Hemorrhoids

The primary cause of hemorrhoids is increased pressure in the lower rectum. This pressure interferes with blood flow, causing the veins to swell and the supporting tissues to stretch and weaken. Research published in the World Journal of Gastroenterology (2023) suggests that chronic inflammatory processes in the anal canal may also contribute to the degradation of the vascular cushions.

Non-Modifiable Risk Factors

• Age: The tissues that support the veins in the rectum and anus can weaken and stretch as part of the aging process.
• Genetics: A family history of hemorrhoids or weak venous valves may increase susceptibility.
• Pregnancy: The weight of the fetus and the increased blood volume put significant pressure on the pelvic veins.

Modifiable Risk Factors

• Diet: A low-fiber diet leads to hard stools and constipation, which are major contributors to straining.
• Physical Inactivity: Sedentary behavior, especially prolonged sitting on the toilet, increases pressure on the anal veins.
• Obesity: Excess body weight increases intra-abdominal pressure.
• Chronic Straining: Frequent heavy lifting or chronic coughing can exacerbate venous engorgement.

According to the American Society of Colon and Rectal Surgeons (ASCRS, 2024), individuals aged 45 to 65 are at the highest risk. Additionally, those with chronic constipation or diarrhea are significantly more likely to develop symptomatic disease. Socioeconomic factors that limit access to high-fiber foods also correlate with higher incidence rates in certain populations.

Evidence-based prevention focuses on maintaining soft stools. The NIDDK recommends a daily intake of 25 to 35 grams of fiber and adequate hydration. Regular physical activity helps maintain bowel motility, and avoiding 'delayed' bowel movements prevents stool from hardening in the colon. Screening is not typically required for hemorrhoids specifically, but persistent rectal bleeding should always be evaluated to rule out colorectal cancer.

The diagnostic journey typically begins with a clinical history and a physical examination. Because rectal bleeding can also indicate more serious conditions, such as colorectal cancer or inflammatory bowel disease (IBD), healthcare providers may use several methods to confirm the diagnosis.

A healthcare provider will perform a visual inspection of the perianal area to identify external hemorrhoids, skin tags, or prolapsed internal hemorrhoids. This is usually followed by a Digital Rectal Examination (DRE), where the provider inserts a lubricated, gloved finger into the rectum to feel for abnormalities, masses, or the tone of the anal sphincter.

• Anoscopy: A short, rigid tube (anoscope) is used to view the lining of the anus and lower rectum. This is the gold standard for visualizing internal hemorrhoids.
• Proctoscopy/Sigmoidoscopy: These tests involve a slightly longer tube to examine the rectum and the lower part of the colon (sigmoid).
• Colonoscopy: If a patient is over age 45 or has 'red flag' symptoms (weight loss, change in bowel habits), a full colonoscopy may be ordered to examine the entire large intestine and rule out malignancy.

Diagnosis is based on the presence of symptomatic vascular cushions. For internal hemorrhoids, the Goligher Classification system is used to grade the severity (Grades I-IV) based on the degree of prolapse observed during the exam.

Several conditions can mimic the symptoms of hemorrhoids, including:

• Anal Fissures: Small tears in the anal lining (usually causes more severe pain during defecation).
• Perianal Abscesses: Infected pockets of fluid.
• Inflammatory Bowel Disease (IBD): Crohn's disease or ulcerative colitis.
• Colorectal Polyps or Cancer: Which can also cause rectal bleeding.

The primary goals of treatment are to alleviate acute symptoms (pain, itching, bleeding), promote the healing of damaged tissues, and prevent recurrence through lifestyle modification and structural intervention.

According to the American College of Gastroenterology (ACG) guidelines (2023), first-line treatment is conservative. This includes increasing dietary fiber, increasing fluid intake, and using 'sitz baths' (soaking the anal area in warm water for 10-15 minutes several times a day). These measures resolve symptoms for the majority of patients with Grade I and II hemorrhoids.

• Corticosteroids: These are used in topical forms (creams, ointments, or suppositories) to reduce inflammation, swelling, and itching. They are typically intended for short-term use (less than a week) to avoid thinning the skin.
• Local Anesthetics: These provide temporary pain relief by numbing the nerve endings in the anal area. They are often preferred for external hemorrhoids or acute flares.
• Osmotic Laxatives [EPC]: These medications draw water into the colon to soften the stool, making it easier to pass without straining. They are preferred when dietary fiber alone is insufficient.
• Protectants and Astringents: These form a physical barrier over the skin to prevent irritation from fecal matter and can help shrink swollen tissues.

