Chapter 6. Hemorrhoidal Disease

“Fiber enlarges stools. Large stools require straining to evacuate. Straining enlarges hemorrhoids and constricts the anal canal. The narrow anal canal requires even more straining and results in fissures, bleeding, and pain”
National Institutes of Health[1]

What Nature Giveth, Newton’s Law Taketh

From what we already know concerning the impact lifestyle, nutrition, and medicine have on stools, it isn’t hard to comprehend the forces behind the pandemic of hemorrhoidal disease, which actually starts with a little “defect” in human anatomy. Here’s what I mean by this:

Besides pain, discomfort, and embarrassment, the most unple­asant thing about hemorrhoidal disease is its negative impact on the aperture of the anal canal, which maxes out in healthy adults at 3.5 cm (1.37”) or about this much:

As you can see, it’s not that wide. So when the anus is stretched out this much, you’ll certainly feel discomfort, or even pain, just as with any other body orifice when it’s expanded to the max. Just try to swallow a small apple whole. Sure, you can shoehorn it in, but oh, will it hurt.

The anal canal, too, can pass large stools through. It doesn’t have a choice, does it? But it wasn’t intended to do so regularly, in the same way your teeth weren’t intended to open beer bottles, even though they can. Not surprisingly, when the anal canal is overstretched by large stools, the forces needed to pass them—pressure from the inside, straining from the outside—cause hemorrhoids to enlarge, and this brief passage to the sewer gradually becomes one long tortuous journey.

How torturous? Based on the U.S. Census 2000, “half of the population” by age fifty translates into 38 million victims of he­morrhoidal disease. Once you factor in people under fifty and the undiagnosed, the actual number is much greater.

Fiber-related constipation and straining (a telltale sign of latent constipation and dysbacteriosis) are the two principal causes of hemorrhoidal disease. The number of affected individuals illu­strates just how widespread those two problems are.

What giveth? Newton’s third law, of course: for every action there is an equal and opposite reaction. Here’s what I mean:

• As hemorrhoids get larger, the anal canal aperture gets smaller, and the stools become harder to pass;
• As the difficulty of passing stools intensifies, the need to strain grows more pronounced, and the hemorrhoidal pathologies grow worse;
• As the first two problems evolve, people keep increasing the amount of dietary and/or supplemental fiber to counteract de­fe­cation difficulties;

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• As people increase the amount of fiber in their diet, their stool keep getting larger, causing further enlargement of hemorrhoids, while the anal aperture becomes smaller and smaller;
• As the anal aperture becomes smaller and the stools larger, people experience more constipation, strain harder, feel more pain, and begin experiencing other complications described elsewhere in this book.

If not interrupted by luck, education, or God’s will, this vicious cycle continues unabated until patients may need surgery to fix rectal prolapse, anal fissures, fistulas, abscesses, fecal incontinence, or other related ailments.

Because most surgeries leave scars, damage nerves, and affect surrounding tissues, recovery is rarely one hundred percent. The muscle damage alone may place you in diapers for the rest of your life because of fecal incontinence. The residual pain may cause incomplete or delayed stools—the culprits behind chronic fecal impaction with its own compliment of nasty ills, such as diverticular disease, irritable bowel syndrome, ulcerative colitis, precancerous polyps, and, to top it off, colorectal cancer itself.

No, I’m not making all this up. Here is what proctologists—the physicians who specialize in mending hemorrhoids—have to say about the unfolding of hemorrhoidal disease:

That is certainly true if you continue treating constipation and hemorrhoidal disease with evermore fiber, water, and exercise. Otherwise, never say never!

A case of mistaken identity

It may surprise you to learn that every individual on planet Earth possesses hemorrhoids since birth. It’s true, because hemorrhoids aren’t what you think they are. What you think they are, is, in fact, hemorrhoidal disease, not hemorrhoids. What’s the difference?

Well, hemorrhoids (plural) are the internal bundles of vascular, muscular, and connective soft tissue that lines the anal canal and the region around the anus. The three main bundles (also referred to as anal cushions) encircle the anal canal, and some minor ones are situated in between. A ligament connects each sponge-like bundle to the underlying muscle, and the mucous membrane protects them from above.

Just like all other organs, hemorrhoids develop while still in the womb. They are part and parcel of human anatomy, not a patho­logy or disease. Their function is to protect (cushion) the internal structures of the anal canal from the passing stools. They are almost like the bearings on which the stools ride.

