External hemorrhoids bleeding,external hemorrhoids are covered by a thin layer of skin and located below the dentate (pectinate) line that divides the anal canal. They are close to the nerve supply but are usually painless unless thrombosis occurs. This is when blood clots occur within the hemorrhoids and is known as external hemorrhoidal thrombosis, or EHT (see the page on hemorrhoid thrombosis). It occurs due to blood pooling in the swollen, engorged veins of the hemorrhoids. Constipation and straining will make things worse in this case. You may notice a painful, hard lump in your back passage if this happens, and thrombosed hemorrhoids are more likely to rupture. This causes further pain and bleeding.
External and internal hemorrhoids. Anoderm: the skin that covers external hemorrhoids.
Certain factors increase or decrease your risk of developing EHT. Factors that increase your risk include age less than 47, strenuous physical activity and use of dry toilet paper followed by wet cleaning after defecation. Conversely, factors that reduced the risk were warm baths, showers and genital cleaning before sleep.
If your hemorrhoids are thrombosed, surgery is the best option, usually as an outpatient. Bleeding hemorrhoids can be treated with ligation, sclerotherapy injection, infra-red or laser photocoagulation (clotting), stapling or hemorrhoidectomy surgery, depending on the severity. If you have surgery, the entire hemorrhoid will be removed to prevent recurrence. More unusual treatments include Pycnogenol® (pine bark) medication, which has shown some effectiveness.
There are many techniques used in hemorrhoidectomy. Two popular methods are the Milligan Morgan, which is an “open” technique popular in Europe, and Ferguson, which is “closed” and commonly used in the USA. If you have the Milligan Morgan technique, you will be likely to have a shorter operation time. However, with the Ferguson technique, you may experience faster wound healing by one month.
The requirements for pain relief are debated, with some studies finding lower pain requirements with the Milligan Morgan operation, and others with the Ferguson technique. The Milligan Morgan operation may be more commonly used with thrombosed hemorrhoids as it can give a better view and increased access to the affected area. A further development is stitch-free surgery, which may reduce complications.
Laser treatment for hemorrhoids
One study compared laser therapy with conventional surgery for hemorrhoids in 88 patients. Patients with external hemorrhoids were treated with carbon dioxide lasers while in those with internal hemorrhoids, an Nd-YAG laser was used. In the laser therapy group, there were significantly lower requirements for pain relief, a lower rate of urinary retention and a shorter hospital stay. Wound healing was slightly slower than with hemorrhoidectomy, but the overall rate of complications between the two was very similar. This suggests laser therapy is a viable alternative to hemorrhoidectomy.
Stapled hemorrhoidopexy is a procedure to “fix” the hemorrhoids back into their normal place, usually using Procedure for Prolapse Hemorrhoids (PPH) equipment. It has a faster recovery time than conventional surgery, a high patient satisfaction rate and a similar rate of complications, but your hemorrhoids are more likely to come back (7.6% of people in one study required re-operation). Some clinics have investigated the possibility of using a local nerve block with stapling rather than a general or spinal anaesthetic, with promising results. However, this is a relatively new procedure and long-term results are still being awaited, as stapling has only been in common use since 1998.
Focus on sclerotherapy
Sclerotherapy involves the injection of 3-5ml of a solution such as quinine urea or phenol. This scars the hemorrhoids and leads to them shriveling up. Initial success rates for sclerotherapy range from 75% to 89%, although relapse occurs frequently so it is really only a temporary therapy.
Rarely, serious side effects such as perforation or necrotizing fasciitis (“flesh-eating disease”) may occur. However, more common complications are bleeding following the injection or slight discomfort during the procedure. The advantages include a lower amount of bleeding, which is helpful if you take anticoagulants or have a bleeding tendency, and a quick recovery time. You should be pain-free and able to carry on with normal activities after a few days.
External hemorrhoids will not always be treated with surgery. This depends on the level of pain you are experiencing as EHT itself is not life-threatening. If the pain is not severe, you can wait until they improve, usually after four to five days with a peak around 48 hours. You will be treated with a combination of painkillers (such as lidocaine local anaesthetic or aspirin tablets), muscle relaxants (such as nifedipine), steroid creams, stool softeners and a high-fiber diet.
Your doctor may want to check there are no other causes for your bleeding. They may take blood tests for clotting factors and ask about your family history of cancer and inflammatory bowel disease. In the majority of cases, the bleeding is due to hemorrhoids alone.
For more tips on how to treat external hemorrhoids at home, please watch this video:
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