What are Hemorrhoids?
Key Symptoms
What Causes Hemorrhoids?
Conventional Treatments
Medications
Tests and Procedures
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
When to Call a Doctor
Evidence Based Rating Scale
References

What are Hemorrhoids?

Hemorrhoids, also known as piles, are actually just enlarged (varicose) veins that occur in the anus or rectum. Because the veins in these areas are located in the lower part of the body, gravity causes the blood to pool in them instead of flowing back to the heart. This causes the veins to stretch and weaken. The blood can also sometimes flow backward, since these veins lack valves to prevent this.

When veins enlarge, two types of hemorrhoids can develop—internal and external. Internal hemorrhoids form inside the rectum, about an inch above the anus. Though they can cause bleeding after a bowel movement, they are painless and cannot be seen or felt easily. However, internal hemorrhoids can painlessly pop out through the anus (prolapse). Patients quickly discover that prolapsing hemorrhoids can be reinserted with gentle manual pressure. External hemorrhoids form around the anal opening. These hard, itchy, tender bumps are fragile, so they are likely to be tender and bleed easily after a bowel movement or when wiped with toilet tissue.

Prolapsed internal hemorrhoids become acutely painful if their circulation is constricted causing additional blood to build up in them. If a prolapsed hemorrhoid develops a blood cloth (thrombosis) inside it, it may become too hard and large to reinsert. This can result in loss of blood supply to the whole hemorroid (strangulation) similar to ligation. But without having actually tied off the vein, hemorrhage could ensue as it degenerates.Fortunately, this is an uncommon event, which is quickly remedied with a surgical procedure. Doctors recommend that repeatedly prolapsing hemorrhoids undergo surgical removal to avoid this painful occurrence.

Hemorrhoids are a common problem, afflicting nearly three-quarters of all Americans at some point in their lives. Because they cause few symptoms, however, some people are not even aware that they have them. While hemorrhoids can be a nuisance, they are not a serious health risk.

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Key Symptoms

• Bright red blood on toilet tissue, in the stool, or in the toilet bowl after a bowel movement
  
• Painful bowel movements
  
• Itchy anal area
  
• Painful, hard bump on or near the anus
  
• Anal discharge of mucus

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What Causes Hemorrhoids?

Other possible causes are:

• Pregnancy, childbirth or obesity, all of which put excess pressure on both the upper and lower abdomen causing a reduction in the return of venous blood from the abdomen back to the heart through the liver (the portal circulation).  The venous blood takes an alternate path back to the heart, including a path through the hemorrhoidal veins, with the additional blood and pressure inside the veins resulting in enlarging and weakening them
  
  
• Prolonged periods of sitting or standing
  
  
• Loss of muscle tone due to old age or rectal surgery: some muscles help pump blood through veins
  
  
• Heredity
  
  
• Frequent diarrhea.

Conventional Treatments

Mild cases of hemorrhoids are primarily treated by drinking plenty of fluids and increasing fiber in the diet in order to keep the stool soft. A variety of over-the-counter topical hemorrhoid treatments may help to reduce pain and swelling. A doctor may also recommend taking daily sitz baths to ease pain and itching.

Surgical treatment of internal hemorrhoids includes rubber band ligation—placing a tiny rubber band around the hemorrhoid, which cuts off the blood supply and causes it to wither and fall off. Cryosurgery – applying extreme cold to destroy tissue – also may be used to treat internal hemorrhoids. A procedure called sclerotherapy, which involves injecting a chemical solution (like concentrated salt water) into the vein is another option to treat internal hemorrhoids. The sclerosing solution causes inflammation inside the vein and this leads to scarring, causing the hemorrhoid to shrivel-up and fall off. Prolapsing hemorrhoids require a hemorrhoidectomy – surgical removal of the hemorrhoid – or a less invasive option, such as a Transanal Hemorrhoidal Dearterialization (THD) procedure.  This consists of using a Doppler ultrasound to identify and "tie-off" the arteries that provide blood flow to the hemorrhoids. As a result, the size of the hemorrhoids decreases (becomes “decongested” of blood) with a reduction in pain, swelling and bleeding tendency.

Medications

The over-the-counter creams, ointments or pads used to treat hemorrhoids may contain corticosteroids or local anesthetics, such as lidocaine to help swelling and pain, respectively.

Stool softeners and bulk laxatives can help to prevent hard stools or constipation when taken with sufficient fluid, thus helping to reduce straining during bowel movements.

Tests and Procedures

External hemorrhoids can be diagnosed by a simple physical examination. For internal hemorrhoids, a doctor may need to do a rectal examination (inserting a gloved finger in the rectum). An anoscope can be used to look inside the anal canal.  A proctoscope and a sigmoidoscope also can be used to look progressively deeper, inside the rectal canal and the distal part of the lower intestine, respectively. 