To some degree the function (and dysfunction) of hemorrhoids is similar to calluses that protect joints from friction damage. And, just as calluses on your palms can bulge, blister, and bleed as the result of too much hard labor, so can hemorrhoids from large stools and straining. No surprise there.

The term hemorrhoid(singular) means the condition, the sum of symptoms related to the inflammation, enlargement, thrombosis, and/or prolapse of hemorrhoids (tissue bundles). Doctors and patients alike universally refer to hemorrhoidal diseaseas hemorrhoids, which is technically incorrect. That’s why this chapter refers to hemorrhoidal disease throughout, rather than hemorrhoids.

The two types of hemorrhoids are distinguished anatomically—internal and external. While the external hemorrhoids are innervated by the same nerves that supply the skin in the perianal region, the internal hemorrhoids aren’t innervated at all and do not cause pain, even when enlarged. Let us be grateful to Mother Nature for small mercies!

Enlarged internal hemorrhoids are detected in two-thirds of all patients during routine anorectal examinations.[3] The absence of innervation explains why many people with a history of constipation may not realize that they have hemorrhoidal disease, until suddenly confronted with hemorrhoidal bleeding or prolapse.

In the case of external hemorrhoidal disease, the pain emanates from the area protruded by dilated hemorrhoidal veins. The dilation is caused by venal thrombosis. The thrombosis is caused by blood clots. Usually, the clotting happens from a specific event that can cause venal obstruction. It may be the passing of large stools, intense straining, the lifting of heavy objects, hard labor, diarrhea, childbearing, anal intercourse, and similar actions.

The pain goes away after the blood clot dissolves and the affected vein shrinks, though never completely. The vein’s new shape causes skin folds (tags) which may protrude temporarily (after defecation) or permanently. That’s when secondary conditions, such as prolonged sitting or standing, an alcoholic binge, smoking, a hot bath, sauna or the like, trigger events that may cause a recurrence of another clot and protrusion.

Unlike external hemorrhoids, internal hemorrhoids cause pain indirectly. The pain is precipitated by rectal prolapse—the protrusion of internal hemorrhoids outside the anus, while the following conditions cause actual pain:

• The spasm of the anal sphincter complex caused by the prolapsed hemorrhoids.
• The strangulation of the prolapsed hemorrhoidal tissue.
• The inflammation of the perianal skin caused by the residue of mucus and fecal matter, supplied by prolapsed tissue.
• The spasm of the anal sphincter may cause the thrombosis of underlining hemorrhoidal veins, which in turn may cause new external hemorrhoids, or aggravate existing ones.

To prevent a possible necrosis of strangulated hemorrhoidal tissue, an affected individual must seek medical attention immediately. When it isn’t available, the prolapsed hemorrhoids should be returned back into the anal canal in order to relieve pain and prevent possible necrosis and infection. The affected area must be cleansed with warm water, which also helps to relax the anal sphincter. Petroleum jelly or non-medicated hemorrhoidal cream should be used to lubricate prolapsed hemorrhoids and the surrounding area before maneuvering them back inside.

Taking care of bloody business

Bleeding specific to hemorrhoidal disease isn’t from the thrombosed veins (another popular misconception), but from the abrasions, cuts, fissures, fistulas, or ulcerations of the mucosal membrane that lines the anal canal. The bright red color of the blood indicates its arterial, rather than venous, nature.

Hemorrhoidal bleedings are distinguished by crimson streaks of fresh blood on the passing stools. The stool itself doesn’t change color, because there was no prior contact between it and the wound. At times, the bleeding may be profuse, but it usually stops when defecation is completed. In any event, it is best to see a doctor, and get checked out for this or any other source of bleeding.

The mucosal membrane that lines the anal canal is quite resilient and infection-proof. It quickly heals, and will not bleed again as long as stools remain soft and small (BSF type 5 or 6). If the stools remain type 1 to 4 (lumpy, large, hard), or you strain while relieving yourself, the bleeding may continue and get worse. In those instances, an initial small abrasion may turn into a fissure (split that won’t heal), a fistula (duct from anus into perianal region), or an abscess (encapsulated pus)—conditions which, considering the location and “traffic,” are extremely painful, infection-prone, and hard to treat and heal.

If the stool’s appearance is tar-like, it may mean that there is internal bleeding at some point upstream, beginning from the esophagus. The color changes to tar after coagulated blood mixes with feces.

