Causes of hemorrhoids
The cause of hemorrhoids is a weak connective tissue of the anal or rectal veins. As they lose their elasticity and strength, this causes swelling and bulging of the veins. This makes them susceptible to irritation.
These swelling and bulges of hemorrhoids can be supported by several things, including:
- Standing or sitting for a long time
- Having to press on the toilet
- Chronic constipation or diarrhea
- Low fiber diet
- Holding your breath while lifting heavily
An increase in intra-abdominal pressure during pregnancy, constipation and/or frequent pressing urges on the toilet are the most common factors in the development of hemorrhoids. Weakening of the supportive tissue due to aging and genetics can also be a cause.
Enlarged hemorrhoids are associated with the following symptoms:
- Mucus secretion
- Burning sensation around the anus
- Mild to severe pain
- A feeling that the bowel is not really empty
- Bleeding without any pain
The most common symptom and sign of hemorrhoids is painless bleeding. A person with hemorrhoids may notice bright red blood on the outside of the chair, on toilet paper or it may drip into the toilet.
Bleeding usually goes away on its own without a treatment. However, bleeding from bowel movements is never normal and should encourage a visit to a health professional.
While hemorrhoids are the most common cause of bowel movement bleeding, there may be other reasons for bleeding, including:
- Inflammatory bowel diseases
Hemorrhoids are divided into two general categories:
- Internal, originating in the rectum and
- External, that originate in the anus
Internal hemorrhoids sit in the lining of the rectum and are not obvious, unless they are significantly enlarged, then they can be felt. Internal hemorrhoids are usually painless and become apparent because they cause bleeding when you defecate.
Sometimes hemorrhoids prolapse or protrude from the anus. If so, you may see or feel them as skin pads that are rosier than the surrounding area. Prolapsed hemorrhoids may hurt because the anus is dense with pain-sensitive nerves. Prolapsed hemorrhoids usually go back to the rectum on their own. If they don't, they can be pushed back gently.
Diagnosing an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a gloved finger rectal exam may reveal an internal hemorrhoid at the top of the anal canal, the rectal exam is more helpful in excluding rare cancers that begin in the anal canal and rectum.
A more thorough examination for internal hemorrhoids is done using an anoscope, which is similar to a proctoscope, only smaller.
If bleeding occurs during bowel movements, the colon (the section of the intestine above the rectum) must also be examined to rule out other important causes of bleeding than hemorrhoids, such as colon cancer, polyps or colitis.
External hemorrhoids are located under the skin that surrounds the anus and are deeper than internal hemorrhoids. They can be felt when they swell and can cause the following:
- Bleeding during bowel movements
When an external hemorrhoid pushes itself outward (which usually happens during bowel movements), you can see and feel it.
Sometimes, when external hemorrhoids prolapse, blood clots form which can be extremely painful. This is called thrombosis. When an external hemorrhoid thromboses, it can look scary because it turns red or blue and may also bleed.
Despite their appearance, thrombosed hemorrhoids are usually not serious, although they can be very painful. They usually dissolve on their own in a few weeks. If the pain is unbearable, the doctor can remove the blood clot from the thrombosed hemorrhoid, which will stop the pain.
See a doctor for hemorrhoids
Many people think it's embarrassing to go to their doctor about their hemorrhoid problems, which is probably why only an estimated 4% of people see their doctor, even though 75% of people have enlarged hemorrhoids at one point in their life.
Despite the embarrassment, hemorrhoids should always be examined professionally. A medical exam will help your doctor recommend effective treatment and will rule out more serious causes of your symptoms.
When you see your doctor, you will likely be asked to describe your symptoms. The doctor will do an exam to see if your anus is inflamed and if there are enlarged hemorrhoids. Hemorrhoid examinations are somewhat embarrassing and uncomfortable, but are usually painless.
