Prevention and Treatment of Hemorrhoids

A: Internal hemorrhoids are normal blood supply anatomy in the rectum. They are not quite arteries and not quite veins, but they aren’t quite capillaries either. They are more like sinusoids, or irregular tubal spaces that allow for blood flow in the rectum. They are supposed to swell a little bit when you go to the bathroom and, from research, we’ve learned they help a bit with continence.

External hemorrhoids are not a normal part of anatomy. Swelling on the outside of the anus can cause hemorrhoid symptoms because skin can stretch, causing itching and pain. Generally speaking, more pain likely means some form of external hemorrhoids, while more bleeding is indicative of internal hemorrhoids after straining.

Symptoms of hemorrhoids include pain, swelling, itching or burning, bleeding and delayed leaking of brown-tinged mucus or difficulty cleaning after bowel movements. Incomplete evacuation after a bowel movement or delayed leaking is caused when some mucus or fluid caught behind the swollen hemorrhoid leaks after the swelling goes down.

A: The blood sources in the rectum have no muscular layer in their walls, so they are prone to swelling and bleeding. Pregnancy, straining due to constipation and frequent diarrhea can all contribute to symptomatic hemorrhoids. However, the No. 1 cause of symptoms is poor toileting habits. People take their phone into the bathroom because they want to get away for a few minutes and lose track of time. They end up in the bathroom for 10, 15, even 20 minutes.

The increased pressure in the pelvis due to the above reasons can cause venous congestion – blood flows in but not as much blood flows out – and may result in pain, discomfort, itching and bleeding.

When the pelvic pressure continues over time, the tissue on the pelvic floor can stretch and doesn’t spring back quite as easily. As you age, you lose strength in your pelvic floor muscles, you lose elasticity and the tissue doesn’t bounce back as well. Aging isn’t necessarily a cause of hemorrhoids, but unfortunately it doesn’t help.

A: There are many, many people out there who have at least minimally symptomatic hemorrhoids. At least 5% of the population in the U.S. report hemorrhoids, but because of the number of patients who ignore it and never talk to their doctor about it, the actual number is likely much higher. Hemorrhoid symptoms – mainly pain or bleeding – lead people to at least 4 million office visits with physicians annually and at least 200,000 hospitalizations annually. People also may go to the emergency room to be treated for hemorrhoidal symptoms.

A: The most significant underlying cause of hemorrhoidal flares is a person’s behavior. The vast majority of people with hemorrhoids need to flip their behavior. Most of my patients who come in with hemorrhoids tell me they drink a couple glasses of water a day, 3 or 4 cups of coffee throughout the day, some soda and maybe a glass of wine or a cocktail at night. What they should be drinking is 2 liters of water a day, at minimum. Anything that causes dehydration should be limited – coffee, tea and sodas with caffeine act as diuretics and will actually force water out of you.

My recommendation is to cut back to 1 cup of caffeinated coffee or tea every morning, drink 2-3 liters of water daily and anything else is OK in moderation. One juice or soda a day; one beer, wine or cocktail at night; one cup of coffee, but 90-95% of what you drink every day should be water.

People also need to increase their daily fiber intake. Almost no one gets the amount of fiber they need from their diet. I recommend 30 grams of fiber a day for everyone. It’s really hard to get that much no matter how healthy we eat, so I also recommend a powder fiber supplement. Fiber pills and gummies don’t actually work well, so use a powder fiber.

Most people can get the fiber they need with a healthy diet that includes a lot of vegetable and some fruit with a tablespoon of fiber supplement once in the morning and once in the evening. Enough fiber plus enough water equals firm but soft bowel movements, which is the ideal. It should be firm enough to hold shape but soft enough that you don’t have to strain to pass it.

A: If you are doing all the things mentioned above, drinking plenty of water, limiting caffeine and alcohol intake and eating a healthy diet supplemented with fiber, most people won’t need a stool softener. But stool softeners are safe to take daily.

Laxatives, however, should not be taken every day. They should be used only occasionally when nothing else works.

A: There are several reasons you should schedule an appointment with your primary care provider or a gastroenterologist for your hemorrhoids:

• If the hemorrhoids have lasted more than a week after trying lifestyle changes and over-the-counter remedies
• If you are experiencing bleeding when you have a bowel movement
• If you are experiencing severe pain
• If your hemorrhoids continue to get worse despite treatment

A: If you have tried all the above lifestyle changes, which should become lifelong habits, and your hemorrhoids don’t improve, it may be time to schedule an appointment with a specialist, such as a colon and rectal surgeon, for some extra help. Hemorrhoids that don’t respond to behavioral and dietary changes may need to be physically removed.

There are 2 main procedures I use to remove hemorrhoids. The first is rubber band ligation, which can be performed in the office. This procedure involves placement of a rubber band at the base of the hemorrhoid, which squeezes off the blood supply. In about 3-5 days, the hemorrhoid will shrivel up and fall off. However, if you are on any kind of anticoagulant or blood-thinning medication, rubber band ligation is not an option.

The other procedure, which is safe for people taking anticoagulant medication, is a Doppler-guided transanal hemorrhoidal dearterialization, or THD. This is a relatively new technique. A Doppler device is used to locate the blood source of the hemorrhoid. Then a few stitches are placed around it, effectively cutting off blood supply and affixing the tissue to the underlying muscle. Because there is no surgical removal of tissue, it is much less painful with a much faster recovery. The risk of infection or bleeding after the procedure is also much lower.

A: If you do not continue the lifestyle changes recommended by your doctor, including improving toileting habits and making dietary changes, the likelihood of your hemorrhoids recurring and needing a repeat treatment procedure is much higher. If you make the lifestyle changes a lifelong habit, the chance of hemorrhoids recurring that require intervention is much, much lower.