HEALTH AND MEDICAL PRODUCTS:HEMORRHOID TREATMENTS.

HEMORRHOID TREATMENTS

The term hemorrhoids, often called piles, refers to a condition in which clusters of veins just under the membrane that lines the lowest portion of the anus or lower rectum become swollen and inflamed. They are thought to represent the engorgement or enlargement of the normal fibrovascular cushions lining the anal canal. Clusters of vascular tissue (e.g., arterioles, venules, arteriolar-venular connections), smooth muscle, and connective tissue lined by normal epithelium of the anal canal constitute the hemorrhoids normally present in humans from the time in utero throughout normal adult life. Pathologic hemorrhoids are thought to result from chronic straining secondary to constipation, prolonged attempts at defecation, or occasional diarrhea. Hemorrhoids have three main cushions, situated in the left lateral, right posterior, and tight anterior areas of the anal canal, with minor tufts located between the cushions. As an individual strains rectally repeatedly over time, the fibrovascular cushions eventually lose their attachment to the underlying rectal wall, leading to the prolapse of hemorrhoidal tissue through the anal canal. As the hemorrhoids engorge with blood, the overlying mucosa becomes friable and the vasculature increases, leading to rectal bleeding in the form of bright red blood.

Hemorrhoids have plagued humans throughout history, sometimes associated with the assumption of an upright bipedal posture. Beginning in Medieval times, hemorrhoids were known as Saint Fiacre’s curse. This legend is based on the story of Saint Fiacre, the patron saint of gardeners. Having developed a terrible case of prolapsed hemorrhoids after cultivating a large patch of farmland in one day, Saint Fiacre was miraculously cured after sitting on a stone and praying for a resolution of his problems.

Hemorrhoids are very common in both men and women and may result from any increase in pressure in the veins of the lower rectum; such sources of pressure include constipation and the accompanying extra straining to move stool, sitting or standing for excessive lengths of time with associated increased resting anal pressure, obesity, heavy lifting, portal hypertension, and pregnancy and childbirth. Other contributing factors may include aging, chronic diarrhea, anal intercourse, and a genetic predisposition to develop hemorrhoids. While the most common symptom of hemorrhoids is rectal bleeding, such bleeding may be associated with many other anorectal problems, including anal fissures (tears in the anus lining), fistulae (abnormal channels that develop between the anal canal and the skin around the opening of the anus), abscesses, pruritus ani (anal irritation and itching), proctitis (an inflammation of the inner lining of the rectum), colon or rectal growths (polyps), colorectal cancer, viral and bacterial skin infections, rectal prolapse (a portion of the rectum protrudes through the anus), or diverticular disease (small sacs or pouches [diverticula] that form from the lining of the large intestine).

Hemorrhoids generally cause symptoms when enlarged, inflamed, thrombosed, or prolapsed. Hemorrhoidal symptoms are divided into internal and external sources of anatomical location. Those originating above the dentate (pectinate) line (higher up in the rectum) are termed internal hemorrhoids, and those originating below the dentate line (arising at the entrance to the anal opening) are termed external hemorrhoids. Because internal hemorrhoids lack pain-sensitive somatic sensory nerve fibers, they usually do not cause cutaneous pain. However, they are associated with rectal bleeding and a feeling of fullness in the rectum after a bowel movement, often becoming more severe with straining and eventually bulging (prolapsing) outside the anal opening to cause a constant dull ache and irritation with itching and bleeding. Prolapsed internal hemorrhoids can cause perianal pain by producing a spasm of the sphincter complex and can deposit mucus onto the perianal tissue, causing localized dermatitis. A grading system is used to describe the severity of internal hemorrhoids: grade 1 (mild distention), grade 2 (prolapse with bowel movement, with spontaneous reduction back into the rectum), grade 3 (prolapse with bowel movement, with manual reduction back into the rectum required), and grade 4 (prolapse without the ability of reduction, with additional prolapse of the rectal mucosa [inner lining]).

Externally prolapsed hemorrhoids tend to be associated with symptoms such as severe pain (caused by their innervations by cutaneous nerves that supply the perianal area, such as the pudendal nerve and sacral plexus), inflammation (swelling), and irritation with itching and bleeding. Often, blood will pool within an external hemorrhoidal vein and form a clot (thrombus), resulting in acute pain from the rapid dis- tension of innervated skin by the clot and surrounding edema (fluid buildup). The pain may last seven to fourteen days and may vacate from resolution of the thrombosis. However, remnants of the thrombosis may persist as excess skin or skin tags and occasionally leads to erosion of the underlying skin and additional bleeding. The skin tags may then cause patient difficulty with maintaining adequate rectal hygiene by mechanically interfering with cleansing of the perianal skin area after a bowel movement. Excessive rubbing or cleaning around the anus may remove healthy and protective mucus, leading to irritation with bleeding and/or itching, producing a vicious cycle of symptoms.

In many cases, hemorrhoids may be prevented by self-care and life- style changes, such as eating high-fiber foods (e.g., fruits, vegetables, and grains), drinking plenty of liquids daily, ingesting a bulk stool softener or fiber supplement (e.g., psyllium or methylcellulose), exercising, avoiding long periods of standing or sitting, avoiding lower rectal straining during defecation, and voiding stools in timing with the natural accompanying urge to have a bowel movement.

While surgical intervention may be indicated in some cases of hemorrhoids, temporary relief of the mild pain, swelling, and inflammation symptoms of most hemorrhoidal flare-ups may be accomplished with the use of warm water bath soaking of the affected area several times daily and application of a variety of over-the-counter topical hemorrhoidal cream, ointment, foam, spray, or suppository medications multiple times daily for a limited duration. Such medications can contain active ingredients that provide a physical barrier with additional lubricant qualities (e.g., petrolatum, mineral oil, shark liver oil, cocoa butter, zinc oxide) with additional skin-protecting lubricants (e.g., shea butter, Aloe vera gel, simethicone, beeswax, lanolin, glycerin). Phenylephrine hydrochloride is often included, acting as a local vasoconstrictor, thus reducing the symptoms of swelling and itching. The use of topical astringents (e.g., witch hazel) can provide a soothing effect, along with skin-soothing vitamins (e.g., tocopherol acetate) and herbal extracts (e.g., green tea extract, grape seed extract). Topical corticosteroids (e.g., hydrocortisone acetate) may be included to reduce inflammation, itching, and swelling. Bismuth can be combined with such corticosteroids and provides a protective barrier to the irritated area and prevents cutaneous water loss. In addition, many products contain local anesthetics such as benzocaine and pramoxine hydrochloride to relieve acute pain.