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Hemorrhoids occur in up to 50% of the adult population. They are the most misunderstood Anorectal problem for patients and physicians alike and most often wrongly treated. Patients also often wrongly blame them for virtually any Anorectal symptom.

Hemorrhoids occur in up to 50% of the adult population. They are the most misunderstood Anorectal problem for patients and physicians alike and most often wrongly treated. Patients also often wrongly blame them for virtually any Anorectal symptom.

Two common varieties of hemorrhoids exist: 

  • External hemorrhoids
  • Internal hemorrhoids

The mere presence of hemorrhoids does not constitute an indication for treatment, irrespective of size, and only symptomatic hemorrhoids require treatment. Definitive diagnosis is done by inspection and anoscopy.

Hemorrhoids during pregnancy are common. Treating hemorrhoids during pregnancy only rarely requires surgical modalities.

What are hemorrhoids?

Hemorrhoids are a normal part of the 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 the prevention of leaking of fecal matter), anal cushions also play a role. They support the anal sphincters and are also 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 the 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). [1]

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 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 [2]:

  • 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 of developing the hemorrhoidal disease are [3]:

  • Aging,
  • Obesity,
  • Abdominal obesity,
  • Depressive mood pregnancy
  • Conditions related to increased intra-abdominal pressure (constipation and prolonged straining)
  • Some types of food and lifestyle, including a low fiber diet, spicy foods, and alcohol intake. 

General measures for internal hemorrhoids:

  • High-fiber diet
  • Increased fluids
  • Avoidance of straining
  • Fiber supplements such as psyllium, methylcellulose  or calcium polycarbophil
  • Sitz baths

General measures 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

    Hemorrhoids during pregnancy

    Hemorrhoids are common during pregnancy; up to 30% of women are affected by hemorrhoids during pregnancy [4] and by the second and third trimester of pregnancy up to 85% of female population encounters hemorrhoids. The older the pregnant woman, the higher the likelihood of suffering from pregnancy-related hemorrhoids. [5] Except for pregnant women, hemorrhoids are rarely encountered in persons under age 30. Contributing factors for hemorrhoids during pregnancy include [6]:

    • 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 the pooling of blood in the blood vessels

    Treatment options during pregnancy 

    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 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, then no active intervention is needed. If the symptoms are longstanding and increased during pregnancy, then hemorrhoids should be treated. The majority of patients with hemorrhoids are treated without surgery, particularly during pregnancy.

    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. If possible, avoid them during pregnancy. 
    • 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 hemorrhoid and places a rubber band tightly around it.
    • Acutely strangulated hemorrhoids from thrombus formation require emergency debridement.

    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. More aggressive therapies, such as sclerotherapy, cryotherapy, or surgery, are reserved for patients who have persistent symptoms after at least 1 month of conservative therapy.

    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:

    • Surgery can prematurely induce labor
    • Surgery can lead to perineal infection
    • Surgery can lead to post-procedure urinary retention.
    Hemorrhoids in pregnancy should be controlled by a regime of a high fiber diet, stool bulking agents, stool softeners, increasing fluid intake, and training in toilet habits. These preventive measures should alleviate symptoms in most pregnant women. If conservative methods don't offer relief, women should receive topical treatment. [6]

    For the majority of women, most symptoms will resolve spontaneously soon after giving birth. Only a few cases will require a surgical evaluation during pregnancy or after delivering.

      Hemorrhoidectomy is reserved for patients who have third- and fourth-degree internal hemorrhoids and those in whom banding has been unsuccessful. Surgery for the intractable disease should be delayed until the growing fetus becomes viable or until the delivery.