Medical Edge Newspaper Column

Hemorrhoids: When Suggested Treatments Don't Help

August 13, 2007
Dear Mayo Clinic:
What can cause pain, but no bleeding, from inflamed internal hemorrhoids (a physician's diagnosis)? My daughter has severe discomfort from this condition, and the suggested remedies have been ineffective.

Answer:
Let me begin by explaining that "anal cushions" -- collections of blood vessels, smooth muscle fibers, and elastic connective tissue -- are normal structures that ease the passage of feces through the anal canal. When a cushion's supporting tissue deteriorates, often because of straining during a bowel movement or from pregnancy, the downwardly displaced and therefore abnormal structure that results is called a hemorrhoid.

Hemorrhoids can be internal (located on the rectum or protruding from the anus) or external (confined to the outside of the anus). Either type can cause bleeding, but typically only external hemorrhoids cause severe pain, as internal membranes lack pain-sensitive nerve fibers. For milder cases of hemorrhoids, simple treatments are generally effective. They include over-the-counter creams, ointments, suppositories or pads (containing witch hazel or a topical anti-inflammatory agent such as hydrocortisone), often combined with the use of bulking agents to soften the stool, and daily warm baths to sooth the discomfort.

When hemorrhoids are more persistent, there are a variety of medical options:

Rubber band ligation. The doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation, and the hemorrhoid falls off.

Sclerotherapy. The doctor injects a chemical solution around the blood vessel to shrink the hemorrhoid.

Surgery. In a procedure called a hemorrhoidectomy, the surgeon removes the problem tissue.

Stapling. This is a relatively new treatment technique in which the downwardly displaced anal cushion is pulled back and stapled into position using a special circular device.

Of course, the best way to deal with hemorrhoids is to prevent their formation in the first place. Eating high-fiber foods, taking fiber supplements, and drinking plenty of liquids will soften the stool and increase its bulk, thereby lessening the straining that can cause hemorrhoids. Exercising regularly, avoiding long periods of standing or sitting, and losing excess weight all help to reduce pressure on the veins in the anus. It's also important not to strain when trying to pass a stool, as this creates greater pressure on the veins; and to go as soon as the urge is felt, otherwise the stool could become dry and harder to pass. Even after successful treatment of hemorrhoids, these measures are important to prevent recurrence.

When treatment fails to relieve symptoms, it may be that hemorrhoids, if present, are just bystanders -- that your daughter's diagnosis is not complete. She may indeed have internal hemorrhoids, which are very common. Over half of adults over age 50 experience hemorrhoids of one type or another. But given that there is "severe discomfort," and that internal hemorrhoids do not cause pain, some other abnormality is likely to be present in addition. Two possibilities are an anal fissure or anal abscess, but there are also many others. The next step should therefore be for her to undergo a more detailed and comprehensive evaluation by a specialist in diseases of the colon, anus and rectum.

-- Heidi Nelson, M.D., Colon and Rectal Surgery, Mayo Clinic, Rochester, Minn.