade III.: Internal hemorrhoids prolapse, requiring manual reduction

Grade IV.: Hemorrhoids prolapsed and irreducible

How to Manage Hemorrhoids at Home

In case of symtoms do not self-medicate. Seek an expert opinion.

Most mild cases can improve with simple lifestyle changes:

  • Eat more fibers (fruits, vegetables, and whole grains) to soften stool
  • Stay hydrated by drinking plenty of water (2000-3000ml per day)
  • Avoid straining during bowel movements
  • Don’t spend more than 3-5 minutes on the toilet
  • Use rather “shattaf” or bidet, then dry the area with soft towel - instead of toilet paper or wipe, because those can cause more irritation
  • Exercise regularly to improve circulation, but avoid heavy weightlifting
  • Use soothing creams and medication recommended by your doctor [WIPES ARE RATHER HARMFUL]

Treatment Options for Hemorrhoids

If symptoms persist, your doctor may recommend non-surgical or surgical treatment.

  1. Medical treatment / conservative management -> the doctor will decide which is the best therapy combination is suitable for you (eg. tablets, ointment, suppositories).
  2. Office-based procedures:
    • Rubber band ligation: placing a tiny rubber band around the hemorrhoid to cut off blood flow, causing it to shrink
    • Sclerotherapy (injecting a chemical solution to shrink hemorrhoids), cryotherapy, photocoagulation
  3. Surgical treatment
    • Minimally invasive THD [Transanal Hemorrhoidal Dearterialization]
    • Minimally invasive Anolift technique
    • Minimally invasive Mucopexy with dearterialization
    • HAL RAR technique [Hemorrhoidal Artery Ligation and Recto Anal Repair]
    • Laser surgery -> mostly in combination with other minimally invasive techniques
    • Excision with Ligasure or Ultrascision high-energy devices
    • Milligan-Morgan open haemorrhoidectomy
    • Ferguson closed haemorrhoidectomy
    • Stapled haemorrhoidectomy/haemorrhoidopexy: PPH [Procedure for Prolapse and Hemorrhoids], STARR [Stapled Transanal Rectal Resection] procedure, Longo procedure
    • Hybrid techniques
    • Revisional surgeries for recurrent cases
    • Anal thrombectomy
    • Residual haemorrhoidal skin tag excision

When to See a doctor

Contact a doctor immediately if:

  • You have rectal bleeding
  • You have anal pain
  • You notice tissue or mass protruding from the anus that cannot be pushed back in
  • You experience severe pain or difficulty passing stool
  • You experience anal itching or burning

Hemorrhoids are common and treatable. Early evaluation by a specialist in proctology / general surgery or gastroenterology can help relieve discomfort, prevent complications, and ensure proper care.

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