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Treatment and Prevention

Avoid constipation and straining during bowel movements. Eat a high-fiber diet with plenty of fruits (especially citrus fruits which also contain vein-strengthening flavonoids), vegetables, grains, and legumes. Fiber supplements also can be helpful to meet daily fiber recommendations of 25-30 grams.

Drinking six to eight glasses of water daily may help to prevent constipation when sufficient fiber is in the diet to hold the fluid in the stool rather than just making more urine.

Avoid straining excessively during bowel movements, and don't stay on the toilet longer than necessary. Do not make the bathroom the reading room.

Just a reminder: Talk to a doctor before starting a supplement program.

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How Supplements Can Help

Taken together, vitamin C, flavonoids, and the herb butcher's broom can help to tone and shrink enlarged veins. These supplements have been shown to strengthen veins and improve circulation overall, alone and in combinations such as butcher's broom taken along with vitamin C. (1-6) While butcher's broom has a long history of traditional use for hemorrhoids, scientific evidence is lacking.

Some of the most promising studies regarding hemorrhoids involve flavonoids. Several studies have shown the flavonoids hydroxyethylrutosides (HERs) help to relieve signs and symptoms of hemorrhoids in pregnant women as well as non-pregnant patients. (7-10) In one study, 90% of pregnant women taking HER (1,000 mg daily for four weeks) showed improvement in symptoms, compared to only 12% in the placebo group. (7) In another study, 50 pregnant women with acute hemorrhoids took a flavonoid combination (90% diosmin and 10% hesperidin) for eight weeks before delivery and four weeks after delivery. Symptoms had dissipated in 66% of women by the fourth day of treatment, and fewer than half of the women had relapses before delivery. Treatment was well accepted and did not affect pregnancy, fetal development, birth weight, infant growth or feeding. (10) More research is needed.

Zinc helps to speed the healing process. (11) In a 2005 study of 252 patients with mixed hemorrhoids, using a suppository cream containing zinc oxide (Titanoreine) resulted in increased and more rapid pain relief than the control cream. However, no significant changes were noted in symptoms such as bleeding or edema. (12) In another study, Titanoreine cream improved wound healing time after surgery for prolapse and hemorrhoids. (13)

Psyllium is rich in soluble fiber and has been shown to provide significant relief in bleeding and pain caused by hemorrhoids. In a placebo-controlled, randomized study of 50 patients with bleeding internal hemorrhoids, supplementation with psyllium led to significantly less bleeding (detected by endoscopy) compared to a control group. In the psyllium group, hemorrhoids bled on contact in 5 out of 22 patients before treatment and in none after treatment; no improvement was noted in the control group. (14) Another study showed that taking psyllium along with a flavonoid combination seems to help relieve bleeding from non-prolapsed hemorrhoids. The study also showed that taking psyllium with the flavonoid combination relieves bleeding more rapidly than psyllium alone or when used with rubber band ligation. (15)

Flaxseeds are another great source of fiber and can help to ease the passage of stools and pain from hemorrhoids. While large studies have shown efficacy of flaxseed as a source of dietary fiber that produces a bulk forming laxative effect, research regarding the use of flaxseed to treat hemorrhoids is lacking. (16, 17)

Witch hazel is another popular topical remedy in the form of creams, gels, glycerin, or pre-medicated wipes. Traditional medicine indicates applying witch hazel topically may help to relieve itching, discomfort, irritation, and burning associated with hemorrhoids. (18) Avoid alcohol–based witch hazel products, however, as they will be very irritating to rectal and anal tissues.

Consuming wheat bran prophylactically has been shown to reduce the risk of hemorrhoids. (19, 20) In one study, eating a high-fiber diet of unprocessed bran for 18 months increased the long-term cure rate (decreasing recurrence) among 92 patients with severe hemorrhoids initially cured by rubber band ligation. (19)

Because hemorrhoids are the result of weakness of the walls of the veins, using the herbal "vein tonic" horse chestnut may help to increase the muscular tone of the vessels and keep the veins from bulging. A 2001 review of conventional and alternative treatments for hemorrhoids indicates that taking horse chestnut prophylactically may prevent symptoms and problems resulting from hemorrhoids. (21) Another review found that the anti-inflammatory and pro-circulatory effects of aescin, the active agent in horse chestnut, may be beneficial to patients with hemorrhoids. (22) More research is needed to confirm or refute efficacy. (Be sure to use a commercial product and not parts of a tree. Unprocessed horse chestnut may contain toxins.)

