Two common varieties are encountered, external and internal hemorrhoids. The mere presence of hemorrhoids does not constitute an indication for treatment, irrespective of size. Only symptomatic hemorrhoids require treatment. Definitive diagnosis is by inspection and anoscopy. Hemorrhoids during pregnancy are common. Treating hemorrhoids during pregnancy only rarely requires surgical modalities.
What are hemorrhoids?
Hemorrhoids are normal part of human anatomy. Hemorrhoids are in fact vascular cushions. They contain blood vessels, elastic tissue and smooth muscle. Though the anal sphincters are very important for maintaining anal continence (for prevention of leaking of fecal matter), anal cushions also play a role. They support the anal sphincters and also are critical in providing complete closure of the anus, further aiding in anal continence. When a person coughs, sneezes or strains, these anal cushions increase in size and maintain the closure of anus and prevent the leakage of stool. Hence surgical removal of these anal cushions can lead to some degree of fecal incontinence (leakage of stool).
What is hemorrhoidal disease?
Hemorrhoids are normal structures. Hemorrhoidal disease indicates abnormal hemorrhoids which cause symptoms. Though hemorrhoidal disease is the appropriate term, the term hemorrhoids is commonly used in persons presenting with various symptoms of hemorrhoidal disease. Hemorrhoids can be internal or external hemorrhoids. Internal hemorrhoids are located in the upper two thirds of the anal canal and external hemorrhoids are located in the lower one third. Internal hemorrhoids are not sensitive to touch, pain or temperature.
Many patients presenting in the office complaining of hemorrhoids are frequently found to have other anal problems such as anal fissures, anal fistulas and skin tags. Patients with hemorrhoidal disease may complain of bleeding mucosal protrusion, pain, mucus, discharge, difficulties with perianal hygiene and a sensation of incomplete evacuation. Anoscopy permits visualization of the hemorrhoids.
There are four grades of internal hemorrhoids:
- First degree hemorrhoids- bleeding hemorrhoids that visibly bulge on examination
- Second degree hemorrhoids - hemorrhoids that prolapse with defecation, but spontaneously reduce
- Third degree hemorrhoids - hemorrhoids that prolapse with defecation, but require manual reduction
- Fourth degree hemorrhoids - permanently prolapsed hemorrhoids
Causes of hemorrhoids
Repeated stretching of the anal supporting tissues leads to hemorrhoidal disease. The factors that are associated with an increased risk for developing hemorrhoidal disease are:
- Prolonged straining
- Pelvic malignancy
Hemorrhoids during pregnancy
Hemorrhoids are common during pregnancy. Except for pregnant women, hemorrhoids are rarely encountered in persons under age 30. Contributing factors for hemorrhoids during pregnancy include:
- Increased constipation, resulting in increased straining at defecation
- Increases in the circulating blood volume, resulting in dilatation and engorgement of blood vessels
- Blood vessel compression from the enlarging gravid uterus resulting in pooling of blood in the blood vessels
There are a number of different options available for the treatment of hemorrhoidal symptoms. The ultimate decision as to which treatment to utilize will be based on the symptoms, the nature of the hemorrhoids (internal vs. external), and the patient’s motivation. Some patients are content with the assurance that their symptoms are due to hemorrhoids and not other, more life-threatening disorders. The treatment of hemorrhoids is almost always elective, and many patients will defer treatment to a more convenient time.
The majority of patients with hemorrhoids are treated without surgery. Patient symptoms may often be controlled by a regime of a high fiber diet, stool bulking agents, and fluids. Mild symptoms may respond to dietary measures alone. Office procedures, such as rubber band ligation, infrared coagulation, or sclerotherapy, may be used for persistent bleeding from first, second, and selected cases of third degree hemorrhoids. Hemorrhoidectomy (surgical removal of hemorrhoids) is required in fewer than 10% of patients with symptomatic hemorrhoids and is reserved for patients with large third and fourth degree internal hemorrhoids.
For internal hemorrhoids:
- High-fiber diet
- Increased fluids
- Avoidance of straining
- Fiber supplements such as psyllium, methylcellulose or calcium polycarbophyl
- Sitz baths
For external hemorrhoids:
- When thrombosis is present, sitz baths are recommended three to four times per day and after each bowel movement
- High-fiber diet
- Stool softener
- Fiber supplements
- Topical local anesthetic creams (such as lidocaine, benzocaine, or pramoxine) should be applied two to four times per day
- Avoiding straining
Treatment of hemorrhoids during pregnancy
The first step in treating hemorrhoids during pregnancy is to know whether the symptoms appeared before pregnancy or after the women became pregnant. If the symptoms resolve without getting worsened, then no active intervention is needed. If the symptoms are longstanding which got worsened during pregnancy, then hemorrhoids should be treated.
Treatment of hemorrhoids during pregnancy initially involves a conservative approach. These include:
- Dietary fiber supplementation to help relieve constipation and reduce straining. Episodes of bleeding and symptoms can be improved, but the degree of prolapse does not change. Often 6 weeks or longer are necessary before improvement is noticed.
- Anesthetics and steroids can provide short-term relief, but they do not affect the underlying disease process.
- Rubber-band ligation provides significant improvement for patients who have second- and third-degree internal hemorrhoids. This is an outpatient procedure performed after placement of an anoscope. A specialized device grabs the hemorrhoid and places a rubber band tightly around it
- Acutely strangulated hemorrhoids from thrombus formation require emergency debridement
Though hemorrhoidal symptoms are common in pregnancy, they are rarely critical enough to require surgical intervention because symptoms tend to resolve after delivery. Although hemorrhoidectomy seems safe during pregnancy, it should be done only in unusual circumstances and only after assessing the conditions of both the mother and the growing fetus. In fact, one should be cautioned against surgical intervention until the pregnancy is completed because of the following reasons:
- Can prematurely induce labor
- Can lead to perineal infection
- Can lead post-procedure urinary retention.
Hemorrhoidectomy is reserved for patients who have third- and fourth-degree internal hemorrhoids and those in whom banding has been unsuccessful. Surgery for intractable disease should be delayed until the growing fetus becomes viable or until the delivery.