• What exactly are hemorrhoids?
• What are the types of hemorrhoids?
• How do hemorrhoids affect a patient and how does a doctor evaluate hemorrhoids?
• How are hemorrhoids treated?
• What are the over-the-counter treatments for hemorrhoids and anal itching?
  • Non-drug measures
  • Local anesthetics
  • Vasoconstrictors
  • Protectants
  • Astringents
  • Antiseptics
  • Keratolytics
  • Analgesics
  • Other agents
• How are treatments for hemorrhoids and anal itching used?
• What precautions or instructions are there for using these products?
• Hemorrhoids At A Glance

What exactly are hemorrhoids?

Everyone has veins (low pressure blood vessels that return blood to the heart) around the anal opening. When these veins become abnormally enlarged or dilated, they are called hemorrhoids. The typical American diet is relatively high in refined and processed food and low in grain and bulk forming foods. Stools that have less bulk are harder to pass and lead to constipation . This in turn, causes an increased pressure in the veins around the anal canal. The veins thereby become dilated and enlarged, resulting in hemorrhoids. The common name for hemorrhoids (haemorrhoids in U.K.) is "piles."

Hemorrhoids are quite common. The majority of people will experience symptoms of or problems from hemorrhoids during their life. Men and women can both develop hemorrhoids.

What are the types of hemorrhoids?

Hemorrhoids are classified into internal and external hemorrhoids. There is a line (the dentate line) in the anal canal which separates two different types of anal skin. Whereas the skin above the dentate line is not sensitive to pain, the skin below this line is quite sensitive to pain.

Internal hemorrhoids occur above the dentate line and are, therefore, usually painless. They can cause bleeding or they may push out of the anal opening (prolapse) when they become quite large.

External hemorrhoids occur below the dentate line and are generally painful. They are sometimes called skin tags, or can be seen or felt as extra skin around the anus. External hemorrhoids can become very distressing when the blood in the external hemorrhoid clots and inflammation irritates the nearby, pain-sensitive skin. This condition is called a thrombosed external hemorrhoid and is quite painful.

How do hemorrhoids affect a patient and how does a doctor evaluate hemorrhoids?

Symptoms of hemorrhoids can include bleeding, mucous or fecal soiling of undergarments, itching, and occasionally pain. Painful bowel movements are not typically associated with hemorrhoids and usually indicate another problem, often an anal fissure .

The diagnosis of hemorrhoids is made by an office examination of the anus and anal canal. This can include the use of a small tube, called an anoscope, to help see into the anal canal. It is very important in the evaluation of hemorrhoids and anal bleeding to exclude more serious causes of bleeding such as colon or rectal polyps and cancer . Further examination of the colon with colonoscopy or sigmoidoscopy may be necessary.

How are hemorrhoids treated?

The best treatment of hemorrhoids is prevention. A diet high in fiber and bulk can prevent constipation. If this cannot be accomplished with diet, adding bulk laxatives such as psyllium mucilloid (Metamucil), Konsyl, or polycarbophil (Fibercon) may be necessary. This applies to people who have established hemorrhoids since proper diet can prevent worsening of the condition.

There are numerous creams and suppositories which can help relieve the irritation and pain symptoms of relatively minor hemorrhoids, such as hydrocortisone (Proctofoam HC) and (Anusol).

If the pain is not too severe, conservative management consisting of stool softeners, topical pain relieving creams and Sitz baths (sitting in a tub or bathtub of warm water) may suffice. If the pain is severe, it is usually more effective to surgically drain the thrombosed hemorrhoid because this usually provides immediate relief from the pain. It is a procedure that is easily performed in a doctor's office using a local anesthetic to numb the skin during the procedure. Thrombosed external hemorrhoids are ultimately best treated by surgical removal of the offending hemorrhoid if diagnosed within the first few days of its onset. Over the course of one to two weeks, the body will usually dissolve the clot or it can break through the skin and bleed.

Hemorrhoids that bleed are most often internal hemorrhoids. These can be treated by various methods, including rubber band ligation, injection sclerotherapy, infrared coagulation or surgical hemorrhoidectomy.

