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hemorrhoids

Synonyms in a broader sense

Rectal varicose veins
Hemorrhoid disease

outdated: blind / golden veins

English: hemorrhoids

definition

The term "hemorrhoids" in colloquial terms refers to the pathological swelling or varicose vein-like changes in the vascular network in the rectum, the Hemorrhoidal plexus.

This "venous cushion" is arranged in a ring in front of the sphincter muscle. The normal task of hemorrhoids is to close the anus, they act like a cavernous body. The urge to defecate swells Hemorrhoidal plexus and thus supports the sphincter.

One speaks of hemorrhoids when these vessels are and remain swollen permanently and beyond the normal extent. Hemorrhoids can be divided into four degrees of severity, depending on their size and symptoms.

Grade 1 denotes barely noticeable, minor swellings in the veins that are not visible from the outside and often resolve without treatment.
Grade 2 denotes visibly enlarged hemorrhoids that are pushed outwards when pressed, but lie inside when relaxed.
3rd and 4th degree hemorrhoids are massively enlarged and visibly protrude from the rectum, whereby 4th degree hemorrhoids can no longer be pushed inwards.

Read more about these topics: Symptoms of hemorrhoids

Frequency distribution

Haemorrhoids can be detected in 70% of all adults over 30 years of age with a corresponding proctological examination. However, these often do not cause any symptoms and therefore do not require treatment.

More men than women are affected, in a ratio of 2: 1. The average age of the patient with hemorrhoids is 50 years.
There are around 1,000 new cases per 100,000 inhabitants every year.

causes

Hemorrhoids usually form after the age of 30 due to degeneration of the elastic fibers within the vascular plexus. As a result of these natural processes, the walls of the vascular cushion can no longer return to their normal size if there is no urge to defecate.

Other causes are also chronic constipation or the resulting frequent and intense pressing during bowel movements, as well as frequent increased tension of the anal sphincter, for example through frequent stool holdings. Furthermore, the regular consumption of laxatives can promote the development of hemorrhoids. The reason for this is then the stronger pressing during bowel movements when no laxatives have been taken.

In addition, people who sit down are at a higher risk of developing hemorrhoids than people who stand or walk more often. Here, too, the cause is ultimately permanent pressure on the veins and arteries of the hemorrhoids.

Hemorrhoids are also very common during pregnancy. The loosening effect of the hormones on the connective tissue may be responsible for this.

However, it is important to know that hemorrhoids never appear overnight. They arise within years to decades and the predisposition is genetically inherited.

Hemorrhoids During Pregnancy

An increased incidence of hemorrhoids can be observed during pregnancy. 65-85% of women with hemorrhoidal symptoms state that they first observed them during pregnancy. If hemorrhoids already exist at the beginning of the pregnancy, then in 85% of the cases during pregnancy and delivery the hemorrhoid condition worsens. Repeated pregnancies and childbirths increase the risk of hemorrhoids.

This can be explained on the one hand by a hormonally induced increased arterial blood flow and the restricted venous outflow of blood by the increased pressure in the small pelvis (from the uterus and the unborn child). The increased pressing due to the often observed clogging (Constipation) during pregnancy promotes the development of hemorrhoids.

During delivery or during the expulsion phase, pre-existing hemorrhoids can worsen or new hemorrhoids can develop, since the return of blood from the corresponding vessels is restricted in this phase of the birth process. However, apart from the pain, it does not have a negative impact on childbirth. For a woman with hemorrhoids, the quadruped position is recommended for birth. To relieve pain, the hemorrhoids can be cooled with some counter pressure.

Symptoms of hemorrhoids during pregnancy and in the puerperium (period of six to eight weeks after birth) can in most cases be managed well by conservative measures, such as a diet rich in fiber, sufficient exercise and adequate drinking, and local, symptomatic ointment treatment.

The hemorrhoids that have formed usually regress well during the puerperium, as the triggering factors are no longer present. Targeted treatment should therefore be considered two months after delivery at the earliest.