Most people who have hemorrhoids either discover them
- by feeling the knot of an external hemorrhoid when wiping off after a bowel movement or
- by noticing drops of blood in the toilet bowl or on the toilet paper or
- feeling a prolapsing hemorrhoid (protruding from the anus) after defecation
If you suspect enlarged hemorrhoids, your doctor will likely recommend a proctoscopy (colon endoscopy). During a proctoscopy, a short tube with a light and a lens is used to examine the membranes that line the rectum. This will allow your doctor to see the enlarged hemorrhoids and determine their size. This procedure is also usually pain free.
Based on the course of the symptoms, a doctor can start a diagnosis based on a careful examination of the anus and the anal canal. During the exam, he will also try to rule out other causes of hemorrhoid-like symptoms that require different treatments, such as
- Anal fissures
- Perianal skin diseases (around the anus)
Many doctors use a rating system to categorize hemorrhoids according to four levels:
- Grade 1 hemorrhoids: Hemorrhoids that bleed but do not prolapse. These are slightly enlarged hemorrhoids, but they do not come out of the anus.
- Grade 2 hemorrhoids: Hemorrhoids that prolapse and withdraw on their own (with or without bleeding). These may come out of the anus during certain activities, such as passing stool, and then return to the body.
- Grade 3 hemorrhoids: Hemorrhoids that prolapse and must be pushed back with a finger.
- Grade 4 hemorrhoids: Hemorrhoids that prolapse and can't be pushed back into the anal canal. Grade 4 hemorrhoids also include hemorrhoids that are thrombosed (contain blood clots) or that pull much of the lining of the rectum through the anus.
Symptoms of prolapsed internal hemorrhoids
Internal hemorrhoids prolapse when their blood vessels swell and expand from their location in the rectum through the anus. In the anal canal, the hemorrhoid is exposed to the pressure of the excreted stool. Hard stool with constipation is a problem. This can cause bleeding and pain when the stool is excreted.
The presence of stool, inflammation and constant moisture can lead to anal itching (pruritus ani) and occasionally the constant feeling that you need to have a bowel movement. The prolapsing hemorrhoid usually returns to the anal canal or rectum on its own, or can be pushed back in with a finger, but prolapses again during the next bowel movement.
Symptoms of thrombosed external hemorrhoids
External hemorrhoids can be felt as a swelling around the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids.
However, external hemorrhoids can cause problems if blood clots inside of them. This is called thrombosis. Thrombosis of an external hemorrhoid causes an anal lump, which is very painful and sensitive and often requires medical attention.
The thrombosed hemorrhoid may heal with scarring and may leave an appendage to the skin that protrudes from the anus. Occasionally the appendage is large, which can complicate anal hygiene (cleaning) or irritate the anus.
What helps against hemorrhoids?
Hemorrhoids are a very common rectal disorder. Almost 75% of all people will eventually develop hemorrhoid symptoms. It is therefore important to know how to prevent and treat hemorrhoids.
Various hemorrhoid home remedies are recommended for treating the uncomfortable symptoms. Read here which home remedies, natural vital substances and foods can help with hemorrhoids.
Treat hemorrhoids naturally
Various natural vital substances can help strengthen the function of the hemorrhoid walls and stop the bleeding. Changing the diet and toilet habits can also reduce the frequency and severity of hemorrhoid symptoms.
Diosmin and hesperidin
- It has been shown that the flavonoids diosmin and hesperidin can inhibit the inflammatory response and maintain the function of the capillary endothelium (lining of the blood vessels). They also change the way norepinephrine improves the tone of the veins. In addition, diosmin and hesperidin reduce edema and thus improve the drainage of the lymph.
A study was conducted in Singapore to investigate the role of the flavonoids diosmin and hesperidin in the treatment of bleeding, non-prolapsed internal hemorrhoids. A total of 162 test subjects were randomly assigned to groups who received either dietary supplements with fiber (Ispaghula shells), a rubber band ligation plus fiber or a 9:1 mixture of the flavonoids diosmin and hesperidin plus fiber. There were 66 subjects in the fiber group, 57 in the rubber band fiber group and 39 in the flavonoid fiber group. The study observers did not find out which test subjects received which treatment.
The result showed that hemorrhoidal hemorrhage stopped fastest in the flavonoid fiber group, on average within 4 days. The average time was 6 days in the rubber band fiber group and 11 days in the fiber group. No complications or side effects were noted.
