Dear Doctor Column, December 16, 2002

Question:

I'm having a lot of bleeding from external hemorrhoids. I'm a 61-year-old female with a history of a heart condition and would like to be treated without surgery.

Answer:

Hemorrhoids are swollen blood vessels in and around the anus and lower rectum that stretch under pressure, similar to varicose veins in the legs. The increased pressure and swelling may result from straining to move the bowel. Other contributing factors include pregnancy, heredity, obesity, and aging. About 50% of the population have hemorrhoids by age 50.

Increased pressure also can result from lifting heavy objects, a low-fiber diet, standing or sitting for long periods, or lingering on the toilet following a bowel movement. Diarrhea can promote or aggravate hemorrhoids, as well. Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.

Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external). The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. 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.

Treatment is aimed at easing symptoms, which typically include pain, burning, and itching. Measures to reduce symptoms include: Warm tub or sitz baths several times a day in warm water for about 15 minutes; ice packs to help reduce swelling; and application of a hemorrhoidal cream or suppository to the affected area. In addition, your doctor may suggest a bulk stool softener or a fiber supplement, such as psyllium (Metamucil) or methylcellulose (Citrucel).

It may be necessary to surgically treat persistent, painful hemorrhoids or those that continue to bleed. These methods are used to shrink and destroy the hemorrhoidal tissue and are performed in an outpatient setting under anesthesia:

• 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 days.
• Sclerotherapy. A chemical solution is injected around the blood vessel to shrink the hemorrhoid.

Other techniques used to treat both internal and external hemorrhoids include:

• Electrical or laser heat or infrared light. Both techniques use special devices to burn hemorrhoidal tissue.
• Hemorrhoidectomy. Extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy. This is the best method for permanent removal of hemorrhoids.

The following measures can ease the discomfort of hemorrhoids and can keep them from getting worse:

• Avoid constipation. Eat a high-fiber diet, consisting mainly of fruits, whole-grain products, and vegetables. Drink six to eight glasses of water a day to increase fecal bulk and prevent straining.
• Do not strain or hold your breath on the toilet. Choose a time when you are not rushed, and do not ignore the urge to defecate.
• Wipe the anal area with a moistened cloth or stream of warm water, instead of dry toilet paper. Cool compresses soaked in water or witch hazel also can help.

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.

Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching, have similar symptoms and are incorrectly referred to as hemorrhoids. A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. This is not a sign to be ignored or self-diagnosed as bleeding from hemorrhoids. Bleeding also may be a sign of other digestive diseases, including colorectal cancer, which is curable if diagnosed early.