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Getting to the Bottom of Hemorrhoids

Ah, hemorrhoids. Even if you didn’t know how to spell the word correctly, you have certainly heard a joke or two about them. But for those who’ve ever had hemorrhoids, they are no laughing matter.

So rather than being the butt (no pun intended) of many jokes, what exactly are hemorrhoids, who gets them and how can you prevent them? Bradford Keeler, MD, a general surgeon who specializes in colon and rectal surgeries at Banner Health Clinic in Loveland, CO, gets to the bottom of hemorrhoids.

What are hemorrhoids?

Hemorrhoids are swollen veins in the anal canal that can develop inside the rectum (internal) or under the skin around the anus (external). When they get irritated or enlarged, they can cause problems such as bleeding, itching and pain.

Types of hemorrhoids

As mentioned above, there are two sets of hemorrhoidal veins: internal and external hemorrhoids.

Internal hemorrhoids

Internal hemorrhoids are roughly 2-3 centimeters (about an inch) inside the anal canal and are relatively painless. You usually won’t even notice them until straining while passing a stool. This can cause the blood vessels to dilate and then tear and cause bleeding.

Sometimes internal hemorrhoids can enlarge enough that they bulge out of the anus (prolapsed or protruding) and this can cause itching. Usually, these prolapsed internal hemorrhoids go back inside the anal canal on their own, or they can be gently pushed back into place. Rarely, however, an internal hemorrhoid can get stuck in a prolapsed position and can restrict blood flow and cause pain.

External hemorrhoids

External hemorrhoids are visible and can feel sensations like the skin. When they are irritated and dilated, they can sometimes develop thrombosis.

Thrombosed hemorrhoids happen when a hemorrhoid fills with blood clots. Despite their appearance, thrombosed hemorrhoids are usually not serious, but they can be painful. When the thrombosis resolves or is removed, there can be residual external skin tags that can be a challenge for daily hygiene.

“In general, if you see visible tissue and have pain, you have external hemorrhoids. If you experience bleeding with no pain, it is likely an internal hemorrhoid problem,” Dr. Keeler said.

Who’s most likely to get them?

If you’ve had to deal with them, you aren’t alone. It’s estimated that they affect about 1 in 5 Americans, and about half of adults older than age 50 will have them.

Hemorrhoids can be caused by several things, including:

  • straining on the toilet bowl
  • heavy lifting
  • chronic constipation
  • urinary retention issues
  • chronic cough
  • obesity
  • age
  • pregnancy
  • anal sex

The key to avoiding hemorrhoid problems

The key to preventing hemorrhoids is maintaining a regular bowel movement with a soft stool. This can be helped in the following ways:

  • Eat plenty of foods rich in fiber or take a fiber supplement, if necessary
  • Drink plenty of fluids
  • Don’t wait to go No. 2
  • Stay active
  • Maintain a healthy body weight
  • Avoid traumatic insertion of objects into the anal canal
  • Use stool softeners and regulators, as necessary

“Regular use of laxatives should be avoided as the body can become dependent on these medications and create even bigger problems,” Dr. Keeler added.

Treatment options

To ease discomfort, Dr. Keeler suggests the following:

  • Take a sitz bath, a warm water soak in the tub or place a warm washcloth to the area
  • Avoid straining during bowel movements
  • Use over-the-counter hemorrhoid creams, ointments or pads containing hydrocortisone or witch hazel to help reduce swelling and skin irritation

“Creams and ointments work fine for external hemorrhoids. For internal hemorrhoid problems, you need a suppository treatment with an internal application device similar to a low-pressure enema,” Dr. Keeler said. “Prescription strength medications usually add steroids as a higher strength anti-inflammatory to try and shrink the dilated hemorrhoidal tissue.”

Surgical interventions

“Technically, every person has hemorrhoids, but only some people will have problematic hemorrhoids,” Dr. Keeler said. “Between 50-75% of people will have some type of hemorrhoidal irritation in their lifetime, but only 5% will need surgery.”

Surgery may be necessary when there is a lack of response from home treatments, over the counter treatments, or there are continued bleeding problems. Rubber band ligation is a minimally invasive surgical procedure used for treatment.

Dr. Keeler says that surgery to remove hemorrhoids is a permanent solution for that hemorrhoidal column, but there may be other hemorrhoids present that could become a problem in the future. Surgeons don't remove all the hemorrhoidal tissue because doing so could cause anal stenosis (narrowing of the anus) due to the extensive scarring that would result.

When should you seek medical attention?

While rare, if your symptoms continue after a week of home care, or if you are experiencing rectal bleeding, you should see your doctor for a physical exam.

“If you see blood in your stool or on your toilet paper, it is most often from a hemorrhoid, but it can be from other problems including colon, rectal or anal cancer,” Dr. Keeler said. “You should not assume blood passing from the anal canal is not a big deal. This is particularly true for people over the age of 40, but these types of cancers are becoming more common in younger people. A health care provider must be made aware of any episodes of rectal bleeding.”

Big takeaway

Although hemorrhoids aren’t a joke for those who have them, they are easily treated and very preventable. While you may feel embarrassed by them, don’t wait to consult a doctor. A digital rectal exam can help diagnose hemorrhoids and fissures. Early interventions can ease discomfort and reduce complications.

If you are experiencing uncomfortable or painful hemorrhoids, schedule an appointment with your primary care provider. To find a specialist near you, visit bannerhealth.com.

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Updated: Minor content edits were made to this article on September 12, 2022. 

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