Hemorrhoidal disease (HD) is a common anorectal disorder that affects at least 10 million people in the US, with a peak incidence in individuals between the ages of 45 and 65.1,2 Rectal bleeding, pain, and discomfort from straining with bowel movements associated with chronic constipation and HD negatively impact quality of life. Approximately 2 to 4 million people seek medical treatment annually for symptomatic HD.1,2 This article discusses signs and symptoms, risk factors, classification, treatment, and nursing interventions for patients with HD.
Understanding the normal anatomy
The term "hemorrhoids" is often used to describe anal pathology when, in fact, hemorrhoids are normal vascular structures of the anorectal anatomy.1 Hemorrhoids are vascular cushions that contain submucosal connective tissue, blood vessels, smooth muscle, and nerves that control the opening and closure of the internal and external anal sphincters. They also help determine the difference between gas or stool in the rectum to maintain fecal continence.1,2 Arterial supply to hemorrhoids occurs through the superior, middle, and inferior rectal arteries also known as the hemorrhoidal arteries. Venous outflow occurs through the superior, middle, and inferior rectal veins also known as the hemorrhoidal veins. Muscle fibers arise from the longitudinal muscle and internal sphincter. The pudendal nerve and sacral plexus are somatic nerves that innervate external hemorrhoids, which cause pain if stimulated, whereas internal hemorrhoids are not innervated by somatic nerves.1,2 Internal and external hemorrhoids become a disease entity when symptomatic or asymptomatic pathology is present.1
Pathophysiology
HD is a pathologic process that occurs when hemorrhoidal veins become engorged with blood and distend, degrading connective tissue within the anal cushions.1,2 The muscular submucosal connective tissue may weaken over time, allowing the hemorrhoid to displace, protrude, or prolapse through the anal sphincter.1,2
Hemorrhoids are classified as internal or external relative to their position to the dentate line, also known as the pectinate line. The dentate line separates the upper and lower anal canals. Internal hemorrhoids are superior to the dentate line and do not have pain fibers; external hemorrhoids are inferior to the dentate line and contain pain fibers. There is no widely used classification system for external hemorrhoids. However, internal hemorrhoids are graded according to the degree to which they prolapse from the anal canal:
Grade I: Hemorrhoids are seen on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Anal cushions may bleed without any prolapse.
Grade II: Anal cushions prolapse through the anal orifice with defecation or with straining and reduce spontaneously.
Grade III: Anal cushions prolapse through the anal orifice with defecation or straining, and require manual manipulation for reduction.
Grade IV: Anal cushions are irreducible and may strangulate.
Grade I and Grade II are low-grade internal hemorrhoids, while Grade III and Grade IV are high-grade internal hemorrhoids.1-3 Thrombosed hemorrhoids and strangulated hemorrhoids are considered complicated and require urgent surgical intervention.1
Signs and symptoms
There are many reasons why hemorrhoids become symptomatic. For example, straining at the stool because of insufficient fiber and fluids in the diet, sedentary lifestyle, obesity, and pregnancy.
