Enlarged Veins Inside and Outside of the Anal Canal 

Hemorrhoids are a common medical problem that no one likes to talk about. With millions of people experiencing discomfort from hemorrhoids every year, it’s also one that doctors are very familiar with. Fortunately, there are straightforward ways to get relief.

Though people often use the term hemorrhoids to describe a medical condition, everyone has these veins inside the anal canal. They help support the sphincter muscles and maintain your ability to control bowel movements, which is called continence. When these veins become enlarged and the tissues that support them weaken, people develop the condition of the same name. 

Is it really a hemorrhoid?

Don't always assume that the rectal bleeding and/or pain you experience is due to hemorrhoids. 
Two conditions in particular are often confused with hemorrhoids:

  • An anal fissure is a tear in the anal canal, similar to getting a paper cut on a finger. The fissure may burn or cause bleeding when having a bowel movement. It can often heal on its own, but any straining will slow down the process. A topical agent like lidocaine ointment may ease the burning sensation, but treatment with increased dietary fiber will usually result in healing.
  • A more serious condition, though less common, is a colorectal polyp or cancer. People who are age 45 or older and those with a family history of colorectal cancer should see their health care provider and have a colonoscopy before assuming bleeding is from hemorrhoids.

Symptoms, Diagnosis and Outlook 

There are two types of hemorrhoids: internal and external. 

Internal hemorrhoids originate in the anal canal. You may only find out they’re there from a colonoscopy report. You may experience symptoms in the following cases:

  • The most common symptom is bleeding, usually when you move your bowels or wipe. Keep in mind that a single drop of blood can turn the whole toilet bowel red, so it’s important not to panic. However, if a hemorrhoid gets larger and starts to bleed more, you should not ignore it. 
  • An internal hemorrhoid can grow and develop a stalk that gets longer until it actually protrudes from the anus. This is called a prolapsed hemorrhoid and can cause discomfort or pain or itching. 

External hemorrhoids occur outside the rectum. You can generally see them with a mirror. They can be irritated and/or painful if the area is inflamed and swollen. 

  • Typically, there isn’t much bleeding, but an external hemorrhoid can swell suddenly to the size of a walnut. 
  • This condition is called thrombosis, which can lead to pain and swelling, and needs to be evaluated by your health care provider.

Besides being a natural consequence of aging, hemorrhoids can develop from everyday habits that increase pressure in the anal canal. These habits can include:

  • Constipation – most commonly because of a low-fiber diet
  • Straining to pass stool, called pelvic floor dysfunction
  • Sitting for long periods on the toilet
  • Not getting enough exercise
  • Being overweight 
  • Straining from work that requires heavy lifting

What you can do

Some people swear by topical over-the-counter products, like phenylephrine (Preparation H) or witch hazel. While they may provide temporary relief, they are usually not a good long-term solution. To address the underlying problem, follow some simple guidelines:

  • Increase fiber. Getting more fiber in your diet with fruits, vegetable and whole grains helps soften stool, increase its bulk and reduce constipation, which in turn prevents the straining that leads to hemorrhoids. As a bonus, fiber also has other tremendous health benefits, including weight loss and reduced risk of diabetes, stroke, heart attack and high blood pressure. The recommended daily fiber intake is between 25 to 35 grams depending on body size. This amount can be difficult to get from your diet and usually requires taking over-the-counter fiber supplements that contain psyllium, which is the best way of getting large amounts with the least effort. 
  • Drink plenty of fluids. Aim for the often-suggested eight glasses of water to help keep stool soft and help fiber supplements do their job.
  • Rethink bathroom habits. Stop scrolling on your phone and doing other types of reading on the toilet. This extra sitting time leads to extra straining and more intra-anal pressure. It’s also important to go to the bathroom as soon as you feel the need to go. If you delay, stool can actually harden and become difficult to pass.  
  • Lose weight, if needed. Extra pounds put a strain on anal veins. In addition to changes in diet, try to move more. Sitting all day isn’t good for health or hemorrhoids, and regular exercise also helps your bowel movements stay regular.

When to seek treatment

When conservative measures do not improve symptoms, talk to your health care provider. Don’t let any feeling of embarrassment stand in your way. Doctors who treat hemorrhoids are called colorectal specialists, and they see this condition frequently. The specialist will examine your hemorrhoids and determine what treatment is needed. For 90% of patients, hemorrhoid treatment is focused on preventing progression, encouraging regular bowel movements and avoiding straining.

When lifestyle changes don’t relieve hemorrhoid discomfort, the next step is an in-office procedure, such as:

  • Rubber-band ligation, which involves tying the hemorrhoid off
  • Sclerotherapy, where a liquid agent is injected into the hemorrhoid

Both usually involve several office visits. These procedures carry a small risk of a local infection, usually in the first few days, and your doctor will tell you what signs to watch for, such as severe pain, fever and the inability to urinate.

Sometimes a more invasive surgical procedure is needed. A hemorrhoidectomy can reach the very base of the hemorrhoid and remove it. Improvements in surgical techniques have come a long way in reducing the pain associated with this surgery, but it may take up to four weeks for pain and bleeding to stop. Nonsteroidal anti-inflammatory drugs are the first-line medication for managing pain. Doctors try to avoid prescribing opioids, not only because of the risk of addiction, but because constipation is a major side effect. That’s the last thing you want when recovering from anal surgery. Soaking in a tub and applying warm compresses help some people, while others find relief with a cold pack.

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Penn State Health Colon and Rectal Surgery provides advanced and effective medical care, including advanced diagnostic capabilities, the latest drug therapies and leading-edge surgical techniques for benign and malignant colorectal disease.

From treating cancer and inflammatory bowel disease (IBD) to performing advanced diagnostics and robotic surgery, our colorectal team is one of the largest and most experienced in Pennsylvania. Based at the region's premier academic medical center, we have the medical, surgical and support services needed to provide you with the most comprehensive colorectal care.

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