Hemorrhoids are the most common anorectal disease in the western world.
About 75% of people will have hemorrhoids at some point in their lives, according to the U.S. Department of Health and Human Services, and about half of all people will have them after age 50. In the United States10.4 million people, or 4.4 percent of the general population have hemorrhoids. Approximately 1 million new cases are diagnosed per year.
However, only one-third of these 10.4 million seek treatment each year. Among many other factors, this figure is caused partially by physicians not performing simple, routine internal hemorrhoid treatments. However, with the growing popularity of rubber band ligation, more medical professionals are diagnosing and treating internal hemorrhoids.
What Are Hemorrhoids?
Hemorrhoids are vascular structures that lie along the anal canal to help with stool control and protect the anal sphincter muscles. These cushions generally lie below the mucus membrane along the anal canal in three columns: the left lateral, right anterior, and right posterior positions. They are composed of blood vessels called sinusoids (a type of capillary), connective tissue, and smooth muscle. This set of blood vessels is known as the hemorrhoidal plexus. Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes, such as swelling or becoming distended.
Internal vs. External Hemorrhoids
Hemorrhoids are classified into two general categories, internal and external, which are defined by location above or below the dentate line. The dentate line, the structure separating the rectum from the anus, is located approximately 1.5 cm proximal to the anal verge which leads out of the digestive tract to the exterior of the body.
Unlike external hemorrhoids, which are located distal to the dentate line and cause acute pain, internal hemorrhoids are located proximal to the dentate line and can prolapse outside the anus.
An internal hemorrhoid located above the dentate line may not produce pain because the sensory nerve does not reach the rectum. This surface is covered by columnar epithelium, which lacks pain receptors but bleeds easily because it is covered only by a mucous membrane.
As a result, patients may not wish to receive treatment for internal hemorrhoids because they believe it involves a surgical procedure. However, doctors who inform them of virtually painless treatments such as rubber band ligation are more likely to:
- Put patients at ease about treating their internal hemorrhoids.
- Avoid dangerous repercussions of untreated internal hemorrhoids.
Patients at Risk: Contributing Factors
The National Center for Health Statistics reports that nearly 23 million people (12.8 percent of US adults) have symptoms from internal hemorrhoids. Other studies report up to a 40 percent prevalence of symptomatic internal hemorrhoids in the United States.
Blood Flow Factors
Hemorrhoids are often associated with:
- Chronic constipation
- Straining during bowel movements
- Prolonged sitting on the toilet
All these acts interfere with blood flow to and from the anal canal, causing it to pool and enlarge the vessels lining the anus and/or rectum. This pattern also explains why hemorrhoids are common during pregnancy, when the enlarging uterus presses on the veins.
Age is associated with symptomatic internal hemorrhoids, with an increasing incidence in people over age 45. The connective tissues that support and hold hemorrhoids in place can weaken with age, causing hemorrhoids to bulge and prolapse.
Throughout adulthood, women report more often than men that they have experienced hemorrhoids. According to a data sheet from the Centers for Disease Control and Prevention, although women report a greater incidence of hemorrhoids than men do throughout adulthood, women report receiving surgical treatment much less often for their hemorrhoids than men.
Although people with a family history of hemorrhoids appear predisposed to developing this symptomatic disease, neither definite genetic markers nor racial differences have been identified for symptomatic internal hemorrhoids.
Diagnosing Internal Hemorrhoids: Symptoms
Inadequately controlled symptoms or complications from internal hemorrhoids can result in disability, hospitalization, and, rarely, death.
As stated above, by age 50, about half the population has experienced one or more of the classic symptoms, which includes rectal pain, itching, bleeding, and occasionally prolapse. Although hemorrhoids are rarely dangerous, they can be a recurrent and painful intrusion. Fortunately, there are more options than ever for physicians to easily treat internal hemorrhoids.