Hemorrhoids are typically caused by repeated or constant pressure to the anal or rectal veins. As pressure increases, blood begins to pool, causing veins to swell. The swollen vein(s) begins to stretch the surrounding tissues, creating a hemorrhoid. Although hemorrhoids can be painful, they are not serious and are quite common. Between 60 and 70 per cent of Canadians will develop hemorrhoids at some point in their lifetime. At least 50% of people over the age of 50 will experience hemorrhoids and there is an increased likelihood for pregnant women to develop hemorrhoids.

There are two types of hemorrhoids, internal (found in the lower rectum) and external (found under the skin around the anus). It is possible to experience external and internal hemorrhoids at the same time.

Internal hemorrhoids are found inside the lining of the rectum. You cannot feel them unless they are unusually large. Typically small and painless, internal hemorrhoids can produce streaks of bright red blood, which you will see on toilet paper or on stool after a bowel movement. Some people may experience larger internal hemorrhoids, which sag and bulge from the anus, these are called prolapsed hemorrhoids. These larger hemorrhoids can cause some irritation, but often tend to recede into the rectum and resolve without treatment.

External hemorrhoids are found beneath the skin of the anus and can be painful. External hemorrhoids looks and feel like a hard lump in which occurs when the blood clots and within a protruding external hemorrhoid. This can result in a painful thrombosed external hemorrhoid which looks bluish-purple and can bleed, but again tends to clear up on its own within a week or two.

How can I prevent hemorrhoids?

To help protect you against developing hemorrhoids, try incorporating the following lifestyle changes:

Don’t hold it

Use the washroom when you have the urge to go, avoid straining, prolonged sitting or reading on the toilet, and don’t rush; all these will help avoid the build-up of pressure.

Inactivity

Avoid sitting or standing still for long periods of time, inappropriately lifting heavy items or holding your breath while lifting. This increases pressure on the anus causing local blood vessels to swell. If pregnant, sleeping on your side can reduce pressure on the blood vessels in your pelvis, preventing hemorrhoids from increasing.

You may have a hemorrhoid if you notice:

• Small amounts of bleeding during bowel movements, especially if straining
• Itching or irritation from bulging hemorrhoids
• Pain or discomfort in the rectum
• Soreness or pain when cleaning the anal area
• A lump close to the anus, which may be painful or sensitive
• Stool leakage

There are many factors that may increase your risk of developing hemorrhoids:

• Low fibre intake in your diet
• Obesity
• Straining during a bowel movement
• Chronic constipation or diarrhea
• Sitting for long periods of time on the toilet
• Rushing to complete a bowel movement
• Pregnancy
• Anal intercourse
• Alcoholism
• Illness; long-term heart or liver disease which can cause blood pooling in the abdomen and pelvic area

Risks associated with hemorrhoids

Sometimes, although rare, complications may arise from bleeding hemorrhoids. Anemia occurs when the red blood cell count is lower than normal, and can develop when you continually loose blood. Symptoms of anemia include fatigue and weakness.

Another complication is a strangulated hemorrhoid. When the blood supply to a hemorrhoid is cut off, the hemorrhoid may become strangled, which causes severe pain and tissue death.

If bleeding from hemorrhoids continues without improvement for more than one week, you should contact your physician.

Preparing for an Appointment to Discuss Hemorrhoids

Working collaboratively with your health care professional will help you protect your body from digestive problems and maximize your digestive health. When you report your health status completely, concisely and accurately, your physician can provide you with the best care and treatment plan. Be sure to stay informed on ways to maintain your health and well-being, track and record your symptoms, and write down questions and concerns to discuss at your next appointment.

Good communication with your doctor is an important part of any effective health management strategy. Before you visit your doctor, write down:

• Symptoms that you are experiencing
• How often you are experiencing symptoms
• Streaks of blood in the toilet, on toilet paper or on stool
• Location and severity of pain or discomfort, if any
• Changes to your bowel movements
• A list of medications you are taking and why you are taking them
• Questions you want answered during the appointment

A doctor can diagnose hemorrhoids by taking your medical history and conducting a physical exam. This may include a digital rectal exam (inserting a gloved finger into the rectum) to check for internal hemorrhoids, as well as conducting an anoscopy (inserting a small tubular instrument to examine the anus) or proctoscopy (inserting a small tubular instrument to examine the anal cavity, rectum or sigmoid colon). If traces of blood are found in your stool, your physician may request a flexible sigmoidoscopy (a flexible tube that looks at the anus, rectum, and lower intestine) or colonoscopy (a thin, flexible tube that looks at the inner lining of the large intestine) to rule out other possible conditions.

If hemorrhoids are present, your physician will evaluate the location and size of the hemorrhoid(s) and develop a treatment plan, based on severity, and what’s best for you.

Treating hemorrhoids

Treating and preventing hemorrhoids can often be done on your own by making simple lifestyle and dietary changes, these include: Increasing fibre: Too many of us don’t eat enough fibre. Eating a diet rich in fibre, along with adequate, non-caffeinated fluids, will help soften stools and make them easier to pass. High fibre foods include: beans, broccoli, oat bran, and fresh fruits. However, be aware that increasing fibre too quickly can cause bloating and gas, so start slowly and increase your fluid intake at the same time. You should aim for a maximum of 25-30 grams of fibre a day.

