Written by Manuel Francisco T. Roxas, MD, FPCS, FPSCRS, FPSGS, FACS | 18 March 2010

• How do hemorrhoids look and feel?

Hemorrhoidal cushions are skin, vascular and soft tissues that line the anal canal, playing a small role in defecation and continence.  Everyone has them, although with our daily travails of straining and movement, they do change over time, becoming more lax or loose as we age.  

Hemorrhoidal disease occurs when these changes result in bothersome symptoms such as bleeding, prolapse, or pain.  Almost everyone may develop hemorrhoidal symptoms at some point in their life, but these are not life-threatening, and may be safely observed.

Treatment is usually required for those whose hemorrhoidal symptoms impact on quality of life and daily living.

• What are the symptoms of hemorrhoids?

Bleeding from hemorrhoids is usually bright red, often dripping into the toilet bowl, or noticed when wiping. The stools themselves are normal looking, indicating that the bleeding is originating only from the anorectal area.  Sludge of dark blood and stool mixed thoroughly together is usually from a source within the small and large intestines and not hemorrhoids. Hemorrhoidal bleeding is painless, and this differentiates it from anal fissures, which is also a very common anal condition that presents with similar bright red bleeding during defecation, but with anal pain.

Hemorrhoids only become painful when they thrombosed or incarcerated.  Thrombosed hemorrhoids occur when blood clots within the hemorrhoids, causing very obvious swelling and pain.  While surgery for this may be effective during the first 4 days of the attack, if left alone the swelling and pain gradually subside and disappear after 2 weeks.  Usually this occurs just once or twice in a person’s lifetime, and it is uncommon to have repeated episodes of thrombosis.  

Doctors often classify patients as to having either external or internal hemorrhoids.  External hemorrhoids are located just outside the anus, and hence are always visible on routine inspection.  They hardly cause any bleeding, and are painful only if thrombosed.  Many people have them without suffering from any symptoms, and therefore these may be safely left alone.  Sometimes external hemorrhoids may make cleaning difficult, allowing sweat and anal discharge to hide between folds, resulting in anal itching.

Internal hemorrhoids arise from inside the anus and are therefore only visible when, because of excessive laxity, they protrude outside.  This condition is called prolapse, and usually occurs during defecation.  When internal hemorrhoids prolapse they may either slip back inside on their own, or require manipulation by the person for it go back in.  When the prolapsed hemorrhoids cannot be returned, they become trapped outside, resulting in pain and swelling.  This scenario is called incarcerated hemorrhoids.

• What are the forms of treatment – surgical and non-surgical?

Hemorrhoids only require treatment when there are symptoms.  And the type of treatment depends on the severity of symptoms.  Mild symptoms may be managed just by eating a lot of fiber and taking in bulk laxatives such as psyllium to improve the consistency of stools and ease bowel movement.  Some over-the-counter creams may provide symptomatic relief.

Non-surgical and almost painless treatments for hemorrhoids include injection sclerotherapy, infrared photocoagulation (often mislabeled as “laser treatment”), and rubber band ligation, any of which can be done safely in the clinic as an out-patient procedure.  In scientific studies comparing these methods, rubber band ligation was found to be the most effective and cheap, which is why it is the most common non-surgical procedure for hemorrhoids in the world today.

Non-surgical treatment is often ineffective for large, incarcerated or thrombosed hemorrhoids.  Surgery is usually recommended in these situations, and also when non-surgical treatment has failed to relieve symptoms.  Traditional surgery requires cutting out the hemorrhoid using a variety of instruments such as scissors, knives, cautery, and ultrasonic dissectors. Unfortunately, any wound created in the outer skin of the anus results in often sever post-operative pain, which is responsible for the reputation of hemorrhoid surgery being one of the most painful of operations.

• What are the advances in hemorrhoids treatment?