Approximately 40% of patients with HD are asymptomatic.1 Rectal bleeding, pain, and hemorrhoidal prolapse are the most common signs and symptoms of HD, especially when there is an increase in intra-abdominal pressure during defecation.1-3
Internal HD usually produces painless rectal bleeding with an increase in intra-abdominal pressure from straining with defecation, pregnancy, obesity, prolonged periods of sitting or standing, and weightlifting.1,4,5 Blood is generally bright red and noted when using toilet tissue, in the toilet water, or on the top of the stool.1,4,5 Seeing blood on the stool may alarm patients, but the blood is generally self-limiting. Severe bleeding may lead to anemia.1,2
A variable degree of prolapse may be present and appear as a purplish mass of tissue protruding from the anus.1,3 Patients may describe prolapse as a feeling of fullness, pressure, irritation, and as if the anal area has not been cleaned sufficiently with toilet tissue after a bowel movement.1,2 Patients may experience leakage of mucus and stool and soil on underclothing.3,4
Internal HD may produce pain when prolapse extends inferior to the dentate line, especially during defecation.1-4
External HD may vary in size and appear as purple-blue lumps and swollen areas.1-3 External HD is more likely to produce pain where pain fibers are located.1 HD may produce pruritus and severe pain described as burning, stinging, aching, soreness, tenderness, and sensitivity.1,5 Previously swollen external hemorrhoids may shrink and leave very small, dangly skin tags that pose no harm.1 Patients may also have a combination of internal and external HD.1 Patients with thrombosed HD may have a sudden onset of severe pain and swelling in the perianal area and dark blue or black dots where the thrombus is located within the hemorrhoidal tissue.1,2
Differential diagnoses and special considerations should be explored. If blood is mixed in with the stool during a bowel movement, the site of bleeding is likely the rectum or colon and not from HD.2,6
Bloody stool with mucus may indicate malignancy or inflammatory bowel disease.2,6 Anal cancer, anal fistula, anal fissure, anal condyloma (warts), polyps, and proctitis should also be considered.1,6 Patients with portal hypertension secondary to cirrhosis of the liver may have dilated rectal veins, known as rectal varices, that may be confused with internal HD.1,2,7
Diagnostic approaches
A diagnosis of HD is determined by conducting a thorough health history interview including activities of daily living, medication history, and the presence of any systemic diseases. A comprehensive physical assessment should include a careful inspection of the perianal area and a digital rectal exam.1,5 The healthcare provider (HCP) will first assess the perianal region with the patient in the left lateral position.1 The perianal region should be inspected for erythema, skin tags, hemorrhoids, fissures, bleeding, and mucus and fecal drainage. A digital rectal exam is then performed by the HCP by asking the patient to bear down in a "Valsalva maneuver" that relaxes the anal sphincters, allowing the provider to assess their tone and the presence of masses, pain, and bleeding. Having the patient bear down may reveal prolapsed hemorrhoids.1
A standard procedure for anal canal disease is anoscopy to evaluate the anal canal and the distal rectum. Visualizing the anal canal with an anoscope is necessary to determine the extent of HD, including prolapse, bleeding, and thrombosis. Anoscopy is a highly effective way to evaluate the anorectal tissue (anoderm).1,2 Anoscopy is usually performed with lidocaine 2% jelly inserted into the anorectum approximately 15 minutes before the insertion of the anoscope to prevent pain during the procedure. Light I.V. sedation may be used as indicated. The anoscope is a cylindrical instrument with a removable obturator well lubricated with jelly or lidocaine, then gently and gradually inserted into the anorectum until fully inserted at the anterior axis of the anal opening. The obturator is then removed and the provider may inspect the anorectal tissues with a light source at the distal end of the anoscope. During the procedure, the provider can treat some hemorrhoids by rubber-band ligation and excise tissue that is suspicious for malignancy and other pathologies. Patients should be assessed for bleeding after the procedure.1-5
A sigmoidoscopy or colonoscopy is generally indicated any time a patient has rectal bleeding.1,6
Treatment approaches
Patients with HD who are immunocompromised from disease processes or medications should be treated conservatively, if possible, because these patients are at an increased risk for anorectal abscess and delayed wound healing following anorectal surgical interventions.1,2
The aggressiveness of treatment is determined by the severity of signs and symptoms and the patient's preferences.1,2 Treatment approaches are generally categorized into medical management, office-based treatments, and surgical interventions.
Medical management
The primary approach to preventing HD and treating patients with HD consists of eating a well-balanced diet with plenty of vegetables, drinking plenty of fluids, particularly water, taking a fiber supplement, maintaining ideal body weight, and staying physically active. Foods should contain plenty of fiber.4,5 The Mayo Clinic lists high-fiber foods that patients can use to plan their dietary needs.8 Fiber supplements help to achieve a well-formed, soft, and bulky stool that is easily cleaned with toilet tissue and reduce bleeding from HD by 50%.1,2,8 Fiber supplements are available in capsule, tablet, powder, and chewable forms. A glycerin suppository may also be prescribed by the HCP to lubricate the anorectal area to allow the patient to pass stool more easily without straining. The patient should try to retain the suppository for at least 15 minutes.1,2 The goal of these lifestyle and dietary modifications is to prevent straining with defecation.5,9 Stool softeners may be also helpful.5
A sitz bath with warm water before and after a bowel movement may help to prevent an exacerbation of symptoms of HD. An alternative approach, and perhaps much easier for the patient, is to take a sitz bath in a bathtub. The bathtub should be filled with 3 to 4 in of warm water and a tablespoonful of salt or Epsom salt. The patient should slowly lower themselves into the bathtub and soak for approximately 20 minutes. The patient should raise themselves slowly from the bathtub after they are finished to avoid presyncope and syncope.1,2,4,5,9 The patient may plan to have a sitz bath before and after a daily bowel movement. When the patient has symptomatic HD impacting the quality of life, a warm sitz bath for approximately 20 minutes three to four times per day, or more often, as prescribed, should reduce swelling, bleeding, pain, and pruritus, and prevent the need for advanced procedures to control symptoms.
