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BRUCE ROSEMAN, M.D.
What Are Hemorrhoids?
The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed.
Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse.
Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external). (See figure.)
What Are the Symptoms of Hemorrhoids?
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids.
Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.
Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid.
Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid.
In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.
How Common Are Hemorrhoids?
Hemorrhoids are very common in both men and women. About half of the population have hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.
How Are Hemorrhoids Diagnosed?
A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.
The doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.
Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.
To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.
What Is the Treatment?
Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Measures to reduce symptoms include
Warm tub baths several times a day in plain, warm water for about 10 minutes.
Application of a hemorroidal cream or suppository to the affected area for a limited time.
Illustration reprinted with permission from the American Society of Colon and Rectal Surgeons. Artist: Russell K. Pearl, M.D.
Preventing of the recurrence of hemorrhoids will require relieving the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid (not alcohol) result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.
Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel).
In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to shrink and destroy the hemorrhoidal tissue. The doctor will perform the procedure during an office or hospital visit.
A number of methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include
Rubber band ligation. A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.
Sclerotherapy. A chemical solution is injected around the blood vessel to shrink the hemorrhoid.
Infrared coagulation. A special device is used to burn hemorrhoidal tissue.
Hemorrhoidectomy. Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy.
How Are Hemorrhoids Prevented?
The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.
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The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1980, the clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.
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An anal fissure is a small split or tear in the anal mucosa that may cause painful bowel movements and bleeding. There may be blood on the outside of the stool or on the toilet tissue following a bowel movement.
Causes, incidence, and risk factors
Anal fissures are extremely common in young infants but may occur at any age. Studies suggest 80% of infants will have had an anal fissure by age one. Most fissures heal on their own and do not require treatment, aside from good diaper hygeine. However, some fissures may require medical treatment.
The incidence of anal fissures decreases rapidly with age. Fissures are much less common among school-aged children than among infants.
In adults, fissures may be caused by constipation, particularly when passing large, hard stools, or by prolonged diarrhea. In older adults, anal fissures may be caused by decreased blood flow to the area.
Anal fissures are also common in women after childbirth and people with Crohn's disease.
Pain while having a bowel movement
Blood on the surface of stool (not mixed in with stool)
Blood on toilet tissue or wipes
A crack in the skin that is visible when the anus is stretched slightly (the fissure is almost always in the midline)
Constipation, often with painful bowel movements
Signs and tests
Inspection of the rectum
Physical exam of the rectal mucosa
Dietary adjustment (addition of bulk -- substances that absorb water while in the intestinal tract)
Cleansing more gently
Anesthetic ointment, if pain interferes with normal bowel movement
Topical muscle relaxants
These measures generally heal more than 90% of anal fisssures.
For fissures that do not heal with these home treatments, injection of botulinum toxin (Botox) into the anal sphincter may be used to temporarily paralyze the anal sphincter muscle and promote healing. Another option for nonhealing fissures is a minor surgicial procedure to relax the sphincter.
Anal fissures generally heal quickly without residual problems. However, people who develop fissures are more likely to have them in the future.
Occasionally, a fissure becomes chronic and will not heal. Chronic fissures may require minor surgery to relax the sphincter.
Calling your health care provider
Call your health care provider if symptoms associated with anal fissure are present, or if the fissure does not heal appropriately with treatment.
To prevent anal fissures in infants, be sure to change diapers frequently.
To prevent fissures at any age:
Keep the anal area dry
Wipe with soft materials or a moistened cloth or cotton pad