Keep this important point in mind: if blood emanates from upper intestinal tract organs (esophagus, stomach, duodenum, small intestine), the bleeding may have started at least three to four days before you see first signs of it. That’s how long it normally takes for chyme to turn into stool and reach the toilet bowl. For people who are severely constipated it may take even longer. This means that by the time the blood in stools is detected, its loss may be considerable.

Certain food (beets, blueberries, black licorice), supplements (dietary iron), antacids (Pepto-Bismol), or a sudden release of conjugated biliary salts[4] may also give stools a tar-like appearance. Instead of panicking, don’t flush the toilet, and run to the nearest drugstore to purchase a Fecal Occult Blood Test (FOBT) kit. To regain your piece of mind, follow the instructions provided with the kit—usually a strip of paper that you’ll drop into the toilet—to observe changes. (The occult in the test name means hidden, not mystic.)

If the test is positive, and your pulse rate happens to be high, your blood pressure low, your appearance pale, and you find that you’re short of breath, fatigued, or dizzy, these are the symptoms of serious blood loss and you should call 911 at once. If you still feel fine, get to the nearest emergency room ASAP, and advise the triage nurse that you’ve just had a positive FOBT. They’ll know what to look for next. And don’t waste precious time seeing your local doctor, because you’ll be sent to the nearest hospital anyway, and in the meantime could be losing equally precious blood.

I’m assuming you recognize the importance of inspecting your stools at every opportunity. Besides saving yourself a lot of grief, it may actually save your life. In many cases, the toilet bowl predicts your future with more certainty than a crystal ball.

Good treatment or good grief?

Hemorrhoidal disease is grouped into four categories—from the 1st degree, which is the least serious, to the 4th degree, which usually requires surgery. Repeatedly prolapsing internal hemorrhoids are commonly treated by nonoperative methods, such as rubber band ligation, sclerotherapy, cryoterapy, photocoagulation, laser ablation, and others.

Surgical treatments are reserved for the more complex cases (usually 4th degree). Recurring external hemorrhoids are treated by surgical excision of the overlying skin folds and underlying veins. The procedure is performed under local anesthetic, and usually on an outpatient basis.

The consensus among surgeons who specialize in treating anorectal disorders is that asymptomatic enlarged hemorrhoids are better off left alone, and that the conservative treatment—thorough hygiene, prevention of diarrhea and constipation, avoidance of known triggers, and soft, small, and regular stools that don’t require straining to expel—is the safest, most reliable approach.

The medical profession is also in universal agreement that straining (related either to diarrhea or constipation) and large stools (type 2 and 3) are the primary reasons behind recurring prolapses of internal and/or external hemorrhoids.
Where this book digresses from mainstream medical opinion is on how to prevent diarrhea, avoid straining, eliminate constipation, and achieve small stools.

• This book advises: That fiber, commonly referred to as “roughage” or a “bulking agent” is the progeny of rough, bulky stools, and the overriding cause behind the emergence (etiology) and worsening (regression) of hemorrhoidal disease. Do not use fiber to prevent and treat hemorrhoidal disease.
• Mainstream medicine advises: Use abundant dietary fiber to prevent and treat hemorrhoidal disease. The more fiber, the merrier. Don’t forger the water and exercise, so you can strain harder.

Here’s an example of this reckless advice, excerpted from the on-line patient brochure put out by the American Gastroenterological Association:

Here’s another example, this time from the National Institutes of Health. I underlined two of the most striking contradictions—namely, if you want to relieve pressure and straining, you need to reduce stool’s bulk, not increase it:

Oh, and they didn’t forget about exercise. That’s in another paragraph:

Let’s forgive the authors for stating that “exercise, including walking,” produces softer stool. You can walk yourself to death, and your stool isn’t going to get any softer. The “real” value of exercise isn’t in softer stools, but in stronger abdominal muscles, which are required for the extra straining necessary to squeeze out all the bulk that comes with fiber.

The surgeons, whose “NEVER better” opinion about the outcome of hemorrhoidal disease I cited earlier, don’t diverge from the party line either, and provide equally contradictory advice:

Good grief! The same old story: more fiber, more water, more walking. With advice like this you may as well sell your gut to devil!