Read more about this at: Hemorrhoids in pregnancy

Symptoms

The symptoms of hemorrhoids are fairly uniform for most people. One problem, however, is the fact that these symptoms are quite uncharacteristic at the beginning and can be assigned to a number of diseases in the rectum.

In addition, the typical symptoms depend on both the stage and the extent of the disease. However, some signs can be seen at all stages and therefore provide an initial indication of the presence of hemorrhoids. Most of those affected complain of recurring anal bleeding at the onset of the disease. The intestinal bleeding can be light or severe.

Also read: Blood in the stool due to hemorrhoids

In addition, anal oozing (the discharge of secretions from the anus) and severe itching in the anal area are typical symptoms of hemorrhoids. Pain is rarely described in connection with hemorrhoids in the initial stage and, if present, is more likely to be explained by manipulation of the anus caused by the itching. The degree of symptoms in hemorrhoids correlates with the stage of the disease. Affected patients with grade 1 hemorrhoids have fewer symptoms than patients with grade 4 hemorrhoids. The most harmless form of this disease shows up in the presence of 1st degree hemorrhoids.

Please also read our article on this Pain in the rectum.

Symptoms of Grade 1 Hemorrhoids

In the case of 1st degree hemorrhoids, the anal area of the person affected usually looks completely inconspicuous from the outside. The hemorrhoids are therefore not visible from the outside. During the medical examination, however, the nodular changes can be felt with the finger and can thus be detected.

As a rule, the knots bulge only slightly into the intestinal tube and hardly restrict the passage of the faeces. In contrast to the other grades of hemorrhoids, the nodular changes are still completely reversible at this point and can therefore regress. Surgical correction is usually not necessary despite the symptoms. Even the presence of pain cannot be reported in most cases at this stage of the disease.

In 1st degree hemorrhoids, bright red bleeding from the anus is the main symptom. Most of those affected notice this bleeding as deposits on the surface of the stool (Hematochezia) or on toilet paper. Dark blood on the stool indicates a condition that is found higher up in the gastrointestinal tract. So dark blood in the stool is not a symptom of hemorrhoids. However, a 1st degree hemorrhoid does not bleed continuously. In most cases, periods in which blood is secreted alternate with periods when there is no bleeding. The intensity of the bleeding can also vary from day to day without changing the severity of the nodular intestinal protuberance.

Another, but rather rare, symptom of 1st degree hemorrhoids is anemia (anemia). This symptom can be explained by the bleeding from the intestinal tube. In order to actually trigger an anemia, however, this bleeding must be enormous.

Read more about: Blood in the stool - what are the causes?

Symptoms of 2nd degree hemorrhoids

In contrast to first-degree hemorrhoids, second-degree hemorrhoids can be squeezed out during the medical examination by pressing hard.The knotty changes protrude into the anal canal when pressed and then pull back by themselves after a short time. Furthermore, at this stage the hemorrhoids are no longer capable of regression without surgical intervention; they are considered to be irreversible.

A typical symptom of 2nd degree hemorrhoids is the temporary occurrence of disturbed fine incontinence and an associated increase in intestinal mucus secretion. This means that the chair cannot be fully held or it is difficult to dispense. Affected patients often describe a feeling of incomplete emptying after a bowel movement.

In addition, some patients speak of the occasional occurrence of a foreign body sensation in the anal region. This feeling can be triggered by the sometimes very large nodular changes in the intestinal wall. Due to the increased secretion release, hemorrhoids also make themselves noticeable at this stage through irritation of the skin in the anal region. It is precisely these skin irritations that cause the typical, severe itching that most people suffer from as a symptom of hemorrhoids.

In addition, hemorrhoids can encourage the formation of an anal fissure at this point. An anal fissure is a small tear in the skin and / or mucous membrane of the anal region. If pain occurs at all, it is a typical symptom of second-degree hemorrhoids.

