FDA ("Official")
Position On Hemorrhoids
Source
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No Strain, No Pain: The Bottom Line in Treating Hemorrhoids
by Dori Stehlin
Say the word hemorrhoids to just about anyone and they will either roll
their eyes, moan or both. Invariably they will want to change the subject.
According to the National Institutes of Health, about half the U.S.
population over 50 have hemorrhoids.
"Hemorrhoids are one of the most common complaints a physician must
evaluate," agrees Lee E. Smith, M.D., director of the division of colon and
rectal surgery at the George Washington University Medical Center,
Washington, D.C.
Common, but rarely a serious risk to health, hemorrhoids are the result of
too much pressure on the hemorrhoidal veins in the rectum. The strain of
constipation, diarrhea and pregnancy can cause the veins to swell. Other
factors such as obesity and liver disease can also increase pressure and
cause hemorrhoids.
There are two kinds of hemorrhoids--internal and external. Frequently, the
only sign that internal hemorrhoids exist is
bright red blood that appears on the surface of the stool, in the toilet
bowl, or on the toilet paper. But, if the pressure and swelling continue,
the hemorrhoidal veins may stretch out of shape, sometimes so much that they
bulge through the anus to the outside of the body.
The veins around the anus can also become swollen, causing external
hemorrhoids. These swollen veins bleed easily, either from straining or
rubbing, and irritation from draining mucus may cause itching in the anal
area. If blood clots form in these hemorrhoids, the pain can be severe.
"If you see blood, it's probably hemorrhoids," says Smith. Hemorrhoids are
the most common source of bleeding from the rectum and the anus. However, if
the bleeding lasts for more than a couple of days, it's important to see a
doctor for an exam. Smith stresses that a "thorough physical exam, not just
talking about the symptoms" is essential.
"The unfortunate thing is every year I see somebody who has been seeing
blood and they were treated as having hemorrhoids without really being
examined, and they had a cancer," he says.
Treatment for hemorrhoids depends not only on the severity of the symptoms,
but also on the patient's reaction to those symptoms.
"Hemorrhoids don't cause cancer; they're a nuisance," says Smith. "Rarely do
they cause severe anemia and rarely do they cause something that is
hazardous to health. If the patient doesn't mind, then let them live with
the hemorrhoids."
Even though he's a surgeon, Smith considers surgery an option only after
everything else has failed.
Relieving the Pressure
The first step in treating hemorrhoids is to relieve the pressure and
straining. This can often be done by controlling constipation with a
high-fiber diet, according to Barbara Frank, M.D., director of the division
of gastroenterology at the Crozer-Chester Medical Center, Chester, Pa.
Eating the right amounts of bran (the outer coating of grains, available
mainly as cereals), as well as fruits, vegetables, and whole grains results
in a soft, bulky stool that is easily eliminated without strain or pressure
on the hemorrhoidal veins. (See box for list of good fiber sources.)
"Bran is the cheapest way to go," says Smith, who also recommends bulk stool
softeners (brand-name products include FiberCon, Metamucil, Citracil, and
Serutan) as a way to relieve pressure and straining.
Lots to drink, as long as it isn't alcohol, which can actually cause
dehydration, is also important for the regularity that can relieve
hemorrhoids you already have and prevent new ones.
People should drink "several glasses [of liquid] a day, and it doesn't have
to be just water," says Marilyn Stephenson, a registered dietitian with
FDA's Center for Food Safety and Applied Nutrition. "Fruits and vegetables
are high in fluids, too."
"Several" may seem a little too fluid an amount, but people's needs vary,
sometimes daily, depending on things like the weather or exercise.
"Especially in hot weather, a glass [of water] every couple of hours is very
reasonable," says Smith.
One thing to avoid when trying to relieve constipation is any laxative other
than a stool softener, says Smith. Other laxatives frequently cause
diarrhea, which can be just as rough on the hemorrhoidal veins as straining
due to constipation, he explains.
Besides an improved diet, other simple steps to relieve the irritation some
hemorrhoids cause include:
- warm soaks (sitz baths) three or four times a day
- cold packs
- good hygiene. (Be gentle about cleaning, though. Frank recommends using a
soft, moist pad or even rinsing in the shower as an alternative to wiping.)
