What are hemorrhoids? |

Causes and Symptoms

Hemorrhoids, some physiologists suggest, are one of the prices that humans pay for
walking upright. The vascular system—the veins and arteries that circulate
blood—evolved in an animal that walked on all fours. Now that humans spend most of
their time standing, gravity puts awkward pressure on the system, and at the
bottom of major parts of the system, as in the tissue around the anus, the
column of blood above weighs heavily on the network of small blood vessels there.
It does not take much additional pressure to cause a vessel’s wall to balloon out.
When it does, the result is a hemorrhoid, a little pouch protruding on the surface
of the anus, similar to a hernia or varicose
vein. Most people have hemorrhoids, even if they do not realize
it, and the major symptoms are rarely dangerous, although they can be annoying and
often painful. Sometimes, however, hemorrhoids develop into or mask
life-threatening diseases.

The term “hemorrhoid” derives from Greek words meaning “blood flowing,” an apt
description of the circulatory activity in the anal walls and an inadvertently apt
warning of what most alarms people—hemorrhoids occasionally bleed. (The
alternative, and now obsolescent, term “piles” comes from Latin
pila, a ball, apparently a metaphor for the appearance of
hemorrhoids.) Specifically, the “blood flowing” refers to the supple blood vessels
of the internal rectal plexus, a series of pouches that act as cushions to help
seal the anus shut. When these pouches become enlarged, they turn into
hemorrhoids, which jut from the anus wall and swell up to three centimeters in
length.

Because of the sphincter that controls defecation, not all hemorrhoids are
visible without the aid of special instruments. The anus, an oval opening about
three centimeters in front of the spine, is the valve ending the digestive tract.
Like the mouth’s lips, which begin the tract, the anus can purse shut, a state
made possible by two concentric, circular sphincter muscles which act like
drawstrings on a cloth bag. When sensors in the rectum signal
the time to defecate, these muscles relax to pass stool and then immediately
contract to close the anus again. As in the mouth, external skin meets the
internal mucosal membrane in the anus; the meeting place is a corrugated joint
called the dentate line (or, alternatively, the anorectal juncture or pectinase
line). It is in this area—between the skin covering the external (or lower)
sphincter and the mucosa over the internal (or upper) sphincter—that hemorrhoids
form. Those that bulge out from the dentate line or above are hidden from sight by
the closed anus and are called internal hemorrhoids; those that protrude below the
closed anus, and so can be seen or felt, are called external hemorrhoids.

External hemorrhoids are the ones famed for vexing people. When the skin is stretched over swelled hemorrhoids, its sense receptors are activated, making the hemorrhoids burn and itch, sometimes so intolerably that the urge to scratch them is uncontrollable. Scratching, especially with abrasive materials such as toilet paper, often scrapes and tears the tissue. The bright red blood from these lesions is easily noticeable on the toilet paper and may even drip into the toilet bowl or onto underclothes. Likewise, the passage of a hard, dry stool often abrades hemorrhoids to the point of bleeding.

Internal hemorrhoids do not itch or burn and rarely cause pain because the mucosal
tissue over them has no nerve endings, but they can also bleed when a passing
stool damages them. (Pain may be “referred,” however, from a damaged internal
hemorrhoid to the sciatic nerve, bladder, lower back, or genitals; that is, a
person feels little or no pain in the anorectal area, but suddenly pain flares in
one of these other areas.) An especially elongated internal hemorrhoid at times
can protrude through the anus, a condition called prolapse.
Usually, it spontaneously recedes or can be pushed back inside with a finger, but
upon rare occasion a group of internal hemorrhoids prolapse, swelling and sending
the internal sphincter into painful spasms. A doctor’s help may then be required
to reduce the pain and fit the hemorrhoids inside.

The blood vessels in the internal rectal plexus swell so easily because they lack
valves. Without valves to regulate the local flow of blood, the walls are
vulnerable to any sudden increase in pressure. Even a small, transient increase
above the normal pressure of blood circulation can cause the vessels to bulge.
Often, these bulges disappear when the excess pressure disappears or remain
swollen only briefly afterward. If the increased pressure is high enough, however,
a permanent protrusion results, drooping from the anal wall. Even then, if the
hemorrhoid is internal, the patient may feel no discomfort and may not realize
that a hemorrhoid has formed.

Some people are more susceptible to chronic hemorrhoids than others because of a
hereditary lack of elasticity in the blood vessels. In such people, standing for
long periods of time can add enough pressure to make hemorrhoids swell.
Nevertheless, anyone can get hemorrhoids—all that is needed is enough pressure in
the lower abdomen. Straining on the toilet due to constipation
to pass stool is the most common cause. Since a poor diet can lead to
constipation, hemorrhoids can be a secondary effect of poor eating habits. Those
who like to sit on the toilet a long time, reading or watching television while
waiting for a bowel movement, also increase pressure on the anus because of the
posture and the compressing effect of the toilet ring, and they are likely to
develop hemorrhoids. People who regularly lift heavy weights as part of their jobs
or for recreation are especially susceptible if they hold their breath while
lifting: This action pushes the diaphragm downward on organs below it,
including the anus, putting pressure on them. Similarly, during pregnancy
women can develop hemorrhoids as the expanding womb crowds and increases pressure
on nearby organs; these hemorrhoids are exacerbated by delivery, but they usually
go away afterward. Psychologists add to these causes the guilt that some people
feel about eating and excreting, guilt spawned by overindulgence in food or bad
toilet training; they bear down on their bowels to defecate as quickly as possible
and by doing so stress the hemorrhoidal vessels. Finally, hemorrhoids occasionally
develop because of some serious diseases, such as heart failure
and cirrhosis of the liver, which elevate pressure in the veins,
and rectal
cancer, which can create a false sense of fullness so that
the person strains to pass a stool that is not really there.