Interestingly enough, three of the subjects in the fiber group gave up after 7 days because they thought the treatment would not work. The follow-up after 6 months showed that only 5% had a relapse in the flavonoid fiber group, as compared to 12% in the fiber group and 21% in the rubber band fiber group. Hemorrhoidectomies (surgical removal of hemorrhoids) were finally performed in two of the subjects in the fiber group and in five people in the rubber band fiber group.
No surgery was performed in the flavonoid fiber group, which took the diosmin/hesperidin mixture in combination with fiber. This combination quickly and safely relieved bleeding from non-prolapsed hemorrhoids. The subjects had far fewer relapses, presumably because the flavonoids improved the health of the veins.
Hesperidin and diosmin have also shown that they can help with chronic venous insufficiency. Excessive pressure in the veins stimulate the activity of the white blood cells and causes an inflammatory reaction, which leads to a deterioration in the structure of the veins and to the permeability of the veins. This overworks the lymphatic system and leads to edema and ulceration of the veins.
Hesperidin and diosmin reduce the formation of free radicals and the associated inflammatory response and reduce the capillary fragility of the veins. This can help reduce chronic venous insufficiency.
- Rutin is also a flavonoid, which strengthens the connective tissue and counteracts inflammation in the body by reducing the formation of free radicals. Like hesperidin and diosmin, rutin is recommended for venous diseases and circulatory disorders, as well as for capillary bleeding and to reduce capillary permeability. Rutin is found in various fruits and fruit peels, especially in citrus fruits.
In a randomized study, 66 patients with symptoms of acute hemorrhoids received a mixture of diosmin, troxerutin (a rutin derivative) and hesperidin (group A). 68 patients received a placebo (group B). The pain and bleeding, as well as the proportion of patients suffering from edema and thrombosis, decreased significantly after 12 days in group A, which received the 3 flavonoids. A mixture of diosmin, troxerutin, and hesperidin can therefore be a safe treatment for hemorrhoidal complaints.
Edema in the legs due to a venous insufficiency can cause symptoms such as pain, heavy legs and night cramps. Edema in the legs in pregnant women can also be a sign of preeclampsia if it is accompanied by increased blood pressure or proteinuria. In one study, pregnant women were given rutin capsules for 3 months. The participants noticed an improvement in symptoms and a decrease in the ankle circumference, while these increased slightly in the placebo group.
OPC grape seed extract
- OPC grape seed extract is known for its antibacterial, anti-allergic, antiviral and anti-inflammatory properties.
It also helps strengthen the collagen fibers of the vessel walls and thus reduce hemorrhoid bleeding.
A randomized control study found that proanthocyanidin effectively and safely eliminated symptoms in 74 people with stage III hemorrhoids, including bleeding, pain, itching and irritation after bowel movements.
Numerous studies have shown that OPC is ideal for stabilizing collagen fibers when it is weakened by increasing resistance to enzymes that destroy collagen. OPC also stimulates the production of collagen and elastin, which is helpful in restoring damaged skin in hemorrhoids.
Effect of OPC on hemorrhoids:
- Reduces inflammation
- Reduces bleeding, pain and itching
- Stabilizes the collagen in the damaged tissue
- Reduces skin irritation caused by hemorrhoids
- Vitamin C can also help strengthen the weakened vein walls of the hemorrhoids because it is part of the production of collagen. This is especially the case when it is taken together with bioflavonoids, as these improve the absorption and duration of action of vitamin C in the body.
Vitamin C occurs in combination with bioflavonoids, for example in acerola vitamin C, camu camu, rose hips and amla berries. Flavonoids have shown that they can significantly improve the strength and elasticity of the veins.
Especially people who are stressed, smoke or do not get enough vitamin C from their diet run the risk of developing a vitamin C deficiency. With increasing age, the need for vitamin C increases because the body can't naturally produce enough collagen and elastin to repair damaged collagen tissue.
