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Prisoner Health Update: Hemorrhoids

by Eike Blohm, MD

Hemorrhoids are a very common problem that people do not like to talk about because of their intimate location. Hemorrhoids are both preventable and treatable, but can become significant health problems if ignored.

What exactly is a hemorrhoid?

A hemorrhoid is a vein that has been stretched to the point it bulges into the anal canal. There are two different types of hemorrhoids called “internal” and “external” depending on their location within the anus. The external variety is close to where the stool exits the anus; here the nerves of the somatic (body) nervous system provide sensation. Subsequently, external hemorrhoids often hurt or itch. Deeper in the anal canal the visceral (organ) nervous system takes over – but it isn’t very good at pinpointing pain. Just like we can’t really feel our internal organs, internal hemorrhoids are usually painless.

What causes a person to get hemorrhoids?

Imagine your least favorite guard yelling at someone, the veins in his neck engorged and prominent. Neck veins (e.g., the jugular) swell when there is increased pressure in the chest (e.g., from yelling, coughing). Hemorrhoids are veins, but connected to the abdomen rather than the chest, so they swell when there is pressure in the belly. This most commonly occurs from having to strain because of constipation or lifting heavy weights, but it can also be due to pregnancy or liver disease.

What are symptoms of hemorrhoids?

A mass usually the size of a pea or peanut can be felt while wiping the anus if the hemorrhoid is external, but internal hemorrhoids can be felt only with an inserted finger. A handheld mirror may show a bluish swelling akin to any other vein. Pain or itching are common with external hemorrhoids. Because the protruding swelling makes removal of stools difficult, it often takes many passes before the toilet paper returns unsoiled when wiping. The protrusion also experiences more friction – so small streaks of blood may appear on the toilet paper.

What if symptoms suddenly get worse?

A hemorrhoid can thrombose (develop a blood clot) which is quite painful. When that happens, it is no longer soft but feels like the eraser on a pencil. A small surgical procedure (thrombectomy) can cut out the clot to alleviate pain, but in most cases that is not done. Left alone, the blood clot will either dissolve or the hemorrhoid will die and become a skin tag.

However, some hemorrhoids rupture and cause massive bleeding. Just because blood is coming from the anus (hematochezia) does not mean the source is hemorrhoidal, though. Bleeding could come from anywhere in the digestive tract, necessitating a medical workup to pinpoint the source.

What are available treatments?

First and foremost, a stool has to be soft to avoid the straining that causes or worsens hemorrhoids. Fiber supplements and stool softeners help, as does avoiding opioids (e.g., suboxone). Heavy lifting and prolonged sitting (including on the toilet) should be avoided. Hemorrhoid creams that contain phenylephrine – related to adrenaline, in order to shrink blood vessels – as well as lidocaine (a numbing agent related to cocaine) are effective. So is an astringent, such as witch-hazel, which shrinks tissue. Sitz baths – soaking the hemorrhoids in a small tub – are also effective but impractical in prison. Severe cases of hemorrhoids may necessitate surgical removal (hemorrhoidectomy).

What else could it be?

Not every mass or pain in the anal canal is due to hemorrhoids. An anal fissure – a tear in the skin of the anus – is very painful and can also lead to blood-streaked toilet paper. A painful mass coupled with fever could also be a perirectal abscess, which requires antibiotics and often surgery. Lastly, exposure to human papillomavirus (HPV) can cause anal cancer even in young people.  

Disclaimer: This column aims to educate prisoners about common health concerns but does not constitute medical advice. It is no substitute for evaluation by a trained medical professional.

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