Rubber band ligation is an office procedure in which a small rubber band is placed at the base of the internal hemorrhoid with a special applicator. The rubber band cuts off the blood supply to the hemorrhoid and the hemorrhoid falls off in about four to five days. There is generally minimal or no discomfort associated with this procedure.

Infrared coagulation uses a infrared light source to coagulate the dilated veins of the hemorrhoid. This causes the hemorrhoids to shrink since blood does not flow through the coagulated blood vessels. This is an office procedure and is pain free. It may take more treatment sessions to eliminate the hemorrhoid group when compared to rubber band ligation.

Injection sclerotherapy of hemorrhoids involves injecting an irritating chemical into the hemorrhoid which causes inflammation and closure of the veins, thereby shrinking the hemorrhoid.

The methods described above are used for mild to moderate internal hemorrhoids. If the internal hemorrhoids are large or come out of the anal opening (prolapse), then surgical hemorrhoidectomy (removal of the hemorrhoid) may be the only option for cure. A hemorrhoidectomy involves surgically excising (removing) the hemorrhoid groups in the anal canal. This can be done with a scalpel, cautery device or a laser. There is evidence to suggest that laser hemorrhoidectomy has an advantage of less pain in the recovery period than non-laser hemorrhoidectomy. This surgery is generally done as an outpatient and hospitalization is usually unnecessary. The operation can be done under a general, spinal, or local anesthetic. The choice as to which is most appropriate varies from patient to patient and is best left to the judgment of the surgeon. Complete healing from this operation can take two to four weeks. However, after one week most patients are able to return to their usual activities with minimal or no discomfort.

There are many options for the treatment of hemorrhoids and this treatment must be individualized with each patient. It is imperative that rectal bleeding should not be assumed to be from hemorrhoids as this is often the first and only sign of cancer of the colon or rectum.

What are the over-the-counter treatments for hemorrhoids and anal itching?

Non-drug measures

Cleaning the peri-anal area with mild, unscented soap and water -- available as wipes or pads -- after each bowel movement can reduce swelling and itching. It is important to pat or blot rather than rub the irritated area. Toilet paper, which should also be unscented, should be blotted or patted as well.

Local anesthetics

Local anesthetics temporarily relieve the pain, burning, and itching by numbing the nerve endings. The use of these products should be limited to the peri-anal area and lower anal canal. Local anesthetics can cause allergic reactions with burning and itching (similar to hemorrhoids themselves). Thus, if burning and itching increase with the application of anesthetics, they should be discontinued. Examples of local anesthetics include:

• Benzocaine 5% to 20%
• Benzul alcohol 5% to 20%
• Dibucaine 0.25% to 1.0%
• Dyclonine 0.5% to 1.0%
• Lidocaine 2% to 5%
• Pramoxine 1.0%
• Tetracaine 0.5% to 1.0%

Vasoconstrictors

Vasoconstrictors are chemicals that resemble epinephrine, a naturally-occurring chemical. Applied to the anus, vasoconstrictors make the blood vessels become smaller, which reduces some of the swelling. They also may reduce pain and itching due to their mild anesthetic effect. Vasoconstrictors applied to the peri-anal area - unlike vasoconstrictors that are taken orally or by injection - have a low likelihood of causing serious side effects, such as high blood pressure, nervousness, tremor , sleeplessness, and aggravation of diabetes or hyperthyroidism . Examples of vasoconstrictors include:

• Ephedrine sulfate 0.1% to 1.25%
• Epinephrine 0.005% to 0.01%
• Phenylephrine 0.25%

Protectants

Protectants prevent irritation of the peri-anal area by forming a physical barrier on the skin that prevents contact of the irritated skin with aggravating liquid or stool from the rectum. This barrier reduces irritation, itching, pain, and burning. There are many products that are themselves protectants or that contain a protectant in addition to other medications. Protectants include:

• Aluminum hydroxide gel
• Cocoa butter
• Glycerin
• Kaolin
• Lanolin
• Mineral oil
• White petrolatum
• Starch
• Zinc oxide zinc or calamine (which contains zinc oxide) in concentrations of up to 25%
• Cod liver oil or shark liver oil if the amount of vitamin A is 10,000 USP units/day.