Due to this reputation of being a painful operation, advances in hemorrhoid surgery have focused on making it less painful.  One such operation is stapled hemorrhoidectomy. Using a specially-designed, single-use stapler instrument (which was modified from the staplers used to reconnect intestines during major abdominal surgery), the hemorrhoids are excised and the anus repaired from the inside, something which is difficult to do with traditional surgery.  The end result is that the surgical wound is inside, and no wound is visible outside the anus. Scientific studies have proven that this is less painful than traditional surgery, although with a small recurrence rate.

Another advanced surgical technique is Transarterial Hemorrhoidal Dearterialization (THD).  Using a doppler ultrasound, the blood vessel supplying the hemorrhoid is identified and ligated with stitches.  Deprived of its blood supply, the hemorrhoid then shrinks and shrivels.  Again there is no wound outside and is therefore almost painless.  However, because it is a new technique, not very many studies evaluating its long-term effectiveness have come out.

All surgical procedures for hemorrhoids, whether traditional or innovative, may sometimes develop complications such as bleeding, infection and stricture. Although rare, they do require experienced management.  It is important therefore when seeking treatment, to see an expert in anal diseases.  Aside from hemorrohoids, there are other common conditions that afflict the anus.   A well-trained expert will be able to determine the exact nature of the problem, as well as provide many options of treatment, depending on the patient’s severity of symptoms,  expectations regarding treatment and recovery, as well as budget.

• What are the common misconceptions about hemorrhoids?

One of the most common misconceptions about hemorrhoids is that it is the only disease of the anus.  Many patients with anal symptoms often diagnose themselves as having hemorrhoids.  While this may be true for a majority, a significant number of cases are due to other anal diseases such as fissures, infections, and even cancer.  It is imperative therefore that any one suffering from anal symptoms should seek medical consultation to determine what is the true cause of the problem.

In relation to that, another misconception about hemorrhoids is that it can lead to cancer.  This is not true.  Hemorrhoids are a benign, non-life-threatening condition.  What may happen instead is that a person who has an early anal or rectal cancer may mistake the symptoms for that of hemorrhoids.  This is the reason why the Philippine Society of Colorectal Surgeons recommends that all persons with anal symptoms be first evaluated by a physician.

One misconception about surgery for hemorrhoids is that it can cause fecal incontinence, or the inability to control one’s self from inappropriate farting or defecation.  Again this is not true. Properly done hemorrhoid surgery, using any of the techniques discussed previously, does not entail cutting or injuring the anal muscles.  Therefore no complication such as incontinence should develop.  What may happen is that a fresh wound from a recent operation weeps and leaks out, mistakenly giving the impression of incontinence, but this usually resolves with healing.  Another situation is when patients, usually elderly females, already have weak anal muscles and mild incontinence which are unnoticed, perhaps because of the hemorrhoids.  Unfortunately, only when the hemorrhoids are removed do the true symptoms of the underlying incontinence emerge.  This is the reason why a thorough and experienced evaluation is important, and that various options of treatment are considered aside from just surgery.

Another common misconception about hemorrhoids is the use of lasers.  A true LASER is defined as Light Amplification by Stimulated Emission of Radiation, and in medical applications is used as a very fine, and precise cutting instrument (such as when in ophthalmology).  The technology is very expensive, and therefore using a true laser for hemorrhoid surgery makes the procedure quite prohibitive.  More importantly scientific studies have when used for hemorrhoids that lasers are just like regular knives or scissors, providing no additional benefit in terms of pain or healing.  The same is true with regards cryosurgery, which entails freezing the hemorrhoid using liquid nitrogen.  Again, no clear advantage has been demonstrated of this technique over traditional surgery, and it may actually result in more necrosis and foul discharge.

In conclusion, this last part of the discussion only goes to show that there is a lot of misconception in the public about hemorrhoids and their treatment. Unfortunately this is propagated by many false claims and unscrupulous practices.  Hemorrhoids are a very common condition that is often bothersome, sometimes very painful, but never life-threatening.  All symptoms must be evaluated by a doctor to make sure one truly has hemorrhoids.   There are a variety of surgical and non-surgical options, and these should always be discussed first with an expert in colorectal diseases prior to making a decision on treatment.