Symptoms of Grade 3 Hemorrhoids

Patients suffering from grade 3 hemorrhoids report severe pain in many cases. The nodular changes typically become apparent with every bowel movement and cannot regress without support. It is usually necessary for the affected patient to push the hemorrhoids back into the anal canal on their own.

Any kind of physical exertion can cause the hemorrhoids to shift and cause severe pain. The characteristic of the symptoms of third-degree nodules is the fact that the pain phenomena can occur both at rest and under stress. The intensity of the pain is described differently from patient to patient.

Furthermore, severe itching is one of the most common symptoms of hemorrhoids at this stage. Many patients describe this itching as almost unbearable. Using soothing ointments and creams can help relieve symptoms.

Symptoms of Grade 4 Hemorrhoids

In Grade 4 hemorrhoids, the large, nodular changes are permanently outside the anus. The mechanical push back (Reduction) the hemorrhoids is no longer possible at this point. Affected patients report symptoms such as severe itching of the anus and swelling in the area of the anus at this stage.

The attending physician will also notice reddish and / or bluish discoloration in the anal region during the physical examination. Even at this stage, the size of the knots can vary widely. In most patients, however, they become very large. In addition, slimy secretion comes out of the intestinal tube at regular intervals. The anal canal has a deformed structure that can severely impede the passage of the stool. In addition, heavy bleeding from the hemorrhoids is a typical symptom of this stage.

diagnosis

After determining the classic symptoms such as bright red blood on the toilet paper or stool and possibly itching and / or pain in the anal area, the doctor will give a reflection of the anus (Anoscopy) and palpate the rectum with your fingers. The hemorrhoids can usually be felt here. 2nd and 3rd degree hemorrhoids are also visibly pressed outwards when pressed.

In most cases, these examinations are already sufficient to establish a diagnosis, because, as already described, almost all people in older age suffer from hemorrhoids.

However, if profuse bleeding has occurred or other circumstances, such as a family history or accompanying symptoms, suggest a possibly malignant tumor, this suspicion is raised by performing a rectal endoscopy (Proctoscopy) or a reflection of the entire large intestine (colonoscopy) is excluded. In addition, an X-ray may be necessary after the rectal introduction of contrast agent, which then makes any tumorous narrowing of the intestinal lumen clearly visible.

Therapy for hemorrhoids

When it comes to treating hemorrhoids, there are several options depending on the degree of the disease.

Read our topic: Therapy for hemorrhoids

Hemorrhoids are divided into different degrees of disease. Depending on the stage of the disease and the symptoms that arise, various treatment options are possible. Treatment is only required if the hemorrhoids cause discomfort. Treatment of hemorrhoids is usually done by proctologists.

The symptoms can be relieved by keeping the stool soft and ensuring that the person has regular bowel movements. This has the effect of avoiding heavy pressing when going to the toilet, which is one of the causes of hemorrhoids. A change in diet with an increased fiber content and sufficient fluids are helpful here. In addition, this is promoted through sporting activity.

In the case of less pronounced 1st and 2nd degree hemorrhoids that only cause symptoms for a short time, drug therapy is usually sufficient initially. Here, ointments, creams or gels are applied locally to the affected area. These contain anti-inflammatory agents and / or topical anesthetics to relieve pain and itching in the anus. Some medications also contain cortisone as an active ingredient. There is a risk here of developing a fungal disease of the intestines. In addition, Sitz baths with herbal additives such as chamomile or oak bark can provide relief. Suppositories are also used for local treatment. With this conservative treatment, the symptoms can be alleviated or even disappear completely. However, this will not make the hemorrhoids go away.