The stability of the collagen fibers depends on the strength of the links (amino acids) between the protein chains. The vitamin C joins the links of this chain and thus provides more stability.
Vitamin C, together with bioflavonoids, can stabilize the inflamed hemorrhoids and can thereby stabilize the general condition of the affected veins in the anus and rectum.
- Butcher's broom can help reduce the swelling and inflammation of hemorrhoids. A study conducted in Germany in 2002 found that butcher's broom was an effective way of treating patients who suffered from a chronic venous insufficiency, a condition in which the blood flow through the veins is inadequate, causing the blood to accumulate.
- A 2010 study published in Phytotherapy Research examined the efficacy of orally and locally applied Pycnogenol® hemorrhoid cream for the treatment of acute hemorrhoidal seizures in a controlled, randomized study of 84 subjects.
Patients' signs and symptoms were assessed within less than 48 hours of a seizure. The reduction in point scores was more significant in the Pycnogenol group than in the control group who received a placebo. The study suggests that oral and topical pycnogenol helps reduce acute hemorrhoid symptoms.
Chestnut (Horse Chestnut)
- Chestnut is often used as a herbal remedy for low blood flow and swelling. According to research published in the Alternative Medicine Review, chestnut has been shown to improve microcirculation, capillary flow and vascular tone, all of which are helpful for getting rid of hemorrhoids.
- Psyllium husks are purely natural fibers that are offered in powder form. Studies show that plant fibers such as psyllium husks can reduce the frequency of bleeding when using the toilet and can help reduce constipation or clenching. If you use psyllium husks, make sure you drink plenty of water.
A 2011 animal study published in Digestive Diseases and Sciences found that psyllium husk had an intestinal stimulant and laxative effect on mice. At higher doses, they have an antisecretory activity (which reduces the normal level of body fluid secretion) and reduces diarrhea.
- To soften the stool and increase bowel movements, you can also try magnesium as a dietary supplement. You should take it up to intestinal tolerance. In other words, take enough magnesium to make your stool softer but not too much to cause diarrhea. Everyone reacts differently to magnesium, but generally 500 to 1,500 mg of pure magnesium a day helps.
Reduce hemorrhoids through proper nutrition
The best way to prevent hemorrhoids is to keep the stool soft so that it can be easily excreted and no pressing is required. Eating a high fiber diet and drinking plenty of fluids (six to eight glasses a day) can also help keep the stool soft. It can reduce constipation and therefore reduce the need to press while on the toilet, reducing the risk of developing new hemorrhoids.
Eat high fiber foods
- To reduce the symptoms of hemorrhoids, it is important that you avoid constipation and hard stools. You can achieve this by eating lots of fiber-rich foods to soften the stool. The daily recommended dose is 30- 35 grams of fiber.
Eat foods like avocados, berries, figs, brussel sprouts, beans, vegetables, lentils, nuts, flax seeds, chia seeds and quinoa. In clinical studies, a high-fiber diet reduced the risk of persistent symptoms and bleeding by up to 50 percent.
It should be noted that it may take up to six weeks after you increase your fiber intake until you notice any improvement.
Drink lots of water
- Insufficient fluid intake can lead to constipation because water or fluids are required for fiber to pass smoothly through the digestive tract.
Many studies, including one published in the European Journal of Clinical Nutrition, suggest that fluid loss and low fluid intake can promote constipation, which aggravates hemorrhoid symptoms. To reduce constipation and get rid of hemorrhoids, drink at least one glass of water with every meal and snack of the day.
Eat fermented foods
- Fermented foods such as kefir, kimchi and plain yogurt can help supply the digestive system with healthy bacteria, which contribute significantly to a proper excretion.
Several studies have shown that fermented foods and probiotics improve the health of the intestinal tract, increase the bioavailability of nutrients, optimize the pH in the intestine and support digestion.
Reduce alcohol consumption and eating spicy foods
- Alcohol can dry out the body and worsen hemorrhoid symptoms. Savory foods can also intensify the symptoms of hemorrhoids.
Some studies show that drinking alcohol and savory foods are both risk factors for hemorrhoids, although the data are not consistent. To be sure, limit these foods until hemorrhoid symptoms improve.
