Hemorrhoids are vascular cushions located under the mucosa in the anal canal, starting near the dentate line. These vascular cushions are a natural anatomical structure of the anal canal, and their presence does not necessarily indicate hemorrhoidal disease.
Hemorrhoids are classified into four degrees:
1. First-degree: In this type, bleeding with defecation is observed (the bleeding tends to be bright red and may be seen on toilet paper or in the toilet bowl). Prolapse is not observed, and symptoms are mild, resulting from blood leakage from inflamed veins or thin arteries in the walls. Conservative management with dietary manipulation by adding fiber to the diet and ensuring anal hygiene is usually sufficient. Continuous bleeding may require non-surgical excision of blood vessels. 2- Second-degree: Hemorrhoids prolapse with defecation or straining, and this degree can be treated using rubber band ligation or other non-surgical excision techniques. 3- Third-degree: Prolapsed hemorrhoids require manual reduction, with significant destruction of the supporting ligaments. It may be necessary to relocate the mucous membrane and anchor it to the muscular wall. Rubber band ligation may be a temporary solution initially, but general excision of hemorrhoids is necessary. 4-Fourth-degree: Prolapsed hemorrhoids require excision, especially when prolapsed in multiple directions and are irreducible, which can lead to strangulation.
The direct cause of hemorrhoids is still not precisely defined, but the most likely cause is the descent of vascular cushions downwards. Common causes include:
Straining during bowel movements (whether due to constipation or chronic diarrhea).
Obstruction of venous return due to increased abdominal pressure (e.g., during pregnancy), obesity, prolonged standing.
Low dietary fiber intake.
Genetic predisposition to weakness in the venous wall or supporting ligaments.
Certain sexual behaviors.
Symptoms of hemorrhoids:
Bleeding, pain, and prolapsed hemorrhoids are the most common symptoms in patients with hemorrhoids. Symptoms vary depending on whether the hemorrhoids are internal or external. Internal hemorrhoids are usually painless (as they do not contain pain fibers). Prolapse can vary in severity and may appear as purple tissue protruding from the anal opening, accompanied by sensations of pressure, fullness, and irritation. Patients may also notice mucous discharge from the anal opening. External hemorrhoids are associated with pain, especially during bowel movements, causing itching and severe pain resembling burning or stinging. Swollen external hemorrhoids may shrink and leave marks on the skin without causing any harm.