Astringents

Astringents cause coagulation (clumping) of proteins in the cells of the peri-anal skin or the lining of the anal canal. This action promotes dryness of the skin, which in turn helps relieve burning, itching, and pain. Examples of astringents include:

• Calamine 5% to 25%
• Zinc oxide 5% to 25%
• Witch hazel 10% to 50%

Antiseptics

Antiseptics inhibit the growth of bacteria and other organisms. However, it is unclear whether antiseptics are any more effective than soap and water. Examples of antiseptics in over-the-counter products include:

• Boric acid
• Hydrastis
• Phenol
• Benzalkonium chloride
• Cetylpyridinium chloride
• Benzethonium chloride
• Resorcinol

Keratolytics

Keratolytics are chemicals that cause the outer layers of skin or other tissues to disintegrate. The rationale for their use is that the disintegration allows medications that are applied to the anus and peri-anal area to penetrate into the deeper tissues. The two approved keratolytics used in hemorrhoidal products are:

• Aluminum chlorhydroxy allantoinate (alcloxa) 0.2% to 2.0%
• Resorcinol 1% to 3%

Analgesics

Analgesic/anesthetic products relieve pain, discomfort, and burning by depressing receptors on nerves. Examples include:

• Menthol 0.1% to 1.0% (greater than 1.0% is not recommended)
• Camphor 0.1% to 3% (greater than 3% is not recommended)
• Juniper tar 1% to 5%

Other agents

Anticholinergics are included in some hemorrhoidal products. Anticholinergics are chemicals that block transmission of some nerves, but they only work when given systemically (e.g. orally) and not when applied locally to hemorrhoids.

Wound healing agents speed the healing of inflamed tissues. There is controversy about the effectiveness of an extract of brewer's yeast found in some over the counter medications (also known as live yeast cell derivative or LYCD) as a wound-healing agent. LYCD has not been shown to improve healing. There are no wound healing products available OTC.

Corticosteroids relieve itching and pain, but no products containing corticosteroids are available for the treatment of hemorrhoids without a prescription.

How are treatments for hemorrhoids and anal itching used?

Medications used for the treatment of hemorrhoids and anal itching are available as ointments, creams, gels, suppositories, and foams. Ointments, creams, and gels -- when used on the outside of the anal canal -- should be applied as a thin covering over the peri-anal area. When applied to the internal part of the anus, these products should be inserted with a finger or a "pile pipe." Pile pipes are most efficient when they have holes on the sides as well as at the end. Pile pipes should be lubricated with ointment prior to insertion.

Because suppositories can travel up into the rectum and away from the anal canal, they are not preferred for the treatment of hemorrhoids. They also act slowly since they must melt in order to release their active ingredients.

Foam products have no proven advantage over ointments.

What precautions or instructions are there for using these products?

Pregnant or lactating women should only use products that are recommended for external use (outside of the anal canal) or protectants, which can be used internally (within the anus). For internal use in non-pregnant women or men, additional products that are effective include astringents, vasoconstrictors, and protectants. As a general rule, products containing the fewest number of ingredients are recommended. Scented and tinted products are best avoided.

For maximum benefit, hemorrhoidal products are best used after, not before, bowel movements. If possible, the peri-anal area should be cleaned with soap and water prior to the application of the products. If seepage, bleeding, black tarry stools or protrusion occurs, a physician should be consulted.

Hemorrhoids At A Glance

• Hemorrhoids are dilated veins around the anal opening.
• Hemorrhoids can be internal and external.
• High fiber and bulk diets can minimize constipation and prevent hemorrhoids.
• Hemorrhoid irritation and pain can be relieved with creams and suppositories.
• Thrombosed external hemorrhoids can be painful, are best treated surgically.
• Bleeding internal hemorrhoids are treated by rubber band ligation, sclerotherapy, coagulation, or surgery.

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