Hemorrhoid problems are one of the most common problems our patients face. Approximately 44% of US adults complain of some level of problems with hemorrhoids. Most people choose to “deal with it” as they are often embarrassed or self conscious about the problem. What most don’t realize is that there a very high chance that many of the people around them are also suffering in silence. It’s not uncommon for me to hear from my patients that they have been managing with their symptoms for decades! Many of the treatment options simply TREAT the hemorrhoids; however, they do not cure them. Creams and suppositories may calm an acute flare up; however they do not fix the problem. Most people seek treatment when the hemorrhoids are flared up and leave treatment alone in between flare ups. People who have frequent flare ups feel there is no “good time” to deal with them, especially when in between flare ups (the best time to fix them!).
Hemorrhoids are a set of 3 veins that drain the region around the anus. Veins have valves that keep blood moving toward the heart. However, with prolonged increased pressure in the veins, such as straining with constipation or loose bowel movements, repetitive heavy lifting, or a growing baby during pregnancy, the valves can become damaged. This causes back pressure on the valves below and can cause them to fail as well. When this happens, the veins become varicosed (like varicose veins that may appear in the legs and thighs). The hemorrhoid veins can then become enlarged, swollen, and begin to protrude from the anus. Even the pressure from passing stool can scrape the vein and cause bleeding. The swelling in the vein can cause pain and can even lead to a blood clot developing in the vein (not the dangerous kind that can travel!). This is called a thrombosed hemorrhoid. This can occur in one or all the three veins. When the veins are varicosed above the anus they are considered “internal” hemorrhoids and generally lead to bleeding. They can swell and protrude from the anus, causing prolapse of the hemorrhoid (like pulling a sock inside out). When varicosed closer to the anus, they are considered “external” hemorrhoids and generally lead to thrombosis, swelling and mostly pain and bleeding. Patients can have a combination of internal, external, or internal AND external hemorrhoids causing symptoms.
There are several surgeries that are available to help with your hemorrhoid problems. Hemorrhoid banding can be effective for smaller hemorrhoids; however, this is a less permanent option. Banding can yield good results for a period of six months to several years but often times results in recurrence of symptoms. Banding can be done in the office with minimal discomfort. When combined with medical management including aggressive fiber therapy and management of constipation and or diarrhea intermittent banding can be an acceptable option for some people with grade 1-2 hemorrhoids (out of 4) who do not wish to have surgery. Excision or removal of the internal and external hemorrhoids is the gold standard. This operation is best reserved for patients with significant internal and external hemorrhoids. This involves surgical removal of the veins that are vericosed and usually yields a more permanent result. Unfortunately this does result in a fair amount of post operative pain but still leads to the best long-term results.
After I have performed hemorrhoidectomies on my patients the vast majority are extremely satisfied with the results. For patients with mostly internal hemorrhoids and not extra hemorrhoids another procedure called a PPH might be an option. This involves a stapled removal of the internal hemorrhoids and disrupts the flow in the vein use leading to very good resolution of the hemorrhoid symptoms. The advantage here is that it is done above where the pain fibers around the anus live leading to a much less painful surgery. It is most appropriate for people with purely internal hemorrhoids and has a small chance of the hemorrhoids recurring. Even if the hemorrhoids do recur they usually are not as bad as prior to surgery. Any residual symptoms can be addressed on an as needed basis though most people don’t require further treatment. Any residual symptoms are well within the realm of manageable care.