Hemorrhoids (cont.)

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What are the symptoms of hemorrhoids?

There are two types of nerves in the anal canal, visceral nerves (above the dentate line) and somatic nerves (below the dentate line). The somatic (skin) nerves are like the nerves of the skin and are capable of sensing pain. The visceral nerves are like the nerves of the intestines and do not sense pain, only pressure. Therefore, internal hemorrhoids, which are above the dentate line, usually are painless.

As the anal cushion of an internal hemorrhoid continues to enlarge, it bulges into the anal canal. It may even pull down a portion of the lining of the rectum above, lose its normal anchoring, and protrude from the anus. This condition is referred to as a prolapsing internal hemorrhoid. In the anal canal, the hemorrhoid is exposed to the trauma of passing stool, particularly hard stools associated with constipation. The trauma can cause bleeding and sometimes pain when stool passes. The rectal lining that has been pulled down secretes mucus and moistens the anus and the surrounding skin. Stool also can leak onto the anal skin. The presence of stool and constant moisture can lead to anal itchiness (pruritus ani), though itchiness is not a common symptom of hemorrhoids. The prolapsing hemorrhoid usually returns into the anal canal or rectum on its own or can be pushed back inside with a finger, but it prolapses again with the next bowel movement.

Less commonly, the hemorrhoid protrudes from the anus and cannot be pushed back inside, a condition referred to as incarceration of the hemorrhoid. Incarcerated hemorrhoids can have their supply of blood shut off by the squeezing pressure of the anal sphincter, and the blood vessels and cushions can die, a condition referred to as gangrene. Gangrene requires medical treatment.

For convenience in describing the severity of internal hemorrhoids, many physicians use a grading system:

  • First-degree hemorrhoids: Hemorrhoids that bleed but do not prolapse.
  • Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or without bleeding).
  • Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back in by a finger.
  • Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in. Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the lining of the rectum through the anus.

In general, the symptoms of external hemorrhoids are different than the symptoms of internal hemorrhoids.

External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids. This is perhaps, because they are low in the anal canal and have little effect on the function of the anus, particularly the anal sphincter. External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as thrombosis. Thrombosis of an external hemorrhoid causes an anal lump that is very painful (because the area is supplied by somatic nerves) and often requires medical attention. The thrombosed hemorrhoid may heal with scarring and leave a tag of skin protruding from the anus. Occasionally, the tag is large, which can make anal hygiene (cleaning) difficult or irritate the anus.

Medically Reviewed by a Doctor on 1/31/2013

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