Reduce hemorrhoids through better toilet habits
Improving toilet habits can help reduce the occurrence and intensity of hemorrhoids.
- Squeezing during a bowel movement can be painful and make hemorrhoid problems worse. Don't wait too long before going to the bathroom. Pay attention to your body's signals and if you feel an urge to use the toilet, leave immediately. Otherwise the stool will become harder and this will automatically make you press harder. When you are on the toilet, take your time and relax your body.
Avoid sitting on the toilet for long periods of time
- Spending too much time in the toilet can make hemorrhoids worse. Do not read or distract yourself while using the toilet. This will only result in you spending more time on pressing.
Clean yourself thoroughly
- If stool is left behind after wiping, the hemorrhoid can get worse, so it is important that you clean yourself thoroughly after going to the toilet.
However, do not clean yourself too roughly or use soaps that contain aggressive chemicals, alcohol or perfumes. Instead, use clear water to wipe yourself off and then dry your butt afterwards. A hip bath, sitting in warm water for 10 minutes twice a day, is helpful for patients with anal itching, pain or burning sensations and is known to be one of the best ways to get rid of hemorrhoids quickly.
Make warm hip baths
- A hip bath refers to sitting in a few centimeters of warm water three times a day for 15 to 20 minutes. A hip bath can help reduce inflammation of the hemorrhoids. It is important to carefully dry the anal area after each bath to minimize moisture around the anus that could irritate the skin.
Hemorrhoid ointment and hemorrhoid cream
A hemorrhoid ointment or hemorrhoid cream can reduce the itching and inflammation associated with hemorrhoids.
- Studies have shown that chamomile ointment, like chamomile tinctures used in a hip bath, can improve hemorrhoid symptoms. A chamomile tincture can also reduce inflammation associated with hemorrhoids.
- Witch hazel is a plant that is used for its skin healing, astringent and antioxidant properties. Topical use of witch hazel can help alleviate hemorrhoids by reducing inflammation and pain.
Researchers have found that witch hazel inhibits two enzymes that are involved in the breakdown of connective tissue. As the activity of these enzymes increases, the integrity of blood vessels is compromised.
- Applying marigold ointment to the hemorrhoids can reduce swelling and inflammation in the anus area and promote wound healing of the irritated skin.
OPC and Pycnogenol
- Another possible solution is OPC grape seed extract or Pycnogenol®, which is obtained from the pine bark. Both topical and oral Pycnogenol® improve hemorrhoid symptoms and the combination of both forms appears to be particularly effective.
In a randomized, controlled trial in subjects suffering from acute hemorrhoid pain, the group of patients given local (0.5 percent) Pycnogenol® combined with oral Pycnogenol® had a quicker improvement in symptoms as compared to subjects who only received Pycnogenol® orally. The aim should be to take 100 mg three times a day.
Hemorrhoidal bleeding was completely absent in all patients who were treated with Pycnogenol® for seven days and also in the follow-up examination after 14 days. The researchers still observed bleeding in the control group.
- To reduce the friction in the anal area during bowel movements, you can rub the anal area with coconut oil beforehand, a healthier option of hemorrhoid ointments that contain parabens.
Movement reduces hemorrhoids
People who only sit on their job should get up from their desk every hour and do some exercise. This prevents the blood from building up in the hemorrhoids.
Exercise can also help reduce stress. People who are stressed are more likely to contract the anal sphincter and apply pressure to the rectal area. Stress can also lead to eating low-fiber, sugared foods that increase the likelihood of constipation.
Meditate, take deep breaths to reduce your stress levels. To make you think more about moving and relaxing, attach a note to your computer or set a watch to remind you.
Medical hemorrhoid treatment
Treating enlarged hemorrhoids is important because they tend to worsen over time. Hemorrhoids are treated with a variety of measures and over-the-counter medications, such as
- Hemorrhoid ointments
- Hemorrhoid cream
- Hemorrhoid lotions
- Hemorrhoid suppositories
and different procedures such as
- Rubber band ligation
- Infrared coagulation
When used around the anus, ointments and creams should be applied as a thin layer. When applied to the anal canal, these products should be inserted with a finger or a 'shock tube'.