But we all agree on one point: to prevent and treat hemorrhoidal disease you must have small, soft, regular stools and you must not strain. We just differ on the approach: theirs, with bran; mine, with brain. Take care of the colon’s health, and hemorrhoids will take care of themselves. By the time you’re through with this book, you should be through with fiber dependence, constipation, and, by extension, with aggravated hemorrhoids.

Unfortunately, you can’t undo the damage already caused by large stools and straining—the dilated hemorrhoidal veins, the enlarged internal hemorrhoids, and the skin folds around the anus. But you can prevent veins from getting dilated further, and hemorrhoids from becoming larger and protruding even more. In most cases that’s enough to stop pain, inflammation, bleeding, or pro­lapse, as long as you guard your anus with the same vigilance you guard your credit rating.

Summary: Mind over fecal matter

To prevent hemorrhoidal disease from disfiguring your anus, consider the following key points:

• Hemorrhoids are an intrinsic part of human anatomy. They protect the internal structures of the anal canal (muscles, vessels, tissues) from passing stools.
• There are two type of hemorrhoids—external and internal. They are distinguished by their location and innervation.
• Hemorrhoids enlarge from internal pressure caused by large stools, and external pressure caused by straining.
• Internal hemorrhoids do not cause pain, unless they prolapse outside the anus.
• The prolapse of internal hemorrhoids is caused primarily by large stools and extreme straining specific to late stage latent and organic constipation.
• The prolapse of external hemorrhoids is caused by the dilation and thrombosis of hemorrhoidal veins.
• External hemorrhoids cause pain, the sensation of which is related to inflammation of the skin that surrounds the thrombosed venal prolapse.
• Other conditions cause hemorrhoidal disease indirectly, by either applying pressure similar to the passing of large stools—such as during anal intercourse, or straining during pregnancy and bouts of diarrhea—or through the lifting of heavy objects.
• Enlarged hemorrhoids are a chronic but benign condition. He­morrhoidal disease is an acute recurring condition, characterized by inflammation, pain, and/or bleeding of affected tissues.
• The enlargement of hemorrhoids narrows the aperture of the anal canal. This contributes to the development of constipation, larger stools, and further damage.
• Type 1, 2 or 3 stools (hard and/or large) on the BSF scale cause hemorrhoidal disease because their dimensions exceed the anatomical “specification” of the anal canal.
• Any stools above 2.5 cm (1”) in width are likely to cause the enlargement of hemorrhoids. To prevent hemorrhoids from enlarging, stools must match type 4 to 6 on the BSF scale.
• Dietary fiber is an indirect cause of hemorrhoidal disease, because it causes large stools.
• The elimination of dietary fiber (to reduce stool size and density) from the diet is a principal strategy for the treatment and prevention of hemorrhoidal disease and related complications.
• The commonly accepted recommendation to use dietary fiber for the treatment and prevention of hemorrhoidal disease is incorrect. Dietary fiber will aggravate enlarged hemorrhoids, because increased stool size causes additional pressure inside the anal canal.
• The appearance of blood on passing stools indicates a laceration of the anal mucosa that covers internal hemorrhoids. The blood may appear without any visible symptoms of hemorrhoidal disease. Consult your doctor at once to diagnose the source of bleeding, and to eliminate all other probable causes.
• Asymptomatic enlarged hemorrhoids do not require any treatment except dietary modification (exclusion of fiber), and the maintenance of small, soft stools, which don’t require straining.
• If or when hemorrhoidal disease impacts your quality of life, or prevents you from having timely, regular stools because of pain, fear, or other factors, discuss more proactive treatment options with a specialist.
• Most doctors are qualified to perform outpatient surgeries related to hemorrhoidal diseases. For best results choose a physician who specializes exclusively in anorectal surgeries. There is no substitute for experience when dealing with this delicate area.
• There are many surgical and non-surgical methods to treat hemorrhoidal disease. Some are safer than others. Always ask your doctor about his or her approach, and investigate its pros and cons to avoid common complications such as chronic pain or fecal incontinence.
• If hemorrhoidal disease is left untreated, and its causes aren’t eliminated, there is a distinct possibility of further anorectal complications such as anal fissures, fistulas, and abscesses, which in most cases require surgical intervention.
• If you are experiencing an acute stage of hemorrhoidal disease, follow your doctor’s directions until the symptoms subside. Do not drop prescribed medication. Do not drop supplemental fiber laxatives (to prevent even more severe constipation), unless you replace it by the safer methods described in this book.

Footnotes