There are also other options for conservative therapy. This includes, for example, the use of anal stretchers, which are intended to loosen the tense shooting muscles. This improves the blood flow to the anal region and alleviates the symptoms. Sclerotherapy is used for grade 1 and 2 hemorrhoids. In this case, the blood vessels are sclerosed by the injection of certain substances and the treated tissue dies. The hemorrhoid cushion becomes smaller and can recede into the rectum. Several therapy sessions are necessary, which are usually carried out about four to six weeks apart. The so-called rubber band ligation is also a treatment option. The hemorrhoids are sucked in by the doctor and tied off with rubber bands. After a few days, the constricted tissue dies and the hemorrhoid pad becomes smaller. Both treatment methods are painless for the patient and do not require anesthesia or sedation.

For Grade 3 or 4 hemorrhoids, these conservative treatments or the small outpatient treatments are not enough to relieve the symptoms. Here an operation with a subsequent stay in hospital is necessary (see below). Surgery is also indicated in the case of hemorrhoidal problems for which conservative measures do not provide relief. The aim is to restore the normal anatomical conditions in the anal region, which are a prerequisite for continence.

When the hemorrhoids have exited the anus so far that they cannot regress, the tissue must be removed. This is called a hemorrhoidectomy. General anesthesia or anesthesia close to the spinal cord (Spinal anesthesia) necessary. The so-called staple method can also be used for 3rd degree hemorrhoids. This is a special surgical procedure that is less painful and more comfortable for the patient. The anal skin is lifted internally with a special stapling device.

Another surgical method is hemorrhoidal artery ligation. This is a minimally invasive procedure in which the blood vessels supplying the hemorrhoids are tied off using an ultrasound probe. With this method, however, the hemorrhoids often reappear afterwards. A similar procedure is the transanal hemorrhoidal artery dearterialization.

After hemorrhoid surgery, bleeding and pain in the anal area are common. Control over bowel movements can also be limited in the first few days. However, this changes after a few days.

To prevent relapse, it is important to make sure that the stool is soft and shaped. This can be achieved through a high fiber diet and plenty of fluids.

Read more on this topic at: Treatment of hemorrhoids

Ointment for hemorrhoids

Local treatment for hemorrhoids is a purely symptomatic treatment that can improve the symptoms, but does not treat the actual cause of the symptoms or prevent the disease from progressing. The local therapy is to be used in case of irritation of the skin in the area of the anus and symptoms such as itching, burning and oozing. In the case of minor complaints, in addition to appropriate anal hygiene, ointment treatment with a zinc paste can be carried out.

Cortisone-free ointments with the addition of a local anesthetic can also be used. In the case of more severe symptoms, ointments containing cortisone with an added local anesthetic and astringent, drying agents such as bismuth are appropriate. For complaints caused by tears in the anal canal skin (anal fissures), an ointment with the active ingredient glycerol trinitrate (GTN) can also be used. This ensures the relaxation of the sphincter muscle.

If the symptoms or skin appearances worsen during therapy with an ointment, this should be discontinued immediately, as the active ingredients of the ointment or ointment additives can also cause allergic skin reactions.

Self-therapy with a cortisone-containing ointment must be ended after a treatment period of 10 to 14 days, as otherwise permanent damage to the skin can occur. In general, self-therapy with an ointment should not be carried out for longer than two weeks, as a proctologically trained doctor should be consulted after this period at the latest.

Home remedies

There are numerous home remedies for hemorrhoids. The marigold ointment is locally anti-inflammatory and promotes wound healing. The marigold ointment contains various substances such as calendulin, saponins and flavonoids and soothes the irritated mucous membrane. Sitz baths are another way to relieve hemorrhoids. For example, a Sitz bath with oak bark extract, which is available in the pharmacy, has a healing effect on hemorrhoids. If there is severe itching in the area of the hemorrhoids, a cloth soaked in diluted fruit vinegar can provide relief. Applying sliced cloves of garlic or applying aloe vera juice can also reduce itching. Applying grated ripe bananas to the hemorrhoids can also help.

Diet should also be considered with hemorrhoids. For example, a lot of fiber and whole grain products should be consumed. A varied diet with plenty of fresh fruit and vegetables is recommended. A tablespoon of olive oil after a meal can also stimulate digestion and prevent constipation. Drinking enough fluids throughout the day can also help prevent hemorrhoids from getting worse.

