Hemorrhoids

What are hemorrhoids?

Symptomatic hemorrhoids come from inflammation of the mucosa and interstitial tissue surrounding the normal veins of the anorectum.   These veins provide the normal pathway for return of blood from the anus and rectum back through the circulation to the heart. Of importance is the fact that the veins in the rectum drain into the portal circulation and thus to the liver prior to returning to the heart, while the veins of the anus drain directly into the central circulation.

I am frequently asked questions by patients about internal versus external hemorrhoids. The distinction is somewhat artificial as external hemorrhoids are merely the external component of a hemorrhoid that originates internally. The dividing line between external and internal is called the dentate line, which is the point at which rectal mucosa changes to anal skin.

Millions of people suffer with painful hemorrhoids chronically and regularly. In fact, the majority of people suffer from some hemorrhoid symptoms at least occasionally. Though there are certain groups of people who are at risk for development of hemorrhoids, most cases occur without specific cause. They do occur with greater frequency in people who have jobs that require them to sit for long periods of time such as office workers and taxi drivers.

Diet is also a major factor; people who eat foods low in fiber are prone to constipation and hemorrhoid symptoms. Also, people who eat spicy foods may have exacerbation of their symptoms. Some people who simply do not drink enough fluid may suffer from constipation and hemorrhoid symptoms.

Underlying medical conditions may contribute to hemorrhoid symptoms. Many women very typically develop hemorrhoids during pregnancy. This has to do with the large gravid uterus pressing on pelvic veins and altering circulation in those veins. In addition, pregnancy induces a state in which there is a greater circulating blood volume and general engorgement of blood vessels.

Cirrhosis of the liver is another medical condition which may underlie hemorrhoids. The hemorrhoidal veins are a natural path of collateral circulation for blood trying to return to the heart from the rectum. Under normal circumstances this blood first passes through the liver before entering the central circulation and returning to the heart. In cirrhotic patients, circulation through the liver is obstructed and blood needs to find alternative pathways to return to the central circulation. One of these is via the hemorrhoidal veins, resulting in swelling, inflammation and often bleeding from these hemorrhoids.

Symptoms of hemorrhoids may vary but typically consist of pain and bleeding. The pain may be excruciating after defecation and may be associated with feeling a lump in or around the anus. Bleeding is usually only a few drops seen on the stool, in the toilet bowl or on the toilet paper. This may be caused by tearing of an engorged vein during defecation or by ulceration of the rectal mucosa.

Pain may be caused by simple inflammation of the hemorrhoidal tissue but may also be caused by thrombosis or prolapse of the hemorrhoid. When a hemorrhoid prolapses it may become very painful because of the constant irritation from clothing, sitting, or defecation. Often when the prolapse is reduced symptoms improve but may not disappear entirely. The worst pain and inflammation is often caused with extensive thrombosis within hemorrhoidal veins.

Patients who present with a history of bleeding should undergo proctosigmoidoscopy to rule out the presence of a tumor, which may also cause bleeding and may be missed because of the presence of hemorrhoids and the assumption that they are the source of bleeding. Patients over 50 may require a full colonoscopy.

All patients presenting with symptomatic hemorrhoids should be started on a regimen of stool softeners and warm soaks called sitz baths. For some patients this may be all that is required for symptomatic relief. I prefer to use medications that are relatively natural such as Metamucil and mineral oil so as not to alter the normal motility of the gastrointestinal tract and to avoid over utilization of laxatives.

Patients who have thrombosed hemorrhoids will usually require incision and drainage of the thrombosed hemorrhoid. This is a minor procedure done in the office with local anesthesia and usually provides immediate relief of the exquisite pain caused by the thrombosed hemorrhoid. Additional treatment may subsequently be warranted for removal of the hemorrhoid.

Patients with low grade, non-thrombosed hemorrhoids are very easily treated with rubber band ligation in the office using local anesthesia. Patients with more extensive hemorrhoids or with hemorrhoids in association with a fistula or fissure may require surgery in the hospital setting.