Topical medications, some over-the-counter, may be used for temporary relief of pain and discomfort and include lubricants, anti-inflammatory agents, local anesthetics, antibiotics, corticosteroids, witch hazel pads, and phenylephrine. Phenylephrine is a vasoconstrictor that decreases the size of hemorrhoids and reduces swelling and pain. Topical lidocaine and calcium channel blocking agents are effective in relieving hemorrhoidal pain. Additional research needs to be conducted to determine the efficacy of these products, although research does indicate they are safe to use and bring many patients some relief.
Topical agents, including topical analgesics such as mixed hydrocortisone-lidocaine and steroids such as hydrocortisone cream, may be used in conjunction with a warm sitz bath or tub bath to provide the patient with relief.
Office-based treatment
Treatment in an office or clinic may require a prescribed laxative and N.P.O. status before a procedure. Patients may require local anesthesia, mild sedation, moderate sedation and analgesia, or general anesthesia.1,2,4
The following procedures may be performed during a diagnostic colonoscopy, sigmoidoscopy, or anoscopy:1,2
Sclerotherapy involves the injection of a sclerosant into the apex of a symptomatic internal hemorrhoid. The sclerosant causes an intense inflammatory reaction, decreasing the vascularity of the hemorrhoid, leading to scarring and fibrosis until the hemorrhoid disappears. The procedure may be repeated. Some patients may experience mild bleeding, pain, and pressure after the procedure. Temporary urinary retention and impotence may occur.1,2
Rubber-band ligation is the most commonly used technique for the treatment of symptomatic bleeding internal hemorrhoids.10 A rubber band is placed around the hemorrhoid causing thrombosis, ischemia, and necrosis. The rubber band will dissolve while the hemorrhoid gradually resolves over a few weeks. Potential complications include anorectal bleeding, severe pain, and urinary retention. Patients who have bleeding disorders or are receiving anticoagulants are generally not candidates for this procedure.1,2
Infrared coagulation involves the direct application of infrared light waves to bleeding internal hemorrhoids. The infrared light waves create an inflammatory response and ischemia, scarring, and fibrosis in the hemorrhoid, causing the tissue to slough off. The procedure may be repeated until the entire hemorrhoidal tissue dissolves.1,2
Radiofrequency ablation and laser photocoagulation cause the tissue to coagulate, fibrose, and slough off.1,2
Transanal hemorrhoidal dearterialization (THA) is another approach in which the surgeon ligates arterial flow to the hemorrhoid with Doppler guidance during anoscopy. Ligation is performed above the dentate line, so the patient has very little to no postoperative pain. THA is a safe and effective alternative to hemorrhoidectomy.1,2
Surgical interventions
Patients who do not achieve a therapeutic response to conservative management or have persistent signs and symptoms despite undergoing office-based treatments may require surgical intervention. Approximately 10% of patients with HD require hemorrhoidectomy. Patients who have thrombosed or strangulated gangrenous HD require immediate surgical intervention.1
An excisional hemorrhoidectomy, which requires general anesthesia, is highly effective, with few complications and low recurrence rates. Patients are discharged the day of surgery or the day after.1 Managing postoperative rectal pain and spasms is a major challenge once the intraoperative local anesthetic wears off.1,5,11 Opioids, nonsteroidal anti-inflammatory drugs-especially ketorolac, acetaminophen, and gabapentin-are among the analgesics that may be prescribed. Urinary retention is a common complication.1,5,11 Adrenergic blocking and sympathomimetic agents may be helpful in conjunction with effective analgesia and warm sitz baths or tub baths to promote urination.1,6,11 Rectal bleeding should always be assessed and correlated with any changes in mental status and vital signs.1,6,11 The surgeon typically places gauze rectal packing secured with a T-binder to help absorb bleeding and inject a local anesthetic to reduce pain in the postoperative period. The rectal packing will be expelled when the patient has a bowel movement after discharge. Bowel movements must occur as soon as possible to avoid fecal impaction and pain from constipation.1,6,11 The patient needs to consume a well-balanced diet, sufficient fluids, and take a fiber supplement as prescribed in the immediate postoperative period and as a part of daily lifestyle management after discharge.1,5 A mild laxative may be prescribed for a few days in the postoperative period.