Although they seldom do more than itch, external hemorrhoids can thrombose—develop clots of coagulated blood from a burst or
swollen vessel under the skin—and grow as large as a grape. A doctor can relieve
the pain by slicing open the hemorrhoid and squeezing out the clot. Left alone, a
thrombosed hemorrhoid may rupture, causing a painful and bloody mess that is ripe
for infection. Yet the greatest threat of hemorrhoids lies not
in the symptoms themselves but in how they might be confused with those of other,
deadly diseases. Colorectal cancer, inflammatory bowel
disease, and sexually transmitted diseases such as syphilis,
gonorrhea, and herpes can lead to discharges of blood, as can anal fissures
(cracks in the anal canal), fistulas (tunnel-like passages between
an infected gland and mucosa or skin), and abscesses
(pus-filled sacs under the mucosa). A person who dismisses the bloody discharge as
simply a flare-up of hemorrhoids may be delaying treatment for the real cause. In
the case of colorectal cancer, one of the most common cancers in the United
States, such a delay can be fatal. Only a doctor has the tools and vantage point
to distinguish between the relatively benign hemorrhoids and a dangerous
disorder.

Treatment and Therapy

Since hemorrhoid-like symptoms can be produced by deadly diseases, a thorough
checkup at the doctor’s office includes an examination of the anus and rectum,
especially if the patient has noticed bleeding. In addition to the visual
inspection and “digital” examination, during which the doctor inserts a finger and
feels around for enlarged hemorrhoids or other masses, patients provide clues by
describing the color, amount, and time of bleeding. If the blood is bright red and
occurs in small quantities during or just after defecation, hemorrhoids are most
likely to blame. If dark red blood or clots appear in the stool or seep out
randomly, however, the doctor will look for other causes, inspecting the anus,
rectum, and colon with various types of endoscopes, fiber-optic-filled flexible
tubes that can also collect tissue samples. Once the doctor rules out other
diseases, the patient has three basic choices: change habits, rely on therapy, or
have the hemorrhoids removed.

If a person’s hemorrhoids do not cause severe discomfort, the doctor will likely
recommend a diet with high fiber and water intake. Fiber and water
together make stools bulky and soft. They pass more easily during defecation than
small, hard, dry stools. The patient does not have to strain, and so no further
pressure is put on existing hemorrhoids. Furthermore, soft stools do not scrape
hemorrhoids and cause them to bleed. The doctor will also suggest regular
exercise, since this helps the bowels work more efficiently and reduces the chance
of constipation. Finally, the patient may receive instructions on the proper way
to breathe during heavy exertion so as to lessen the stress on the hemorrhoids.
With a better diet, more exercise, and less physical straining, patients may find
that hemorrhoids have disappeared completely. Weight loss may also improve
hemorrhoids.

Until hemorrhoids shrink, they plague the patient, and to reduce the itching and
burning a number of therapies prove effective, if only temporarily. An ice
compress eases the discomfort, as does a sitz bath (sitting for at least fifteen
minutes in shallow warm water), which also cleanses the site of potentially
infecting wastes and promotes healing in damaged tissue. Should these relatively
simple and cheap measures be impracticable, a variety of ointments, creams,
medicated pads, and suppositories, either prescription or nonprescription, may
provide relief. Some are inert, such as petroleum jelly, and coat and lubricate
the hemorrhoids, protecting them from irritation. Some have an astringent effect,
tightening and sealing tissue and thereby protecting it. Others have anesthetic
ingredients, numbing the tissue, or anti-inflammatory effects, decreasing
swelling. None of these medications has a proven capacity to make swelling go away
entirely, and those with active ingredients may cause an allergic response. For
patients with constipation, doctors may prescribe stool softeners to eliminate
straining during defecation. Laxatives are usually to be avoided because the
chemicals in them irritate hemorrhoids, and the resulting diarrhea often causes
urgency and pressure in the rectal area.

When hemorrhoids become chronically and unusually swollen or the patient can no longer endure the discomfort, removing them is the last resort. This cure is certain, although not necessarily permanent, but it has its cost in pain and recovery time. There are seven basic methods, six that cause the target hemorrhoid to shrivel, to drop off on its own, or both, and one, surgery, that removes it directly.

