What are Hemorrhoids?

Hemorrhoids occur when the blood vessels in the anal region swell and fill with blood. Under normal circumstances, the blood that comes from the arteries returns smoothly through the veins. However, factors such as constipation, pregnancy, and straining can hinder this return, leading to blood accumulation and expansion in the vessels. If this condition continues for a long time, the support tissues around the vessels deteriorate, and the vessels cannot return to their original state, becoming permanently swollen, tense, and filled with blood. In hemorrhoid disease, in addition to the expansion of the vessels, there is also deterioration in the ligaments and support tissue around the vessels.

Hemorrhoidal vessels swell due to the retention of solid feces in the last part of the intestine or the inability of the muscles (sphincters) that tighten the anus during defecation to relax. This leads to the formation of the disease. In advanced stages of hemorrhoids, enlarged veins protrude outside the anus.

In most of these patients, the mucosa, which is the inner lining of the last part of the large intestine (rectum), also protrudes out. This is called mucosal prolapse and often accompanies hemorrhoids.

Stages of Hemorrhoids:

First Degree: The expansion of the vessel located above the anal canal line. The vessel has not displaced and usually manifests with bleeding. If there is no bleeding, it is unnoticed and does not cause pain. Most of the time, it cannot be detected by finger examination (rectal touch), but can be seen with anoscopy. Simple measures such as consuming fibrous foods, drinking plenty of water, and increasing activity can prevent constipation and straining, thus improving hemorrhoids.

Second Degree: The vessel above the anal canal has expanded further. It protrudes into the anus canal with defecation and then retracts on its own; it does not descend below the anus line. It tends to protrude with straining and does not cause pain. It can be seen with anoscopy and usually improves with medication treatment. If there are symptoms like bleeding and the condition does not respond to treatment, rubber band ligation and infrared coagulation treatment yield good results.

Third Degree: Hemorrhoids that protrude with straining or after using the toilet must be pushed back manually. They may protrude with coughing or straining as the condition progresses. Usually does not respond to medication treatment. Symptoms such as bleeding and swelling may improve, but the hemorrhoidal vessels do not heal completely. Treated with surgical or non-surgical methods.

Fourth Degree: Protruding hemorrhoids can no longer be pushed back manually. Clots (thrombosis) can easily form inside the external nodes and cause severe pain. If erosions and abrasions occur on them, serious bleeding can happen. Surgical treatment is generally required; however, before surgery, a period of medication treatment is needed to reduce swelling and thrombosis.

Hemorrhoids are caused by two main mechanisms:

Increased Abdominal Pressure: During pregnancy, the abdominal pressure increases, which makes it difficult for the blood in the veins to return to the heart, leading to the formation of hemorrhoids around the anus. Additionally, during pregnancy, changes in diet due to psychological reasons and decreased physical activity can lead to constipation; this, in turn, exacerbates hemorrhoids and other anal diseases.

Constipation: Typically caused by improper diet, poor bowel habits, and a sedentary lifestyle, constipation results in increased straining. Chronic constipation is more common when the diet lacks vegetable fibers, there’s inadequate water intake, and minimal physical activity. Increased straining associated with constipation is one of the main causes of hemorrhoids.

Diarrhea: Just as constipation can lead to the development of hemorrhoids, so can diarrhea. Frequent bowel movements, prolonged sitting on the toilet, and straining during defecation can contribute to the formation of hemorrhoids and may also lead to other anal diseases such as fissures, anal hematomas, and anal dermatitis.

Genetic Predisposition: Genetic factors can cause multiple members of the same family to suffer from hemorrhoids.

Position: Standing or sitting for long periods, such as in the case of drivers, can increase the frequency of hemorrhoids.

Toilet Habits: Incorrect toilet habits, such as sitting on the toilet for long periods and straining, can increase the risk of hemorrhoids.

Other Factors: Obesity, smoking, hot baths, a sedentary lifestyle, severe diarrhea, chronic cough, lung diseases, intense physical activity, and heavy lifting can all increase the risk of developing hemorrhoids. Obesity is associated with multiple factors such as a diet low in fiber, lack of physical activity, and high abdominal pressure.

Aging: As people age, the support tissue around the hemorrhoidal vessels and in the anus weakens, making the formation of hemorrhoids more likely.

