Symptomatic hemorrhoid disease is one of the most common ailments associated with significant impact on quality of life. Management options for hemorrhoid disease are wide, ranging from conservative measures to a variety of office and operating-room procedures. Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis, accounting for ∼3.3 million ambulatory care visits in the United States. Self-reported incidence of hemorrhoids in the United States is 10 million per year, corresponding to 4.4% of the population. Both genders report peak incidence from age 45 to 65 years. Notably, Caucasians are affected more frequently than African Americans, and higher socioeconomic status is associated with increased prevalence. Contributing factors for increased incidence of symptomatic hemorrhoids include conditions that elevate intra-abdominal pressure such as pregnancy and straining, or those that weaken supporting tissue. Despite its prevalence and low morbidity, hemorrhoid disease has a high impact on quality of life, and can be managed with a multitude of surgical and nonsurgical treatments.
Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective tissues that lie along the anal canal in three columns—left lateral, right anterior, and right posterior positions. Because some do not contain muscular walls, these clusters may be considered sinusoids instead of arteries or veins. Hemorrhoids are present universally in healthy individuals as cushions surrounding the anastomoses between the superior rectal artery and the superior, middle, and inferior rectal veins. Nonetheless, the term “hemorrhoid” is commonly invoked to characterize the pathologic process of symptomatic hemorrhoid disease instead of the normal anatomic structure.
The exact pathophysiology of symptomatic hemorrhoid disease is very poorly understood. Previous theories of hemorrhoids as anorectal varices are now obsolete—as shown by Goenka et al, patients with portal hypertension and varices do not have an increased incidence of hemorrhoids. At the current moment, the theory of sliding anal canal lining, which proposes that hemorrhoids occur when the supporting tissues of the anal cushions deteriorate, is more widely accepted. Advancing age and activities such as strenuous lifting, straining with defecation, and prolonged sitting are thought to contribute to this process. Hemorrhoids are therefore the pathological term to describe the abnormal downward displacement of the anal cushions causing venous dilatation. On histopathological examination, changes seen in the anal cushions include abnormal venous dilatation, vascular thrombosis, degenerative process in the collagen fibres and fibroelastic tissues, and distortion and rupture of the anal subepithelial muscle. In severe cases, a prominent inflammatory reaction involving the vascular wall and surrounding connective tissue has been associated with mucosal ulceration, ischemia, and thrombosis.
Management of Hemorrhoid Disease
The natural history of most cases of hemorrhoid disease is self-limited. For symptomatic hemorrhoid disease that presents to the clinic or emergency room, treatments range from nonoperative medical interventions and office-based surgical interventions. One general guiding principle is that the least-invasive approaches should be considered first, except in cases of acute thrombosis. Specific choices of treatments depend on patients’ age, severity of symptoms, and comorbidities. The usual lifestyle and dietary modifications are the mainstays of conservative medical treatment of hemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake(especially water), reducing fat consumptions, avoiding straining, and regular exercise to create the much needed peristalsis. Diet recommendations should include increasing fibre intake, which decreases the shearing action of passing hard stool. Another method that we should consider on how to get rid of hemorrhoids naturally is to use a squat stool. Research has shown that Asians who do not use sitting based toilet bowls, but rather use squat based toilet bowls that are already on the floor tend to have less haemorrhoid diseases and constipations. In order to replicate the squat posture, a squat stool can be placed below the toilet bowl whereby the individual can put his/her legs on it to simulate a squat while defecating.