Exercising:

Moderate exercise is good for your heart, bones, muscles, mental health and can help stimulate bowel function. The recommended level of physical activity for adults is 150 minutes of moderate-intensity aerobic physical activity plus 2 hours of muscle training per week. The 150 minutes of weekly physical activity can be broken out into shorter bouts, at least 10 minutes each, spread throughout the week: e.g. 30 minutes of moderate-intensity activity 5 times per week or no less than 20 mins a day.

Hemorrhoid care:

Should you have a hemorrhoid, try to avoid rubbing the area. You can clean the anus with a piece of moist toilet paper and gently pat dry. Use non-fragrant soaps with no dyes, and wear cotton underwear to prevent moisture build-up.

Treating hemorrhoids with over the counter medications:

Treating mild cases of hemorrhoids can often be done at home using compresses, baths and over-the-counter (OTC) products including ointments (for internal and external hemorrhoids) and suppositories (for internal hemorrhoids), which are available at your pharmacy.

Hydrocortisone:

• Helps reduce itching and swelling
• Treats internal and external hemorrhoids
• Found in ointment, cream and suppository form
• CAUTION: Over-use may weaken skin integrity, use products with hydrocortisone as directed and discuss treatment thoroughly with your healthcare professional.

Witch hazel:

• Helps reduce itching and swelling
• Treats internal and external hemorrhoids
• Found in cream, suppository, pads and liquid form

Zinc sulfate monohydrate:

• Helps reduce swelling and burning
• Treats internal and external hemorrhoids
• Found in ointment and suppository form

Pramoxine hydrochloride:

• Helps relieve itching and pain
• Treats internal and external hemorrhoids
• Found in ointment and suppository form

Phenylephrine:

• Helps reduce itching, swelling, burning and discomfort
• Treats internal and external hemorrhoids
• Found in gel form

• The exact prevalence of hemorrhoids is difficult to establish as most people do not seek care.
• US data from the 1990’s suggest that hemorrhoids affect 4.4% of the population. (Ganz 2013; Sun et al. 2016)
• Peak prevalence occurs between age of 45 to 65 years among both men and women. (Lohsiriwat 2012; Sun et al. 2016).
• As well, hemorrhoids are very common during pregnancy especially in the third trimester. It has been estimated that 25% of pregnant women experience hemorrhoids. (Zielinski et al. 2015)

_Citations:

_{Ganz RA. The evaluation and treatment of hemorrhoids: A guide for the gastroenterologist. Clin Gastroenterol Hepatol. 2013 Jun;11(6):593-603.}

_{Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17.}

_{Sun Z and Migaly J. Review of hemorrhoid disease: Presentation and management. Clin Colon Rectal Surg. 2016 Mar;29(1):22-9.}

_{Zielinski Ret al. Gastrointestinal distress in pregnancy: Prevalence, assessment, and treatment of 5 common minor discomforts. J Perinat Neonatal Nurs. 2015 Jan-Mar;29(1):23-31.}

Are hemorrhoids hereditary?

There are many factors, which contribute to the development of hemorrhoids and genetics can play a role. In fact, if you see a doctor about hemorrhoid symptoms, it’s quite likely that they will ask if anyone in your family has had them. If so, your likelihood of getting them is greater.

Can I get hemorrhoids from sitting on a cold floor?

No, developing hemorrhoids has nothing to do with temperature. Conditions that add pressure to the abdomen, such as constipation, pregnancy, childbirth or obesity can cause hemorrhoids.

How can I prevent hemorrhoids?

To help protect you against developing hemorrhoids, try incorporating the following lifestyle changes:

1. Don’t hold it: Use the washroom when you have the urge to go, avoid straining, prolonged sitting or reading on the toilet, and don’t rush; all these will help avoid the build-up of pressure.
2. Inactivity: Avoid sitting or standing still for long periods of time, inappropriately lifting heavy items or holding your breath while lifting. This increases pressure on the anus causing local blood vessels to swell. If pregnant, sleeping on your side can reduce pressure on the blood vessels in your pelvis, preventing hemorrhoids from increasing.

How do I know if I have hemorrhoids?

Hemorrhoid symptoms include pain, itching, rectal bleeding. Sometimes the hemorrhoid will protrude from the anus. If you are experiencing the above symptoms, visit your physician. A physical evaluation will confirm a diagnosis of hemorrhoids.

What causes hemorrhoids?

There are many factors that may increase your risk of developing hemorrhoids:

• Low fibre intake in your diet
• Obesity
• Straining during a bowel movement
• Chronic constipation or diarrhea
• Sitting for long periods of time on the toilet
• Rushing to complete a bowel movement
• Pregnancy
• Anal intercourse
• Alcoholism
• Illness; long-term heart or liver disease which can cause blood pooling in the abdomen and pelvic area