One complication is anal stenosis, which occurs when the surgeon uses too much anal tissue to close a wound with hemorrhoidectomy, thereby causing a narrowing of the anal canal and difficulty having a bowel movement. Stool bulking agents, stool softeners, and dilatation of the anal canal digitally or by a flexible dilator will help to increase the diameter of the anal canal (see Priority patient discharge instructions).1,5,8,9,12
A stapled hemorrhoidectomy, also known as a stapled hemorrhoidopexy, is a procedure for prolapsed hemorrhoids developed in recent years as an effective alternative to excisional hemorrhoidectomy because of less, but still substantial, postoperative pain.1,13 Patients are generally discharged the day of surgery or the day after.1 The surgeon uses a stapling device to remove hemorrhoidal tissue and then staples the rest of the hemorrhoid into its normal anatomical location.1,13 The staples are later passed in the stool without the patient's knowledge.1,13 The presence of unusual bleeding and urinary retention need to be assessed.1,5,13 Rectal packing will also be passed in the stool.1,6,11 The procedure is safe and effective, but has a slightly higher recurrence rate than excisional hemorrhoidectomy.1,13
A sitz bath is an effective intervention that reduces or prevents edema, bleeding, pain, and pruritus associated with HD and promotes healing of sensitive anorectal tissue. Sitz baths play an integral part in hemorrhoidectomy postoperative pain relief.
Conclusions
Hemorrhoidal disease is a common anorectal problem. Fortunately, lifestyle modification with optimal nutrition, fluid intake, and physical activity can prevent and reduce signs and symptoms. Nurses play a crucial role in teaching patients lifestyle modifications to prevent HD. For patients with persistent signs and symptoms negatively impacting their quality of life, safe and effective treatment options are available.
Priority patient discharge instructions1,5,8,9,12
* A small amount of rectal bleeding is expected after hemorrhoidectomy. You may apply gauze or a sanitary pad over the anal area to keep your underclothing clean. Promptly report prolonged bleeding or blood clots to your HCP.
* Rectal packing may cause a feeling of fullness in your rectum. The packing will be expelled with a bowel movement.
* Local anesthesia wears off quickly. Take prescribed oral analgesics as soon as there is a hint of pain. Apply an ice bag to the perianal area several times a day as prescribed. Promptly report unrelieved pain to the HCP.
* Problems urinating are common. Taking pain medication and a warm sitz bath and tub bath will help relax the urinary muscles. Contact your HCP if you have not urinated in 8 hours.
* Eat a well-balanced diet with plenty of vegetables and drink at least 6 to 8 full glasses of water every day. Your HCP will also prescribe a fiber supplement to help achieve a fully formed and soft stool. A bowel movement will usually occur on day 3 or 4 after surgery.
* Unexpected and urgent bowel movements in the postoperative period are possible. Stay close to a bathroom. This feeling will improve.
* Do not spend long periods of time sitting on the commode, and do not strain. Avoid using toilet tissue to wipe because it is abrasive to sensitive anal tissue. Using soft tissue, cotton, or witch hazel could be soothing. Warm sitz baths and tub baths are very effective in relieving pain after each bowel movement.
* Get plenty of rest. During the recuperation period, stay physically active by walking. Avoid lifting objects over a certain weight as prescribed, driving a car, and sitting or standing for long periods.
* Maintain your ideal body weight.
* Avoid smoking and excessive intake of alcoholic beverages.
* Report a fever, urinary retention, bleeding, unrelieved pain, or persistent or increasing difficulty having a bowel movement.
* Consult with a dietitian to help with nutrition needs.
* Follow up with your HCP and surgeon after surgery.
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