Surgical Hemorrhoidectomy involves removal of the hemorrhoidal tissue in the operating room under spinal or general anesthesia. The tissue is removed with cautery or laser and the resulting defect is repaired with sutures. Patients usually go home the same day. I start all patients on an aggressive regimen to force soft but formed bowel movements to minimize pain with defecation. No narcotic pain medications are used so as to avoid the constipation that is frequently associated with use of these products.

What are Anal Fistula and Fissure?

Fistula in-ano

Other conditions which affect the ano-rectum and may be confused with or occur concomitant with hemorrhoids include anal fistula and anal fissures. 

A fistula is an abnormal communication between the inside of a hollow organ and the skin.  In the case of an anal fistula the communication is from inside the rectum to the skin outside the anus or on the buttock.  The inciting cause is trauma of defecation which causes a break in the mucosa of the rectum.  Bacteria track into the tissue under the mucosa and form an abscess.  The abscess eventually finds its way to the skin where it ruptures and drains.  The outer opening may heal but the inner opening remains and permits the cycle to repeat itself.  Patients often present with years of repeated abscesses in this area which drain, heal and return again.

Surgical treatment involves opening the entire fistula from its outer opening to its inner opening and allowing the wound to heal from the inside out thus obliterating the fistula.  If the fistula track runs deep to the anal sphincter muscle, the muscle will need to be divided; however, doing so carries a risk of causing fecal incontinence.  Often, when this is the case, the procedure will be done in two stages. During the first stage, the fistula is opened to the level of the anal sphincter muscle including the overlying skin or mucosa, but the sphincter is left intact.  A strip of cotton tape called a "Seton" is passed around the sphincter muscle in this area and tied tight.  This causes the sphincter muscle in this area to scar down.  A few weeks later, it is safe to cut the muscle as it will not retract and open up but instead just stays in place and the remainder of the fistula can heal.  The risk of incontinence is greatly reduced performing the procedure in this way when the sphincter is involved. 

Two newer methods for treating anal fistula have recently been introduced.  The first step with both methods is to scrape the inside of the fistula to expose fresh tissue that is more prone to healing. 

The first method involves simply injecting the fistula with fibrin glue.  Fibrin is a protein found in the blood which is involved in the final stages of causing blood to clot.  The glue created from fibrin is effective at sealing the fistula.  The recurrence rate is high, but it is a reasonable first attempt and has no risk of causing incontinence. 

The second option is to use a collagen fistula plug.  Collagen is the major structural protein which holds us all together.  It is present throughout are bodies and forms the matrix upon which cells grow.  Pure collagen has been used to create matrices for a variety of purposes.  In this case a small plug of collagen in placed in the fistula tract and sutured into place.  The tissues may then grow into the collagen and heal the fistula.  This procedure may or may not be augmented with the use of fibrin glue as described above.  This procedure still has a significant recurrence rate, but again is a very good option to try as it has no risk of causing incontinence.

Anal Fissure

A fissure is simply a crack or tear in the anal skin in the anal canal.  The cause is also straining with bowel movement.  They are often exquisitely painful.  So much so, that when I see a patient in excruciating pain in the anus, the patient will not allow me to do a digital exam and I cannot see a thrombosed hemorrhoid, I will usually just treat for a fissure as the presumptive diagnosis.  Surgical treatment involves doing a lateral sphincterotomy.  The skin in the outer part of the anus is opened slightly to expose the sphincter muscle and the muscle is divided superficially.  This does not carry the same risk of incontinence as when dividing the muscle for a fistula, because the location and degree of muscle division can be completely controlled by the surgeon.  With a fistula, the area of muscle involvement is dictated by the disease.

Surgery for fissures can often be avoided with the use of topical Nitroglycerine applied directly to the anus.  Nitroglycerine relaxes the muscles of the anal sphincter the same way it relaxes the smooth muscle of blood vessels when treating Coronary Artery Disease.  It may cause a low blood pressure in normal patients even when applied to the anus in this manner and therefore, may not be suitable for everyone.  It is; however, a good first line treatment option that often resolves the problem and avoids the need for surgery.

Surgical Hemorrhoidectomy may be combined with a Fistulotomy for concomitant anal fistula or with a sphincterotomy for concomitant anal fissure. 

As always, I hope you have found this discussion helpful and invite your commentary.

Steven P. Shikiar, MD, FACS email