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Causes and symptoms
hemorrhoidsLump in the rectum, piles Surgery Engorged veins under the rectal mucosa, associated with constipation, straining while squatting, pregnancy, prolonged sitting, anal infection. See External hemorrhoids, Internal hemorrhoids.
|Mean LOS:||4.4 days|
|Description:||MEDICAL: Other Digestive System Diagnoses With CC|
|Mean LOS:||5.4 days|
|Description:||SURGICAL: Anal and Stomal Procedures With CC|
Hemorrhoids are a common, generally insignificant swelling and distention of veins in the anorectal region. They become significant when they bleed or cause pain or itching. In the United States, at least 10 million people have hemorrhoids, and up to one-third of these people seek treatment. Hemorrhoids are categorized as either internal or external. Internal hemorrhoids, produced by dilation and enlargement of the superior plexus, cannot be seen because they are above the anal sphincter, whereas external hemorrhoids, produced by dilation and enlargement of the inferior plexus, are below the anal sphincter and are apparent on inspection.
Hemorrhoids develop when increased intra-abdominal pressure produces increased systemic and portal venous pressure, thus causing increased pressure in the anorectal veins. The arterioles in the anorectal area send blood directly to the swollen anorectal veins, further increasing the pressure. Recurrent and repeated increased pressure causes the distended veins to separate from the surrounding smooth muscle and leads to their prolapse (enlarged internal hemorrhoids that actually protrude through the anus).
Some factors associated with hemorrhoids are occupations that require prolonged sitting or standing; heart failure; anorectal infections; anal intercourse; alcoholism; pregnancy; colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or hepatitis. Straining because of constipation, diarrhea, coughing, sneezing, or vomiting and loss of muscle tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids.
It is unclear whether familial occurrences of hemorrhoids are related to genetic or environmental factors or a combination of the two. A familial tendency toward weak rectal vein walls and/or valves and varicose veins would increase susceptibility.
Gender, ethnic/racial, and life span considerations
Hemorrhoids are more common in women during late pregnancy and immediately after delivery. Young people who are engaged in heavy weightlifting and exercise are prone to hemorrhoids, and college students who do not eat balanced diets are also at risk. The greatest incidence occurs in adults from 20 to 50 years of age. Men and people with high socioeconomic status are more likely to pursue medical care for the treatment of hemorrhoids than women and people from underresourced communities. In later life, congestive heart failure and obesity contribute to the development of hemorrhoids. There are no known racial or ethnic considerations.
Global health considerations
In Western countries, approximately 4% to 5% of the population is affected with symptoms. This prevalence is likely comparable to most regions around the world.
Establish a history of anal itching, blood on the toilet tissue after a bowel movement, and anorectal pain or discomfort. Ask if the patient has experienced any mucus discharge. Determine if the patient can feel the external hemorrhoids. Elicit a history of risk factors and dietary patterns.
The most common symptoms are anal itching, anal bleeding after a bowel movement, and anorectal pain. Inspect the patient’s anorectal area, noting external hemorrhoids. Internal hemorrhoids are discovered through digital rectal examination or anoscopy. Note any subcutaneous large, firm lumps in the anal area.
Patients with hemorrhoids may delay seeking treatment because of embarrassment relating to the location. Provide privacy and foster dignity when interacting with these patients. Inform the patient of every step of the procedure. Provide comfort during examination.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Proctoscopy: Endoscopic examination of rectum and anal canal||Normal rectal lining: Consistently reddish, free of lesions or inflammation||Visualization of internal hemorrhoids||Determines size and location of hemorrhoids|
Other Tests: Barium enema, proctoscopic ultrasound, virtual colonoscopy, complete blood count
Primary nursing diagnosis
DiagnosisPain (acute or chronic) related to rectal swelling and prolapse
OutcomesComfort level; Pain control behavior; Pain level; Symptom severity; Well-being
InterventionsAnalgesic administration; Anxiety reduction; Pain management; Medication management; Heat/cold application; Bowel management; Coping enhancement
Planning and implementation
Generally, hemorrhoids can be managed pharmacologically. Conservative treatments include application of cold packs to the anal region, sitz baths for 15 minutes twice a day, and local application of over-the-counter treatments such as witch hazel (Tucks) or dibucaine (Nupercainal) ointment. If conservative treatment does not alleviate symptoms in 3 to 5 days, more invasive management may be needed.
