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Understanding Hemorrhoids
A Short Course in Anatomy
To understand hemorrhoids, we need to review the anatomy of the digestive system. Since we're interested in hemorrhoids, let's start backward - from the anus.
The anus is the end-point of the digestive system. It contains sweat and oil glands, hair follicles, as well as many nerve endings, which make it very sensitive to pain and erotic stimulation.
The anal opening is an oval opening located about an inch in front of the spine. When closed, the anus is about an inch in circumference - however, the external sphincter muscle that circles it can stretch to about five times the size. Inside the anal opening is the anal canal. It is approximately two inches deep, with an encircling internal sphincter muscle that controls the passage of stool in the elimination process.
On top of the anal canal, there is a ring of tissue fold arranged in zigzag or sawtooth pattern called the dentate line. Underneath this line lies some vestigial glands - in our evolutionary ancestors, these glands secrete odors that attract mates. Now, however, these glands are empty and unused.
About an inch above the dentate line is the rectum, or the last holding place for feces in the elimination process. The rectum is approximately six inches long, with folds called the valves of Houston. These valves serve as shelves where the feces rest between bowel movements. When the stool becomes heavy, the valve presses against the rectal wall, which results in the "the call of nature" signal or the urge to defecate.
On top of the rectum lies the large intestine (also known as the colon or bowel). It is six foot in length, and is divided into four components: the sigmoid colon, the descending colon, the transverse colon, and the ascending colon. The ascending colon is connected to the small intestine by a structure called the ceccum.
The digestive process of food stops at the small intestine and the fecal waste water-removal process starts at the ascending colon. Fecal matter starts as liquid waste at the cecum and ends up as solid waste in the sigmoid colon.
Hemorrhoid Causes
We all have hemorrhoidal veins in the anus, anal canal, and rectum. These veins do not have valves, which would normally help support and distribute the weight of the blood. Many factors can cause undue pressures on these veins, which can then cause these veins to become distended and swollen hemorrhoids.
Below are some factors that can cause hemorrhoids:
- Straining during bowel movement
One of the most frequent causes of hemorrhoids is straining during bowel movements. Forcing for too long or too hard, because of diarrhea, constipation, or bad bathroom habits (such as reading on the toilet) is actually attributed to the majority of hemorrhoids cases.
It is interesting that some have argued that the design of the sitting toilet actually contributes to straining - hemorrhoids are virtually unknown in countries with squat toilets.
- Genetics
Inherited characteristics such as weak vein walls can result in tendencies to develop hemorrhoids. Heredity alone, however, does not usually lead to a hemorrhoid without additional factor(s), such as a bad bathroom habit or a job that requires standing or sitting for prolonged periods.
Note that although "bad genes" are often blamed, for some, hemorrhoids actually are caused by learned behaviors - these people are simply following the lifestyle and bad bathroom habits of their parents.
- Western Diet
Although it is very common in Western countries, hemorrhoid is actually rare in cultures that eat a fiber-rich diet. A typical Western diet is rich in refined flour, sugar, animal protein, and fiber-depleted carbohydrates, whereas Asian and African diets are rich in natural grains, plant fibers and roughage.
This leads people to think that diet plays a big role: foods that are lacking in fibers actually create stool that is harder to pass. This results in straining during a bowel movement, and thus hemorrhoids.
Indeed, there is some evidence that there is a direct relationship between the amount of fiber in the food, the time it requires to ingest and eliminate the food, as well as the weight and consistency of stool. For example, a typical African villager easily passes about 400 to 500 grams of moist stool approximately 35 hours after eating. A typical Westerner, however, passes 150 grams of stool approximately three to five days after eating!
Interestingly, the incidence of hemorrhoids often increase as the society becomes more affluent and its diet becomes more Westernized.
You may ask: if it's so bad, why does Western food processing get rid of fiber in the first place? Fiber is refined out of flour and other foods for two main reason: consumer convenience and profit for the food manufacturers. It turns out that without the fibers, food is easier to chew and can be swallowed more easily. Also, it takes less digestive gastric juices to process, thus making more room in the stomach for food. This means that consumers can actually eat more of processed food, therefore increasing the profit of food manufacturers.
Indeed, prior to the introduction of the steel roller mills, which deplete fibers from flour, in the 1880s, hemorrhoids were quite rare even in Western countries.
- Pregnancy
Another of the most common causes of hemorrhoids in women is pregnancy: the extra weight of the uterus adds great pressure on the rectal veins. For women who already have hemorrhoids, pregnancy can definitely make their hemorrhoid condition worse.
Even women who do not develop hemorrhoids during pregnancy can still get them because of long and arduous labor and delivery, or because of constipation that arise after childbirth. For example, in the days and weeks after vaginal delivery, some women regularly postpone bowel movements because of tenderness in the anus and perianal area.
See Hemorrhoids and Pregnancy
- Postponing bowel movement
Sometimes when "nature calls", there is no toilet nearby. Usually, by postponing bowel movement, the urge to defecate goes away and does not return until after eating another meal. While occassionally postponing bowel movement does no harm, doing it regularly can contribute to hemorrhoids.
Here's why: the longer fecal matter remains in the colon, the drier it becomes and therefore the harder it is to pass without straining. Repeated inhbition of the urge to defecate can also result in weaker signals to the rectal muscles to pass stool. Eventually, it may be difficult to pass stool naturally without some straining.
Also, a colon filled with fecal matters is heavy and exerts pressure on the blood vessels and veins of the anus and rectum. This can cause these veins to swell and become hemorrhoids.
- Diseases
There are several diseases that can actually lead to the development of hemorrhoids. Of these, the most serious is rectal cancer, which causes a false "call of nature", thus encouraging the patient to go to the bathroom and strain unnecessarily.