Regular exercise and exercise also have a positive effect on hemorrhoid disease.

Read more on this topic: Home remedies for hemorrhoids

Surgery for hemorrhoids

If there are hemorrhoids of a higher degree, i.e. third or fourth degree, surgical therapy is the first choice. It must be considered whether the intervention outpatient or stationary should take place, as postoperative pain as well as other complications such as bleeding or wound healing disorders can occur.

Regardless of whether the procedure is carried out on an outpatient or inpatient basis, anesthesia is always indicated. There is the option of general anesthesia or regional or central anesthesia. There are four different surgical techniques that can be selected depending on the findings.

Open segment removal according to Milligan-Morgen (1937): With the open segment removal according to Milligan-Morgen, segmental III. to IV. grade hemorrhoids are treated. The enlarged nodules and the sensitive anal canal skin are completely resected in a short operation lasting 10 to 30 minutes. The wounds are then left open and heal with the formation of scars after four to six weeks. The procedure can generally be carried out on an outpatient basis, but in the case of extensive findings or severe concomitant illnesses, a two to four day hospital stay should be considered. The disadvantage of the open segment removal is the severe postoperative pain, which requires painkillers to be taken for a period of about one to two weeks. Pain when defecating may persist for up to six weeks after the procedure. The patient's ability to work is also limited for a comparatively long time with this procedure, lasting approximately two to three weeks.
Closed segment removal according to Ferguson or Parks: With this surgical technique, the skin of the anal canal is incised and detached from the enlarged hemorrhoidal nodules. In contrast to the open segment removal according to Milligan-Morgen, the anal canal skin is preserved and not removed. Due to this fact, this surgical method is preferred, especially when the resection of several enlarged vascular nodes is indicated.
The hemorrhoidal nodes are then loosened from the internal sphincter muscle and removed after the supplying vessels have been ligated. With the Ferguson surgical technique, the sensitive anal canal skin is then closed with a suture. If the lining of the anus emerges from the anus unnaturally, the anal canal skin is sutured to the mucous membrane of the rectum so that it is again located in the anal canal. This procedure is also known as Parks' hemorrhoidectomy. With the surgical technique according to Ferguson or Parks, the postoperative pain is significantly lower, wound healing is faster and the risk of scarring after the operation is significantly lower than with the open segment removal according to Milligan-Morgen. This type of operation can also be carried out on an outpatient basis, but a short stay in hospital is recommended in the event of extensive findings or severe concomitant diseases.

Reconstructive haemorrhoid removal according to Fansler / Arnold: Reconstructive haemorrhoid removal according to Fansler / Arnold is used for grade IV hemorrhoids (permanent fixed prolapse of the hemorrhoidal tissue (prolapse)) for use. As part of the time-consuming procedure with an approximate duration of 40 to 60 minutes, a U-shaped anal canal skin flap is formed. Then the hemorrhoidal pads are resected and finally the anatomy of the anal canal is restored. The reconstructive ha? Morroids removal according to Fansler / Arnold can only be carried out in connection with an inpatient stay in the hospital. The disadvantage of this operation is a relatively high complication rate of 20% because the wound area created is large. It is therefore advisable to treat the hemorrhoids in good time so that such a comparatively large procedure is not even indicated.
Circular stapler haemorrhoidopexy according to Antonio Longo (1993): The circular stapler haemorrhoidopexy according to Antonio Longo is performed with a ring-shaped stapler (Circular stacker) and is now used in 25-30% of all hemorrhoid operations. It can be used for circular hemorrhoids III. Degree including the after-incident (Anal prolapse) be performed. The prerequisite for this is that the hemorrhoids can be manually repositioned in the anal canal.
This procedure has many advantages for those affected: the operation time is short at 20-30 minutes, there is usually no postoperative pain and wound healing is faster than with the other procedures, so that the patient after one or two Weeks back to work. This operation should be done in the hospital with a subsequent inpatient stay.