Invasive treatment may be indicated for thrombosis or severe symptoms. Sclerotherapy obliterates the vessels when the physician injects a sclerosing agent into the tissues around the hemorrhoids. With rubber band ligation (RBL), rubber bands are put on the hemorrhoids in an outpatient setting. The banded tissue sloughs. Successive visits may be necessary for many hemorrhoids. Although RBL has a high success rate, it may temporarily increase local pain and cause hemorrhage. In cryosurgery, the physician freezes the hemorrhoid with a probe to produce necrosis. Cryosurgery is used only for first- and second-degree hemorrhoids.
The most effective treatment is hemorrhoidectomy, the surgical removal of hemorrhoids, which is performed in an outpatient setting in 10% of patients. When the patient can resume oral feedings, administer a bulk medication such as psyllium. This medication is given about 1 hour after the evening meal to ensure a daily stool, which dilates the scar tissue and prevents anal stricture from developing. Postoperative care includes checking the dressing for excessive bleeding or drainage. The patient needs to void within the first 24 hours. If prescribed, spread petroleum jelly on the wound site and apply a wet dressing. Complications include urinary retention and hemorrhage. The newest surgical technique for treating hemorrhoids is stapled hemorrhoidectomy. The surgery does not actually remove hemorrhoids but rather the supporting tissue that causes hemorrhoids to prolapse downward.
|Medication or Drug Class||Dosage||Description||Rationale|
|Docusate sodium (Colace)||100 mg bid PO||Stool softener||Eases defecation|
|Anusol suppositories||1 bid PR||Analgesic, emollient||Relieve pain and itching|
|Hydrocortisone ointment or suppositories||Topical or PR as needed for brief courses of therapy||Corticosteroid||Relieve itching and swelling|
Other Drugs: Over-the-counter analgesics such as acetaminophen or topical anesthetics such as lidocaine ointment. Some people find that hamamelis water (witch hazel) effectively reduces anal itching. Note: Laxatives are prohibited.
Most patients can be treated on an outpatient basis. Teach patients and families about over-the-counter local applications for comfort. Explain the importance of promoting regular bowel habits. Emphasize the need for increasing dietary fiber and fluid through a balanced diet high in whole grains, raw vegetables, and fresh fruit. Moderate exercise such as walking can also help regulate bowel function.
Postoperative actions include administering ice packs for pain control and positioning the patient for comfort. After the first 12-hour postoperative period, sitz baths three or four times a day may be instituted to prevent rectoanal spasms and reduce swelling. Explain that the first postoperative bowel movement is painful and may require suitable narcotic intervention for comfort.
Evidence-Based Practice and Health Policy
Lu, L.Y., Zhu, Y., & Sun, Q. (2013). A retrospective analysis of short and long term efficacy of RBL for hemorrhoids. European Review for Medical and Pharmacological Sciences, 17(20), 2827–2830.
- RBL is an effective treatment for hemorrhoids, and evidence demonstrates that complications are typically minimal.
- Investigators conducted a study in which 254 patients with second-degree and third-degree hemorrhoids (69% and 31% of patients, respectively) were treated with RBL in an outpatient setting. Prior to the procedure, 82.6% of patients presented with rectal bleeding, 38.3% of patients reported constipation, 9.5% of patients reported pruritis, and 3% of patients reported pain.
- Postsurgical complications included moderate pain in 41% of patients, severe pain in 1% of patients, bleeding in 2% of patients, and vasovagal symptoms in 1.6% of patients. Two months postprocedure, 92% of the patients with second-degree hemorrhoids and 76% of the patients with third-degree hemorrhoids had no residual symptoms. RBL failed to alleviate hemorrhoids in only 3% of patients.
- Physical findings: Rectal examination, urinary retention, bleeding, mucous drainage
- Wound healing: Drainage, color, swelling
- Pain management: Pain (location, duration, frequency), response to interventions
- Postoperative bowel movements: Tolerance for first bowel movement
Discharge and home healthcare guidelines
Teach the patient the importance of a high-fiber diet, increased fluid intake, mild exercise, and regular bowel movements. Be sure the patient schedules a follow-up visit to the physician. Teach the patient which analgesic applications for local pain may be used. If the patient has had surgery, teach her or him to recognize signs of urinary retention, such as bladder distention and hemorrhage, and to contact the physician at their appearance.
Patient discussion about hemorrhoids
Q. What are hemorrhoids?
Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the opening of the anus to form external hemorrhoids. You can have both types at the same time. The symptoms and treatment depend on which type you have.
Q. What are the symptoms of hemorrhoids? My husband complains that when he goes to the bathroom he bleeds. Does this mean he has hemorrhoids?
Q. How to prevent Hemorrhoids? My brother is suffering from Hemorrhoids. I am very worried about getting them to and want to know how can I prevent them?