OTC Remedies
If necessary, there are several nonprescription drugs available that can
help relieve certain symptoms of hemorrhoids. FDA's review of those drugs,
published in August 1990, found 33 active ingredients safe and effective for
protecting the skin, reducing swelling, or relieving discomfort, itching and
inflammation. At the same time, however, FDA banned more than 30 other
ingredients that have not been proven safe and effective.
Most of the approved ingredients are for external use on the skin, but some
may also be used on mucous membranes just inside the rectum. The best drug
depends on the particular individual's symptoms, and it may be advisable to
consult a doctor or pharmacist about which one to buy, says William E.
Gilbertson, director of FDA's division of over-the-counter drug evaluation.
No ingredients to relieve pain, soreness and burning were approved for
internal use because there are no nerve endings inside the rectum.
Internal hemorrhoids "don't hurt and they don't itch," says Smith. "Pain
means a fissure [break in the skin] or a thrombosed [blood-clot-filled]
external hemorrhoid, but it doesn't mean internal hemorrhoid problems."
Manufacturers had until August 1991, when the FDA regulations went into
effect, to reformulate products that contained ingredients for pain,
soreness and burning or relabel with the statement "for external use only"
and a warning not to put the product into the rectum.
In addition, nonprescription hemorrhoid remedy labels must include the
statement "If condition worsens or does not improve within seven days,
consult a doctor." Two other warnings--"Do not exceed the recommended daily
dosage unless directed by a doctor" and "In case of bleeding, consult a
doctor promptly"--must also be on the label.
Surgical Options
Occasionally, some form of surgery may be necessary to remove or destroy the
hemorrhoid.
One of the most common surgical methods is rubber band ligation. A tiny
rubber band--diameter 1 millimeter (about one-twenty-fifth of an inch)--is
fitted onto a special gun-like device. When the trigger is pulled, the
rubber band is forced onto the base of the hemorrhoid. Because there are no
nerve endings in the rectum, no anesthesia is necessary.
It takes about a week for the strangled tissue to slough off and a scar to
form. Rubber band ligation works best on first- and second-degree
hemorrhoids. (See illustration.)
Other surgical techniques for these less severe hemorrhoids include:
- infrared photocoagulation--A specially designed device uses infrared light
to create a small tissue-destroying burn around the base of the hemorrhoid.
- laser coagulation--The laser causes a minor burn, which seals off the
blood vessels. This results in the hemorrhoid being retained in a
non-prolapsed position.
- sclerotherapy--A solution (either quinine urea, sodium morrhuate, or
phenol in oil) is injected into the hemorrhoid, which causes inflammation
and eventual scarring that eliminates hemorrhoidal symptoms.
Third- and fourth-degree hemorrhoids may have to be surgically removed,
either with traditional scalpels or with lasers.
Complications such as infection and incontinence are possible with all of
these techniques.
External Hemorrhoids
Blood clots in external hemorrhoids are "like a black eye," says Smith.
"Even if the patient does nothing, the clots will eventually disappear."
Treating the pain and irritation with sitz baths, bulk stool softeners, and
pain medication may be all that's necessary, he says.
Sometimes, however, the clots are so painful the patient can't bear to wait,
and traditional surgery to cut out the clots is necessary.
But even surgery is only a temporary solution. If a person's diet isn't
improved, the hemorrhoid may return. And even in the best of cases, in the
end, "hemorrhoids don't go away, they just get better," says Smith. n
Dori Stehlin is a staff writer for FDA Consumer.
Preventing Constipation
A fiber-rich diet can help prevent constipation, which is important because
the strain caused by constipation is how many hemorrhoid problems begin.
Good sources of fiber include:
- potatoes
- beans--kidney, navy, lima, pinto
- whole-grain breads
- bran
- fresh fruits
- vegetables, especially asparagus, brussels sprouts, cabbage, carrots,
cauliflower, corn, peas, kale, and parsnips.
It will also help to limit these low- or no-fiber foods: ice cream, soft
drinks, cheese, white bread, and meat.
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