Hemorrhoids have been discussed throughout history. The first known description of hemorrhoids is actually in the Old Testament, where they were described as an affliction upon the Egyptians. Yet what are these things? How could something so small cause so much pain and suffering throughout society?
Hemorrhoids are a normal anatomic part of what is called the anal canal. Everyone has them! I often introduce the topic to my medical students by walking around the room and pointing to unsuspecting individuals stating “I know you have hemorrhoids!” The point is that they exist to help us control bowel function. Hemorrhoids are often described as vascular cushions. They help cushion the anal muscles during bowel movements and aid in bowel continence.
There are two designations of hemorrhoids, internal and external. Internal hemorrhoids are located above the dentate line, an area separating different cellular lining of the rectum and anal area. More importantly, internal hemorrhoids exist in an area where the nerve fibers are not as sensitive as they are on the skin. External hemorrhoids exist below the dentate line, on the anal skin which has very sensitive nerve endings.
The symptoms from hemorrhoids differ based on which ones are causing the problem. People will never forget an experience with hemorrhoids – whether they are internal or external. Risk factors for hemorrhoids include constipation, straining and irregular bowel habits. Fifty percent of patients have a family history as well, so you can blame your parents for this one.
External hemorrhoids commonly present with the abrupt onset of severe excruciating pain. They are very common in pregnancy (due to the high incidence of constipation in pregnancy) and can be debilitating. The pain is caused by bleeding and a clot forming in the hemorrhoidal plexus, stretching the skin of the anal area. Often, if I see a patient within 3-4 days of the symptoms, we can treat the hemorrhoidal thrombosis in the office. Under local anesthesia, we can excise the clot inside the hemorrhoid. The pain is relieved immediately, and I often joke with my patients that they will be my best friends for life. If I see patients with thrombosed external hemorrhoids 5 days after symptom onset, I usually just offer supportive care and pain medication as the clot inside is already shrinking.
Internal hemorrhoids are graded 1-4. Grade 1 hemorrhoids cause painless rectal bleeding. Grade 2 hemorrhoids cause pain and discomfort because they prolapse or protrude from the anal opening. By definition, they regress after bowel movements. Grade 3 hemorrhoids prolapse and require manual reduction, you need to actually push them back inside. Grade 4 hemorrhoids are stuck in the prolapsed position, and usually require surgery.