The surgical removal of hemorrhoids, called hemorrhoidectomy, is a relatively
simple operation; nevertheless, it is usually reserved for those patients who
cannot undergo one of the other methods. The patient is given a local anesthetic
to deaden sensation in the anus, although some patients are rendered unconscious
with a general anesthetic. The surgeon cuts off the hemorrhoid at its base and
then sews the wound closed with absorbable sutures. The recovery period may
require hospitalization for up to a week, during which pain medication, stool
softeners, and anal pads are necessary until the tissues heal. Bed rest after
hospitalization and sitz baths may also be beneficial. Because of this recovery
time—as much as a month all together—hemorrhoidectomies are not widely popular
among patients or physicians. Moreover, urine retention, infection, and
hemorrhaging after the operation are possible complications.

The remaining methods avoid the trauma of cutting, and the first of them,
ligation, is one of the oldest of all the methods. Ancient Greek physicians tied a
thread around a hemorrhoid to strangle its blood supply; modern
gastroenterologists or proctologists use special rubber bands. The effect is the
same: The hemorrhoid dries up, shrivels, and falls off. Little pain accompanies
the procedure, which is done in the doctor’s office.

Likewise, sclerotherapy, cryosurgery, and infrared coagulation are only for
internal hemorrhoids because the pain would be too intense on external
hemorrhoids. In sclerotherapy, the doctor injects a liquid—usually phenol in oil
or quinine in urea—that seals closed the blood vessels at the base of the
hemorrhoid. With no blood in them, the vessels eventually shrink to normal
dimensions, and, if stressing pressure on them is not resumed, the hemorrhoid
disappears. In cryosurgery, super cold liquid nitrogen or nitrous oxide is applied
to the hemorrhoid, freezing it and killing the tissue. The hemorrhoid slowly melts
and, as it does, shrinks and finally sloughs off. Popular in the 1970s and early
1980s, cryosurgery lost favor because of the messy and extended recovery time.
Useful for mild, small hemorrhoids, infrared coagulation involves a beam of
infrared light that, aimed at the hemorrhoid, shrinks it by cauterizing the
tissue. The heat of the beam can cause pain in other parts of the anus during the
procedure.

The remaining methods, laser surgery and electric current coagulation, can be used
on external hemorrhoids. Like infrared coagulation, laser surgery trains a beam of
light—in this case intense visible light—that burns and shrinks the hemorrhoid to
a stub. Since the laser cauterizes as it destroys tissue and therefore seals off
blood vessels, its main advantage over regular surgery lies in reduced bleeding.
Recovery time is shorter, about a week, and hospitalization is usually not
necessary. In electric current coagulation, electrodes pass either direct or
alternating current through the hemorrhoids. Because tissue is a poor conductor,
the resistance to the current creates heat, which cooks the hemorrhoid,
coagulating and shrinking it.

Which method the surgeon, gastroenterologist, or proctologist uses depends partly
upon the physician’s and patient’s preferences and partly upon the size and
location of the hemorrhoid. Ligation remains the most frequently used method
because it is relatively cheap and fast.

Perspective and Prospects

Certainly, hemorrhoids are no laughing matter. Yet the long-standing taboo in the
United States about excretion and the anus has prompted many Americans either to
laugh nervously about their hemorrhoids or to keep silent, preferring to suffer
stoically rather than to risk becoming the target of jokes. For this reason, it is
nearly impossible to say how many sufferers there are in the United States. The
peak prevalence of hemorrhoids occurs between ages forty-five and sixty-five
years, and men and women are equally affected. An estimated 5 percent of the
general population in the United States is thought to be affected. Hemorrhoids are
also common during pregnancy and childbirth, although they usually spontaneously
regress postpartum.

Whatever the exact statistic, clearly many people share a problem that embarrasses
them too much to discuss openly or that they believe is too trivial for medical
attention. If they need relief from the itching and pain, they treat themselves. A
large industry in home remedies and over-the-counter medications serves them. The
benefits of such medications are difficult to assess, and some authorities claim
that petroleum jelly eases the itching and burning as much as any preparation
specifically intended for hemorrhoids. Folk remedies, such as suppositories made
of tobacco or compresses soaked in papaya juice, can damage tissue outright,
making the problem worse. Moreover, throughout the United States specialized
clinics offer surgical cures for hemorrhoids, promising patients quick relief on
an outpatient basis and using expensive methods, particularly laser surgery.

Many people, therefore, spend considerable money and time to tend a chronic
discomfort that can as readily be prevented or palliated by a change in habits,
doctors claim. Like colon cancer and many other intestinal ailments, hemorrhoids
are most common in populations whose diet includes a high number of processed
foods, which are low in fiber. While fiber is no panacea, people in cultures whose
diet contains significant fiber have larger stools and fewer intestinal complaints
in general. Increasing one's fluid and fiber intake is considered the first-line
treatment of hemorrhoids.

Because hemorrhoids are in most cases preventable or controllable without treatment, they have been cited, along with deadly maladies such as colon cancer and inflammatory bowel disease, in criticisms of both the American diet and Americans’ eagerness to rely on medical intervention to save them from their own unhealthy habits. In the case of hemorrhoids—while they are not exclusively a malady of Western civilization—the fast pace and pressures of life, the attitudes about defecation, and the eating habits of industrial cultures help give them a distracting prominence.

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