Hemorrhoids
Hemorrhoids are dilated, twisted (varicose) veins located in the wall of the rectum and anus.
Hemorrhoids occur when the veins in the rectum or anus become enlarged; they may eventually bleed. Hemorrhoids may also become inflamed or may develop a blood clot (thrombus). Hemorrhoids that form above the boundary between the rectum and anus (anorectal junction) are called internal hemorrhoids; those that form below the anorectal junction are called external hemorrhoids. Both internal and external hemorrhoids may remain in the anus or protrude outside the anus.
Increased pressure in the veins of the anorectal area leads to hemorrhoids. This pressure may result from pregnancy, from frequent heavy lifting, or from repeated straining during bowel movements (defecation). Constipation may contribute to straining. In a few people, hemorrhoids develop from increased blood pressure in the portal vein. A doctor can distinguish the dilated, twisted veins that occur in this condition from common hemorrhoids.
Symptoms and Diagnosis
Hemorrhoids can bleed, typically after a bowel movement, producing blood-streaked stool or toilet paper. The blood may turn water in the toilet bowl red. However, the amount of blood is usually small, and hemorrhoids rarely lead to severe blood loss or anemia.
Hemorrhoids that protrude from the anus may need to be pushed back gently with a finger, or they may go back by themselves. A hemorrhoid may swell further and become painful if its surface is rubbed raw or if a blood clot forms in it. Less commonly, hemorrhoids may discharge mucus and create a feeling that the rectum is not completely emptied after a bowel movement. Itching in the anal region (pruritus ani) is usually not a symptom of hemorrhoids, but itching may develop if hemorrhoids make proper cleaning of the anal region difficult.
A doctor can readily diagnose swollen, painful hemorrhoids by inspecting the anus and rectum. An examination with an anoscope or sigmoidoscope helps a doctor determine if the person has a more serious condition, such as a tumor.
Treatment
Usually, hemorrhoids do not require treatment unless they cause symptoms. Taking stool softeners or a bulking type of laxative such as psyllium may relieve straining with bowel movements. Symptoms can sometimes be relieved by soaking the anus in warm water in what is known as a sitz bath. The soaking is accomplished by squatting in a partially filled tub or using a container filled with warm water placed on the toilet bowl or commode.
Bleeding hemorrhoids can be treated with an injection of a substance that causes the hemorrhoids to become obliterated with scar tissue; this procedure is called injection sclerotherapy.
Large internal hemorrhoids and those that do not respond to injection sclerotherapy can be tied off with rubber bands (a procedure called rubber band ligation). The band causes the hemorrhoid to wither and drop off painlessly. The treatment is usually applied to one hemorrhoid at a time at intervals of 2 weeks or longer. Internal hemorrhoids may also be destroyed with a laser (laser destruction), an infrared light (infrared photocoagulation), or an electrical current (electrocoagulation).
 See the figure Banding a Hemorrhoid.
Surgery to remove the hemorrhoids may be used if other treatments fail. However, hemorrhoid surgery may result in severe pain. New, less painful techniques are being investigated, including Doppler-guided hemorrhoid artery ligation, in which hemorrhoid arteries are identified and tied off, thus reducing the blood supply to the hemorrhoids; and circumferential stapled hemorrhoidectomy.
When a hemorrhoid with a blood clot causes pain, it is treated with warm sitz baths, local anesthetic ointments, or witch-hazel compresses. Pain and swelling usually diminish after a short while, and clots disappear over 4 to 6 weeks. Alternatively, especially when the pain is severe, a doctor may cut the vein and remove the clot, which sometimes relieves the pain rapidly.
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