Postoperative follow-up treatment: After hemorrhoid surgery, the anus region should be showered or taken in a hip bath after each defecation, but at least once a day. For postoperative pain, decongestant pain relievers should be taken for one to two weeks. Depending on the procedure, those affected should take it easy for one to three weeks and not lift heavy loads. If necessary, stool regulation can take place, for example with light laxatives.

homeopathy

There are a large number of homeopathic remedies that are said to have beneficial effects on hemorrhoids. Collinsonia canadensis may provide relief to relieve pain caused by tight stool. Aesculus and Muriaticum acidum can be used for burning pain in the hemorrhoid area. Silicea can have a positive effect on spasmodic complaints and sore anus. Other homeopathic remedies that are used against hemorrhoidal disorders are Kalzium phosphoricum, Kalium carbonicum, Lachesis, Nux vomica and Sulfur.

Read more on this topic: How to Get Rid of Hemorrhoids Using Homeopathy

What to do about bleeding hemorrhoids

If hemorrhoids tear in one place, they can bleed profusely because they are a cushion of vessels made up of small veins and arteries and have a thin vascular wall. Bleeding hemorrhoids are usually noticed by blood on toilet paper or in the toilet. Care should be taken to ensure that soft toilet paper is used and that it is not pressed too hard when defecating.

If the hemorrhoids are painful or bleeding, cooling them can be helpful. However, it is important that the ice pack does not lie directly on the hemorrhoids, but that a thin cloth or something similar lies in between. Creams can also improve the symptoms. For example, creams containing phenylephrine can be used to reduce bleeding. Soothing ointments with aloe, witch hazel and vitamin E can also be used.

In the case of bleeding hemorrhoids, it is advisable to see a doctor and have them checked for an examination. It can make sense to have the hemorrhoids surgically removed with a so-called hemorrhoidectomy.

prophylaxis

Even if all precautionary measures are taken, the development of hemorrhoids cannot be completely avoided. The predisposition to hemorrhoidal disease is hereditary and is also related to the natural degeneration and breakdown processes that occur during aging. In general, however, it can be said that the progression of the haemorrhoidal disease can be delayed through a conscious diet and regular bowel movements. For example, sufficient drinking and a balanced diet rich in fiber are necessary to give the stool an optimal consistency and thus to prevent constipation.

Laxatives should only be used for a limited short period of time, if at all. Getting used to laxatives creates a vicious cycle of constipation and increasing the dose, so this measure is counterproductive in preventing hemorrhoids. Natural bulking agents such as flaxseed are better for softening the stool.

As already mentioned, careful anal hygiene must also be observed in order to avoid hemorrhoids or their further development. Regular Sitz baths (chamomile or similar), as well as cleaning the anus after using the toilet with lukewarm water and then dabbing dry (instead of using sturdy toilet paper) can be beneficial.

When using the toilet, care should be taken not to press too hard or too long. The increased pressure promotes the development of hemorrhoids.

Regular exercise, such as cycling, swimming, gymnastics or yoga, is an important way of compensating for frequent sitting, stimulates the bowel movement and has a positive effect on preventing hemorrhoids. In addition, moderate exercise prevents obesity, which is also a risk factor for the development of hemorrhoids.

forecast

As a rule, hemorrhoids can be treated very well and efficiently with medication or surgically. The earlier the hemorrhoids are treated, the easier and faster the therapy will lead to improvement. Often, however, patients shy away from seeing a doctor with their symptoms, which is why most patients appear for the examination at a relatively late stage.

Also, after successful treatment of the hemorrhoids, recurrences, i.e. the recurrence of the hemorrhoids, can occur.

Bleeding, wound infections, and urination problems may occur after the surgery. In rare cases, surgery can result in a Anal stenosis (Narrowing) arise or the function of the anal sphincter may be impaired, which may require further surgical intervention to restore it.