Symptoms of hemorrhoids include:

Rectal (Anal) Bleeding: The most common and concerning symptom, which often leads patients to seek medical help. Typically, it manifests as bright red bleeding seen after defecation, often noticed on toilet paper. If bleeding occurs right after defecation and drips onto the stool, it’s indicative of hemorrhoids. Blood mixed within the stool, occurring after, not during, defecation and of a darker color usually stems from a deeper intestinal tumor rather than the anus. In cases of prolapsed (3rd and 4th degree) hemorrhoids, blood may stain the clothing. In younger individuals, tighter anal muscles can lead to higher vein pressure and severe bleeding.

The bleeding usually results from the friction and pressure on the swollen blood vessels during bowel movements, causing them to damage. Intense bleeding may occur from the damaged vessel wall.

If there’s no external cause of bleeding seen, internal examination with an anoscope is mandatory. Anoscopy can easily reveal bleeding from internal hemorrhoidal nodes. If the source of bleeding is not hemorrhoids, other sources like ulcers, wounds, or tumors in the rectum can be detected with an anoscope.

Swelling in the Anal Region (Bulges): In the case of internal hemorrhoids that have not prolapsed, swelling is usually not visible. With 3rd degree internal hemorrhoids, the enlarged vessels can prolapse during defecation but often retract automatically. Patients may not notice these bulges outside the anus or might feel them temporarily during cleaning. In some instances, patients may need to push these swellings back in manually.

Prolapsed bulges, or 4th degree hemorrhoids, can cause discomfort, discharge, itching, irritation, and pain.

Vague Complaints: Symptoms might include itching around the anus, a vague feeling of discomfort, and a sensation of fullness.

Pain: Hemorrhoids usually do not cause pain. However, external hemorrhoids might cause mild soreness. Severe pain occurs if the hemorrhoid cannot retract back and swells due to edema. Thrombosis (blood clots) in the veins can also lead to significant pain.

Difficulty in Defecation: The patient might avoid defecation due to fear of bleeding or pain from protruding hemorrhoids, which can worsen the condition.

Hemorrhoid Treatment

Medication Treatment: In the initial stage, where intervention is not yet required, eliminating the causative factors along with certain medications can help alleviate symptoms such as itching and a feeling of fullness. These medications, particularly suppositories and creams, should not be used for more than a week as they contain cortisone. In cases of advanced, swollen, and thrombosed acute hemorrhoids, medication can be applied before any intervention. Procedures during the acute phase can increase complications, so it’s essential first to reduce this condition.

Non-surgical Hemorrhoid Treatments: These treatments are the most comfortable for the patient post-treatment. They can be performed in an office or clinic setting without general anesthesia or hospitalization. The procedure takes about 5-10 minutes, and patients can go home after a short rest period post-procedure. There may be some pain if the treatment is close to the anal canal, but it is less severe and shorter than the pain from traditional surgery.

IRC – Infrared Coagulation: This is an ideal solution for 1st and 2nd degree hemorrhoids, particularly effective for bleeding hemorrhoids. It uses infrared rays to clot the blood inside the vessel and reduce the hemorrhoid. The procedure takes a few minutes, and bleeding can be stopped during treatment. However, the recurrence rate of this procedure is higher compared to other methods.

Rubber Band Ligation (RBL): Suitable for treating 2nd and 3rd-degree hemorrhoids, this method involves using an aspirator to pull the enlarged hemorrhoid into the aspirator and then placing a rubber band around its base to cut off its blood supply. There is usually no pain after the procedure, as the internal part of the anus lacks pain sensation.

Sclerotherapy (Injection Therapy): Once more commonly used, this method has become less popular due to side effects and the risk of the condition recurring in the medium term. A sclerosing agent is injected into the vein to shrink it.

Surgical Treatments: THD (Transanal Hemorrhoidal Dearterialization): In this method, hemorrhoidal arteries are located with the help of a special device and ligated to cut off blood flow. It is less painful compared to other surgical methods.

Longo Surgery (Stapled Hemorrhoidopexy): This technique involves circumferentially cutting and then stapling the prolapsed internal hemorrhoidal tissue. It is performed under general anesthesia.

Traditional Surgical Methods: The most commonly used is the Milligan-Morgan method. In these methods, the hemorrhoid tissues are completely excised, and the cut area is either left open or sutured.

The choice of hemorrhoid treatment depends on the patient’s condition and the stage of the hemorrhoids. Each treatment method has its advantages and disadvantages. The success of the treatment also depends on eliminating the factors causing the hemorrhoids.