If conservative measures fail, office-based procedures may be used:

• Rubber Band Ligation: The most common procedure for internal hemorrhoids, where a small band is placed around the base to cut off circulation.
• Sclerotherapy: An injection of a chemical solution to shrink the hemorrhoid.
• Infrared Coagulation: Using heat to cause the hemorrhoid to wither.

For severe (Grade III or IV) or unresponsive cases, surgical intervention may be necessary. A Hemorrhoidectomy involves the surgical removal of the excess tissue. Hemorrhoidopexy (stapling) is an alternative that repositions the hemorrhoids and cuts off their blood supply.

Conservative treatments usually show results within 7 to 10 days. If symptoms persist beyond this period despite treatment, a follow-up with a specialist (proctologist or gastroenterologist) is required.

In pregnant patients, treatment focuses almost exclusively on conservative measures (fiber and sitz baths) to avoid fetal exposure to medications. In the elderly, providers must be cautious with laxative use to prevent electrolyte imbalances.

> Important: Talk to your healthcare provider about which approach is right for you.

Nutrition is the cornerstone of hemorrhoid management. A 2022 meta-analysis published in the American Journal of Gastroenterology confirmed that high fiber intake significantly reduces the risk of bleeding and symptom persistence. Patients should aim for a mix of soluble and insoluble fiber from sources like lentils, broccoli, whole grains, and pears. It is critical to increase water intake concurrently; otherwise, supplemental fiber can worsen constipation.

Moderate aerobic exercise, such as brisk walking for 30 minutes a day, stimulates bowel function. However, patients should avoid heavy weightlifting or 'powerlifting' during acute flares, as the Valsalva maneuver (straining while holding breath) significantly increases rectal pressure.

While sleep doesn't directly affect hemorrhoids, resting in a side-lying position can help reduce pressure on the pelvic veins, especially during pregnancy. Avoiding long periods of sitting, even while working, is essential.

Stress can lead to digestive issues, including constipation and irritable bowel syndrome (IBS), which exacerbate hemorrhoids. Evidence-based techniques like diaphragmatic breathing can help relax the pelvic floor muscles during bowel movements.

• Witch Hazel: Topical application of witch hazel (an astringent) is widely used for its cooling and anti-inflammatory effects, though clinical data is limited.
• Acupuncture: Some studies suggest acupuncture may help with post-operative pain management following a hemorrhoidectomy.
• Biofeedback: May be useful for patients whose hemorrhoids are caused by pelvic floor dyssynergia (uncoordinated muscle movement during defecation).

Caregivers should encourage hydration and help monitor for signs of anemia if the patient is elderly. Providing a 'toilet stool' (which elevates the feet to create a squatting position) can help the patient pass stools more easily.

The prognosis for hemorrhoids is generally excellent. Most cases respond well to conservative management or minor office procedures. According to data from the American Society of Colon and Rectal Surgeons (2024), over 90% of patients experience significant symptom relief with non-surgical or minimally invasive treatments. However, recurrence is possible if the underlying causes, such as a low-fiber diet or chronic straining, are not addressed.

• Strangulated Hemorrhoid: Occurs when the blood supply to an internal hemorrhoid is cut off, causing extreme pain and potential tissue death (necrosis).
• Anemia: Chronic blood loss can lead to low red blood cell counts.
• Infection: Though rare, an external hemorrhoid or surgical site can become infected.

Long-term success depends on permanent lifestyle changes. This includes a lifelong commitment to high fiber intake and proper 'toilet hygiene'—specifically, not spending more than 5-10 minutes on the toilet and avoiding the use of smartphones while sitting.

Patients can lead a normal, active life by managing triggers. Using moist wipes instead of dry paper and wearing cotton underwear can prevent skin irritation. Joining support groups for digestive health can also help manage the social stigma sometimes associated with the condition.

Contact your doctor if you notice a change in the color or consistency of your stool, if bleeding becomes more frequent, or if a previously soft lump becomes hard and extremely painful (suggesting a thrombus).