Enlargement of the liver, often found in people who abuse alcohol, can create extra pressure on the hemorrhoidal veins. Other digestive diseases, such as intestinal tumor and irritable bowel syndrome, can interefere with normal elimination or cause constipation.
Lastly, although heart attack does not cause hemorrhoids, it does increase venous pressure and therefore can make an existing hemorrhoid worse.
- Bouts of diarrhea
Diarrhea is the body's way of getting rid of bacteria from its digestive system. It is commonly caused by contaminated food. However, diarrhea can also be caused by an allergic reaction to food and milk, by stress and anxiety, as well as by an adverse reaction to medication and laxatives.
In the case of diarrhea, the expulsive force of the watery stool can damage rectal veins and lead to hemorrhoids.
- Constipation
Paradoxically, the opposite of diarrhea can also lead to hemorrhoids! Constipation is defined as infrequent bowel movements or the difficulty in passing stool. The longer the stool remains in the colon, the drier it gets. After a certain point, usually a fair amount of straining is required to pass the dry and hard stool.
A common condition in the elderly, constipation is one of the major causes of hemorrhoids in this segment of the population.
- Extreme physical exertion
Laborers and weightlifters often hold their breath or grunt while lifting heavy objects. This forces air downward in the lungs and exerts pressure on the diaphragm, which in turn exerts pressure on the abdominal organs and rectal veins.
Note that weightlifters can also get hemorrhoids because they eat a lot of animal proteins in order to gain bulk and mass.
- Prolonged sitting or standing and lack of exercise
Sedentary lifestyle, lack of exercise, as well as jobs which require prolonged periods of sitting and standing can lead to, or exacerbate, existing hemorrhoids.
Hemorrhoid Symptoms
We all have hemorrhoidal veins in the rectum, anal canal, and anus. When these veins become irritated and inflamed, they become hemorrhoids or piles, with the accompanying symptoms of swelling, pain, bleeding, itching, or burning sensation.
There are two types of hemorrhoids:
- External hemorrhoids
Hemorrhoids located outside of the anus are called external hemorrhoids. Here, swollen veins cause a soft lump around the anal opening. These lumps can turn hard if blood clot develops, and become painful thrombosed hemorrhoids. Since the anus has many nerve endings, external hemorrhoids can be very painful or itchy. Sometimes, the clot may even break out of the hemorrhoid by itself or dissolve back into normal blood circulation.
- Internal hemorrhoids
Internal hemorrhoids are located inside the rectum or anal canal, and are usually not painful. This is because the anal canal does not have many nerve endings. Indeed, most people are not aware that they have internal hemorrhoids until a hard stool rubbing against them cause these hemorrhoids to rupture and bleed.
Left untreated, some internal hemorrhoids can "prolapse" or be pushed out of the anal opening. Sometimes, the sphincter muscle can close shut in a spasm and trap this prolapsed hemorrhoid outside the anus. This cuts off the blood circulation, and creates a strangulated hemorrhoid.
Some prolapsed hemorrhoids can be manually "pushed" back inside the anus. Advanced cases of prolapsed hemorrhoids, however, must be surgically treated.
Prolapsed and strangulated hemorrhoid are a serious medical condition that requires immediate attention. Also, bleeding of any amount should be checked by a doctor since it may be an indication of more serious conditions, such as colorectal cancer.
Preventing Hemorrhoids
There are simple steps that you can do to avoid getting hemorrhoids. Even if you already have them, these tips should help in preventing hemorrhoid flare-ups:
- Eat more fibers and drink more water
A typical Western diet is high in animal fat and protein, and is often made with refined flours with little fiber content. This fiber-poor diet makes for stool that is smaller, drier, and harder to pass as compared to fiber-rich food.
To avoid hemorrhoids, add fiber to your regular diet by eating raw vegetables and fruits, as well as adding brand and oatmeal. Bran is particularly good because it helps make the stool soft, moist, and easier to pass. Drinking a lot of water can also help make stool softer, especially if you are eating fiber-rich food.
For the elderly, there are fiber-rich food that are not crunchy or hard to chew, such as oatmeal, steamed vegetables and stewed fruits. Drinking water during a meal, instead of between meals, can also help make fiber-rich food easier to digest.
It may take sometime for your body to get used to roughage, so it is sometimes best to change your diet gradually - start by eating more roughage over a period of several weeks.
- Changing Bad Bathroom Habits
Straining on the toilet puts a great pressure on the rectal and anal veins - causing them to distend and swell in a hemorrhoid. When "nature calls" normal bowel movement should be easy - if defecation is difficult, don't strain. Instead, wait a while and then try again.
Postponing bowel movement regularly can also help reduce the capability of the abdominal muscle to push out stool. It can also cause the stool to harden, and thus become harder to pass. So, don't wait when you get the urge to defecate.
Don't read on the toilet - a normal bowel movement only takes between 2 to 5 minutes.
- Exercise
Sitting or standing for long periods of time puts pressure on the rectal veins, so if your job requires you to sit or stand, be sure to take frequent breaks and move around to prevent hemorrhoids.
People who exercise are also less prone to developing hemorrhoids. Exercising can also make you thirstier, so you naturally drink more water. It can also help improve your metabolism and aid digestion.
Aging can weaken the anal sphincter muscle. Indeed, many elderly men and women have trouble passing stool because of this reason. Instead of using laxatives, which can make constipation worse, you can try "buttock" press exercises - tighten the buttock muscles for several second and then relax them in a repeated cycle. This will strengthen the sphincter muscle.
The buttock press can be done several times a day and practically anywhere - while sitting or standing. It is an especially good exercise for the elderly, pregnant women, and for those who cannot do strenuous exercise.
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