For painful hemorrhoids, an oil or ointment containing the herb St. John's wort may help, especially after bowel movements. The anti-inflammatory, antibacterial and antiviral properties of this herb may help to relieve pain and itching, as well as to shrink the inflamed and swollen tissue. While some alternative sources indicate this use for St. John's wort, scientific studies are lacking. (23, 24)

Leaves from the plant gotu kola (Centella asiatica) have been shown to have therapeutic properties, including improving blood flow and elasticity of blood vessels associated with hemorrhoids. (21, 25) Study results have been somewhat promising, showing that topical application of Centella extract (TTFCA) three times daily improves vascular tone in hemorrhoidal vessels. (21) More research in this area is needed, however.

The anti-inflammatory properties of Ginkgo biloba may help to ease inflammation, bleeding and pain associated with hemorrhoids. Alternative sources indicate Ginkgo is effective in controlling the acute phase (bleeding) so that definitive therapy (banding, injection sclerotherapy, cryotherapy or surgery) can be scheduled at a convenient time. (5)

A poultice made from elderberry also may help to soothe swollen veins and relieve pain. This fruit, which contains several flavonoids, has been shown to have anti-inflammatory properties and may help to reduce swelling in hemorrhoids. (26, 27) However, elderberry has not been studied for this use.

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Self-Care Remedies

For external hemorrhoids, try ice compresses or warm-water sitz baths two or three times daily. Some alternative medicine texts recommend “contrast hydrotherapy.” Using two basins, one filled with hot and one with cold water, sit alternately in hot water for three minutes, then in cold water for one minute. Repeat this alternating treatment three times for one set. Do one or two sets a day for three to four times a week. (28) Studies have shown that a hot sitz bath seems to relieve pain through relaxation of the anal-sphincter muscle. (29-31)

To ease bowel movements, apply zinc oxide paste or powder, or petroleum jelly, to the anal opening.

Apply a poultice made from elderberry to soothe swollen veins and relieve pain. Grind a small amount of the herb, mix with warm water until it becomes a paste, spread on gauze, and apply to anus for a couple of hours. A poultice made from grated potato can also be soothing and astringent. (28)

After a bowel movement, clean the anal area thoroughly but gently. Use soft toilet tissue moistened with warm water or witch hazel, or pre-moistened wipes. To dry the area, dab--don't scrub--it with a soft, clean disposable cloth. Another alternative for drying the area is to use a blow dryer. Do not be too aggressive during cleaning, as this can inflame veins.

Stay away from foods that may aggravate hemorrhoids: nuts, red pepper, mustard, coffee (regular and decaffeinated), and alcohol.

Consult a physician before using laxatives. Diarrhea can be as aggravating to hemorrhoids as constipation.

When lifting weights or heavy objects (or during a bowel movement), breathe normally. Holding your breath increases abdominal pressure.

If you have heart disease or diabetes, be sure to check product labels carefully. Some “over the counter” (OTC) products containing compounds that shrink hemorrhoidal tissue may carry warnings.

For comfort, wear cotton underwear and loose-fitting clothes.

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Alternative Therapies

Homeopathic sources indicate that some remedies help to relieve pain and speed healing in hemorrhoids. (32, 33) Homeopathic remedies are classically prescribed on an individual basis, depending on the specific symptoms in each case. A few of the commonly indicated homeopathic medicines for hemorrhoids include:

• Aesculus for burning hemorrhoids with a sensation of a lump in anus and aggravation from walking
• Aloe for a sensation of pulsation in the rectum with large, external hemorrhoids
• Collinsonia for chronic, itchy hemorrhoids with obstinate constipation
• Hamamelis for large bleeding hemorrhoids with raw feeling in the anus.

Take 3-5 pellets of a 12X to 30C potency every one to four hours until acute symptoms resolve. (28) (Note: “potency” in homeopathy refers to the number of serial dilutions used for preparing the medicine, more dilute = more potent. Please see the “How it works” section in the WholeHealthMd article on homeopathy for a more extensive explanation.)

 Ideally, the homeopathic medicine chosen would match the patient's mental and emotional state as well as the specific symptoms associated with the condition. However, very few studies have examined the effectiveness of specific homeopathic remedies: this highly personalized approach makes a controlled study difficult.

Acupuncture has been used to treat hemorrhoids, and preliminary evidence indicates improvement of pain after treatment. (34, 35) One study involving electroacupuncture also showed efficacy to relieve pain during bowel movements. In the study, 120 patients received either electroacupuncture or conventional medication to treat hemorrhoids. Electroacupuncture treatment resulted in a significant reduction in pain during bowel movements compared to conventional medication. (36) More research is needed.

When to Call a Doctor

• At the first sign of blood-streaked toilet tissue, to make sure bleeding is not due to something more serious.
• If blood is dark rather than bright red
• If bleeding isn't due to a bowel movement, even if hemorrhoids are known to be present.
• If a throbbing pain is present in the anal area. (This could indicate a possible blood clot in the hemorrhoid.)
• If hemorrhoids have been diagnosed and daily bleeding is severe. (This could lead to iron deficiency anemia.)
• If hemorrhoids don't improve after self-treatment 

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