Internal Hemorrhoids

The Most Common Symptom of Internal Hemorrhoids is Bleeding

Internal hemorrhoids form when blood vessels inside the rectum become swollen and engorged. Although they form in the lowest part of the rectum, internal hemorrhoids are still far enough inside you may not even know that they’re there. In fact, everyone actually has internal hemorrhoids, but we only notice them once they become a problem. Internal hemorrhoids can worsen over time, but since there are very few pain-sensing nerves in the lower rectal area, you are unlikely to feel any pain. In fact, the most common symptoms of mild internal hemorrhoids is bleeding. However, when internal hemorrhoids become moderate to severe, you will likely begin to experience those hard-to-ignore hemorrhoid symptoms.

Different Kinds of Hemorrhoids can Cause Similar Symptoms

When internal hemorrhoids do progress, they will often protrude outside the anus, becoming prolapsed hemorrhoids. An internal hemorrhoid that has reached this stage can cause some external hemorrhoid-like symptoms, such as itchiness and swelling. Since prolapsed hemorrhoids and external hemorrhoids can cause similar symptoms, it’s sometimes difficult to know which is which without a doctor’s professional diagnosis. It is also not uncommon for both to be present at once.

Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic, and the treatment may be surgical or nonsurgical. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting.

The following is a quick summary of treatment for internal hemorrhoids by grade:

Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods
Grade II or III hemorrhoids are initially treated with nonsurgical procedures
Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy
Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation

Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), is an excellent alternative for treating internal hemorrhoids that have not been amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with procedure for prolapsing hemorrhoids and skin tag excision.

In a meta-analysis of randomized, controlled trials, however, Chen et al concluded that the recurrence rate of prolapsing hemorrhoids was higher with stapled hemorrhoidectomy than with LigaSure hemorrhoidectomy. Operative resection is sometimes required to control the symptoms of internal hemorrhoids.

Internal Hemorrhoids: Causes, Symptoms, Treatments

Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. The blood typically covers the stool (a condition known ashematochezia), is on the toilet paper, or drips into the toilet bowl. The stool itself is usually normally coloured. Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence. Internal hemorrhoids are usually only painful if they become thrombosed or necrotic.

Causes

The exact cause of symptomatic hemorrhoids is unknown. A number of factors are believed to play a role, including irregular bowel habits (constipation or diarrhea), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascites, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging. Other factors believed to increase risk include obesity, prolonged sitting, a chronic cough, and pelvic floor dysfunction. Evidence for these associations, however, is poor.

During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.

Pathophysiology

Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. There are three main cushions present in the normal anal canal. These are located classically at left lateral, right anterior, and right posterior positions. They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle. Sinusoids do not have muscle tissue in their walls, as veins do. This set of blood vessels is known as the hemorrhoidal plexus.

Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool. When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure. Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased. Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms. Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus. The dentate line divides the two regions.

Diagnosis

Hemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. A rectal exam may be performed to detect possible rectal tumors,polyps, an enlarged prostate, or abscesses. This examination may not be possible without appropriate sedationbecause of pain, although most internal hemorrhoids are not associated with pain. Visual confirmation of internal hemorrhoids may require anoscopy, insertion of a hollow tube device with a light attached at one end. The two types of hemorrhoids are external and internal. These are differentiated by their position with respect to the dentate line. Some persons may concurrently have symptomatic versions of both. If pain is present, the condition is more likely to be an anal fissure or an external hemorrhoid rather than an internal hemorrhoid.

Grade of Hemorrhoids

Internal hemorrhoids originate above the dentate line. They are covered by columnar epithelium, which lacks painreceptors. They were classified in 1985 into four grades based on the degree of prolapse:

Grade I: No prolapse, just prominent blood vessels
Grade II: Prolapse upon bearing down, but spontaneous reduction
Grade III: Prolapse upon bearing down requiring manual reduction
Grade IV: Prolapse with inability to be manually reduced.