Symptoms
Hemorrhoids are dilations of the vascular cushions in the anal canal. Possible symptoms include:
- Bleeding, blood on the toilet paper
- Pressure discomfort, pain, burning, itching.
- Unpleasant feeling
- Inflammation, swelling, skin inflammation.
- Discharge of mucus, oozing
- Prolapse, protrusion outside the anus (prolapse).
Hemorrhoids can be classified according to various criteria. Common is the classification according to the anatomical origin of internal and external hemorrhoids. Internal hemorrhoids are more common and originate above, external hemorrhoids below the border between the rectum and anal canal (linea dentata). According to the severity of the prolapse, hemorrhoids are divided into four stages (grades 1 to 4).
Complications
Possible complications include fecal incontinence, thrombosis, tissue breakdown, and ulceration associated with severe acute pain. Prolonged bleeding can lead to iron deficiency and anemia.
Causes
Causes include weakening of connective tissue with age, shear forces during passage of hard stool, heavy pressing, congestion of blood and inadequate venous blood drainage, and excessive pressure in the vessels. Triggering factors include a low-fiber diet and constipation, obesity, pregnancy, lack of exercise, prolonged time on the toilet, and some medications such as phosphodiesterase-5 inhibitors, anti-diarrheal agents, laxatives, and pegvisomant. Nonsteroidal anti-inflammatory drugs can cause bleeding.
Diagnosis
Diagnosis must be made under the care of a physician to rule out other causes, such as tumors, and to direct patients to treatment appropriate to their stage. However, it is estimated that only about one-third of patients see a physician. It is believed that many patients misdiagnose themselves because other causes that produce similar symptoms are poorly understood. Severe pain during defecation indicates anal fissure.
Nonpharmacologic treatment
It is important to regulate stool using dietary and lifestyle changes. It should be neither too liquid nor too solid. Recommendations include:
- Drink enough fluids
- Do not push or lift heavy objects during defecation
- Supplement with dietary fiber or other stool-regulating agents (see below).
- Warm and low irritation sitz baths without soap
- Discontinue NSAIDs
- Avoid irritating spices
- Sufficient physical activity, do not sit for too long
- Hard seat base
- Wet toilet paper
- Cold compresses to relieve pain
Depending on the stage and symptoms, hemorrhoids are treated with minor and major interventions (eg, sclerotherapy, rubber band ligation). Finally, hemorrhoids also often recede on their own within days or weeks – but may recur.
Oral drug treatment
For internal treatment, mainly well-tolerated dietary fibers and laxatives are used in constipation to increase stool volume and soften stool, for example, psyllium, Indian psyllium husk, flaxseed, wheat bran, macrogol 3350, lactulose, and Sterculia. Some venous agents, for example, flavonoids such as oxerutin (Venoruton), troxerutin, and diosmin (Daflon), as well as anthocyanosides from bilberry (Myrtaven) and butcher’s broom extracts (Phlebodril) are approved for treatment. They are supposed to strengthen the capillaries and reduce their permeability and counteract inflammatory processes. Their efficacy is controversial.
Local drug treatment
Hemorrhoid medications are used externally in the form of ointments, suppositories, and tamponades. They relieve symptoms such as itching and pain, and are skin nourishing and lubricating. The duration of treatment is limited to 1-2 weeks for self-medication. If the symptoms do not subside on their own during this time, medical clarification is indicated. Possible adverse effects include allergic reactions. Many components of hemorrhoid medications are known allergens. Mono or combination preparations are used.
- Anti-itch agents such as menthol and camphor are pleasantly cooling, relieve itching and pain.
- Local anesthetics such as benzocaine, cinchocaine, quinisocaine, and lidocaine numb pain and may inhibit itching. Adverse effects include allergic reactions.
- Sitz baths with chamomile are anti-inflammatory. Chamomile is also a known allergen.
- Glucocorticoids such as prednisolone, hydrocortisone, dexamethasone and fluocinolone are anti-inflammatory and have a secondary anti-pruritic effect. According to the professional information, they have an influence on vasodilatation and are supposed to inhibit vascular neoplasms. They should be used only in the short term, because they can damage the perianal skin and possibly increase susceptibility to infections.
- Vein agents, such as horse chestnut extract, are used not only systemically but also locally.
- Tannins such as Policresulen, witch hazel and oak act astringent, anti-inflammatory and anti-itching.
Some hemorrhoid remedies contain disinfectants such as triclosan and dichlorobenzyl alcohol. Other active ingredients include bismuth salts, perubalsam and salicylates, such as mesalazine.
