When our hemorrhoids are irritating and painful, we often say we "have hemorrhoids," although we all have them. Hemorrhoids are vascular structures that help control our stool, and they can become inflamed.

Hemorrhoid pain is common. Both men and women experience it, although women have a higher propensity during pregnancy and childbirth. When our hemorrhoids are irritated, we may experience itchy and painful symptoms, making it hard to concentrate and uncomfortable to sit. This is because the veins in your rectum are swollen. They can also bleed, especially during a bowel movement, which can be scary. Fortunately, they don't portend more serious diseases. There are two types of hemorrhoids: external, occurring outside the anus; and internal, occurring within the rectum.

Managing external hemorrhoids

Fortunately, external hemorrhoids can be treated with over-the-counter options, such as analgesic creams or suppositories that contain hydrocortisone. Another treatment option for relief is a sitz bath. For a more complete solution, the best way to reduce hemorrhoid bleeding and pain is to increase your fiber intake (1). If you have rectal bleeding and either have a high risk for colorectal cancer or are over 50, consult your physician to confirm it is not due to a malignancy or other cause, such as inflammatory bowel disease.

Managing internal hemorrhoids

Internal hemorrhoids are more complicated. The primary symptom is bleeding when you have a bowel movement. Because the hemorrhoids are usually above the point of sensation in the colon, called the dentate line, they rarely hurt. If there is pain and discomfort, it's often because the internal hemorrhoids have prolapsed, or fallen out of place, due to weakening of the muscles and ligaments in the colon. This allows them to fall below the dentate line.

The first step for treating internal hemorrhoids is the same as for external hemorrhoids: add fiber to your diet or through supplementation. Study after study shows significant benefit. For instance, in a meta-analysis, fiber reduced the occurrence of bleeding by 53 percent (2). In another study, after two weeks of fiber and another two-week follow-up, daily incidence of bleeding decreased dramatically (3).

Treating persistent hemorrhoid pain

There are several minimally invasive options to address persistent and painful hemorrhoids, including banding, sclerotherapy and coagulation. The most effective of these is banding, with an approximate 80 percent success rate (4). This is usually an office-based procedure where rubber bands are placed at the neck of each hemorrhoid to cut off its blood flow.

To avoid complications from constipation, patients should also take fiber supplements. Side-effects of the procedure are usually mild, and there is very low risk of infection. However, severe pain may occur if misapplication occurs with the band below the dentate line. If this procedure fails, hemorrhoidectomy (surgical removal) would be the next option.

Prevent hemorrhoid problems

Sitting on the toilet for a long time puts a lot of pressure on the rectal veins, which can increase your risk of inflammation. It's important to get off the toilet as soon as you have finished moving your bowels. Soften your stool and prevent constipation by drinking plenty of fluids. Exercise also helps. You should not hold in a bowel movement; go when you have the urge to keep stool from becoming hard, which can lead to straining and more time on the toilet. Consuming more fiber will help create bulk for your bowel movements, reducing constipation, diarrhea and undue straining.

How much fiber is enough?

Americans, on average, consume about 16g per day of fiber (5). This is well below the U.S.D.A.'s recommendation: 14 grams of fiber for every 1,000 calories we consume (6). The difference between guidelines and our actual consumption has led the medical community to express concern about the "fiber gap."

Fiber underconsumption has greater implications than just hemorrhoids. It contributes to weight control issues, increased insulin sensitivity and chronic inflammation, among others (7). Fiber's benefits are so great that I recommend many patients strive to consume 40 grams a day. You may want to increase your fiber consumption gradually to minimize the potential for gas and bloating during the first week or two. It will take your system some time to adjust. I typically recommend making dietary adjustments before trying supplementation. Fruits, vegetables, whole grains, nuts, beans and legumes all have significant fiber. Grains, beans and nuts have among the highest levels. For instance, one cup of black beans contains 12g of fiber.

References:

(1) Dis Colon Rectum. Jul-Aug 1982;25(5):454-6. (2) Cochrane.org. (3) Hepatogastroenterology 1996;43(12):1504-7. (4) Dis Colon Rectum 2004 Aug;47(8):1364-70. (5) usda.gov. (6) Am J Lifestyle Med. 2017 Jan-Feb; 11(1): 80-85. (7) Nutrients. 2020 Oct; 12(10): 3209.