Paging Dr. Frischer: Hemorrhoids

I’ve been writing this column for over eight years now, and there’s one topic I seem to have avoided. Perhaps it’s because merely the word, if spoken, was enough to empty the room when I was a boy. Today, let’s discuss…hemorrhoids.

There are many veins in and around the anus. An increase in pressure can cause these veins to stretch, bulge or swell, a hemorrhoid can result. Symptoms include itching, bleeding with bright red blood on the toilet tissue, painful bowel movements, and a hard lump near the anus.

Hemorrhoids are an extremely common problem. In 2012, they were the subject of more Internet searches than any other health issue in the United States. Hemorrhoids can occur at any age, and they affect both men and women. About half of the population has had a hemorrhoid by age 50, and perhaps 75% of us will have one at some point. 10-20% of those who see their doctor for a hemorrhoid will end up in a surgeon’s office for treatment.

The first documented treatment for hemorrhoids dates back to Egypt in 1700 BC. In 460 BC, Hippocrates wrote of a treatment similar to today's rubber band ligation. Around the year zero, a Roman physician documented ligation and excision surgeries, including possible complications. An ancient Sanskrit text from around the fourth century described advanced surgical procedures, with an emphasis on wound cleanliness.

Reaching a diagnosis is usually straightforward. A doctor will take a history and examine the rectum for signs of hemorrhoid swelling. However, rectal bleeding can be caused by a number of other problems, including colon cancer, so an anoscopy, sigmoidoscopy, or colonoscopy may be necessary to rule out anything more serious.

Hemorrhoids become more likely as we age because the tissues that support the veins in the rectum

and anus tend to weaken and stretch over time. The chances of getting one increase if there is straining during bowel movements, sitting for long periods of time on the toilet, chronic diarrhea or constipation, a low fiber diet, obesity, liver disease, inactivity, anal intercourse, pregnancy, and childbirth. What do all of these factors have in common? They lead to increased pressure in the rectum, causing veins to swell. When hemorrhoids do form, they occur either inside the rectum (internal hemorrhoids) or near the anal opening (external hemorrhoids).

Complications from hemorrhoids are rare, but significant. Continued blood loss can cause anemia (too few red blood cells), which leads to fatigue and weakness. Also, if a hemorrhoid loses its blood supply and becomes strangulated, it can result in severe pain and tissue death.

The best way to prevent hemorrhoids is to avoid reasons to strain while having bowel movements. Eat a diet filled with foods rich in fiber, such as fruits, vegetables and whole grains. Drink plenty of water. Make a commitment to exercise, and avoid sitting in one place for long. If necessary, take stool softeners and fiber supplements.

Treatment for hemorrhoids can be fairly simple. There are a number of over-the-counter products available. They include corticosteroid creams and suppositories. There are also lidocaine creams to help reduce discomfort. Stool softeners and fiber help to make bowel movements softer and easier. Soaking in a warm bath for 20 minutes with Epsom salts helps to shrink hemorrhoids, as does applying witch hazel. Wear cotton underwear to minimize irritation. Avoid toilet tissue with perfumes or colors, or use baby wipes instead. Avoid scratching or irritating the area if it has become inflamed. Avoid heavy lifting.

On occasion, I do need to send a patient to a surgeon for further treatment. Rubber band ligation is an outpatient procedure, and uses local anesthesia. One or two tiny rubber bands are placed around the base of an internal hemorrhoid to cut off circulation, and the hemorrhoid withers and falls off within a week. Sclerotherapy injects a chemical solution into the hemorrhoid tissue to shrink it. Coagulation uses a laser or infrared light to shrink the hemorrhoid.Hemorrhoidectomy, the surgical removal of a large hemorrhoid, is used in extreme cases. 

Allow me to extend my apologies for taking so long to get around to writing about this extremely common affliction!