Shock tubes are most efficient if they have holes on both sides and the end. Shock tubes should be moistened with ointment before insertion. Suppositories or foams have no advantages over ointments, creams and gels.
Sclerotherapy is one of the oldest forms of treatment for hemorrhoids. During sclerotherapy, a liquid (phenol or quinine urea) is injected into the base of the hemorrhoid.
The veins thrombose, inflammation sets in and finally scarring occurs. Eventually, sclerotherapy causes the hemorrhoid to shrink. Pain may occur after sclerotherapy, but it usually subsides the next day. Symptoms of hemorrhoids often return after several years and may require further treatment.
Rubber band ligation
This procedure is used to remove a hemorrhoid with a rubber band. The doctor inserts a small tool called a ligator through a thin tube into the anal canal. Then the doctor grabs the hemorrhoid with a pair of pliers, pushes the ligator cylinder up and loosens the rubber band around the base of the hemorrhoid. The rubber band cuts off the hemorrhoid's blood supply and causes it to atrophy.
A study from 2000 published in Digestive Surgery found that rubber band ligation is a useful, safe and successful method of treating second and third degree symptomatic hemorrhoids and that it can be used successfully in fourth degree cases as well. However, it has an increased recurrence rate and additional treatment will be required.
The most common complication of the ligature is pain. Bleeding or bacterial infection in the tissues surrounding the hemorrhoids (cellulitis) may occur a week or two after ligation.
Thermal treatment of hemorrhoids
There are various treatments that use heat to destroy hemorrhoidal tissue and promote inflammation and scarring, including
- Infrared photo coagulation
- DC electrotherapy and
- Bipolar diathermy
These procedures destroy the tissues in and around the hemorrhoids and cause the formation of scar tissue. They are used for first, second and third degree hemorrhoids. Pain is common, though less likely than ligature, and bleeding occurs occasionally.
During the infrared photo-coagulation, the doctor uses a special device to generate an infrared light beam. The resulting heat causes scar tissue to cut off the blood supply to the hemorrhoid. Infrared photo-coagulation is a better option for 1st and 2nd degree hemorrhoids because the recurrence rate is high for 3rd and 4th degree hemorrhoids.
In direct current electrocoagulation, the doctor uses a thin wire probe to transmit radio waves to the hemorrhoid tissue. This causes the molecules in the tissue to vibrate, which leads to a rapid increase in temperature and effectively kills the tissue.
DC electrocoagulation works better for 3rd and 4th degree hemorrhoids and is associated with less discomfort and fewer complications. In a study with 120 patients treated with DC electrocoagulation, all patients remained symptom-free during the 23 month follow-up treatment.
In bipolar diathermy, the hemorrhoid is exposed to electrical current. The current only flows through the tissue being treated due to the use of special pliers.
The majority of patients can control their symptomatic hemorrhoids with non-surgical techniques. Non-surgical treatment is preferred because it is associated with less pain and fewer complications than surgical treatment. It is estimated that less than 10% of patients will need surgery if the hemorrhoids are treated early.
The surgical hemorrhoid removal, known as hemorrhoidectomy or stapled hemorrhoidectomy, is primarily used in patients with third or fourth degree hemorrhoids.
During a hemorrhoidectomy, the internal and external hemorrhoids are cut out. The wounds left behind by the removal can be sutured (closed technique) or left open (open technique). The results are similar for both techniques.
A proctoplasty, which extends the removal of tissue farther into the anal canal so that redundant or prolapsing anal lining is also removed, is sometimes also performed. Postoperative pain is a major problem with hemorrhoidectomy and strong pain relievers (narcotics) are usually required.
Stapler-assisted hemorrhoidectomy is a newer surgical technique that is increasingly becoming the treatment of choice for third degree hemorrhoids. This surgery does not remove the hemorrhoids, but rather the tissue that supports the hemorrhoids that allowed the hemorrhoids to prolapse downward.