Is it true that varicose veins can occur in the anus?

Varicose veins are veins that become abnormally enlarged. Varicose veins can occur in any vein in the body, for example, the legs, hands, or throat, and if they occur in the anus, they are called hemorrhoids.

Hemorrhoids are dilated hemorrhoidal veins accompanied by abnormalities in the supporting tissue (anal cushion). Hemorrhoids can be divided into two categories, namely internal hemorrhoids and external hemorrhoids, based on the location of the affected blood vessels.

Symptoms and Diagnosis of Hemorrhoids

Hemorrhoids often show no symptoms and are discovered accidentally during anal examination or colonoscopy. The most frequently encountered symptoms are bleeding from the anus, lumps in the anal area, discharge from the anus, dissatisfaction when defecating, and discomfort in the buttocks area.

Dilation of blood vessels and increased pressure in the anus cause the vessels to easily rupture and bleed. In hemorrhoids, the blood that comes out is fresh red and does not mix with feces; the blood can be in the form of streaks or drips, causing the toilet water to turn red. Continuous bleeding can result in severe anemia (a lack of blood). Pain generally occurs if there is obstruction to the flow of the veins (thrombosis) due to pressure, which is aggravated by infection.

As mentioned previously, hemorrhoids are divided into internal hemorrhoids and external hemorrhoids. Internal hemorrhoids occur if the dilated blood vessels are located at the top. Symptoms include a bluish-red lump coming out of the anus, which is usually painless. Internal hemorrhoids are divided into 4 degrees, namely:

• Grade I: the lump cannot be seen coming out of the anus.
• Grade II: A lump comes out of the anus when pushing (hanging out), but you can still log in yourself.
• Grade III: A lump comes out of the anus when pushing (hanging out) and can only be reinserted with the help of your hands.
• Grade IV: the lump comes out of the anus and cannot be put back in.

External hemorrhoids occur if the dilated blood vessels are at the bottom. External hemorrhoids are covered by the outer skin, which has more nerves, so they will feel more painful and sometimes itchy. Apart from being based on symptoms, hemorrhoids can also be found through examination of the anus area, digital rectal examination, or anal binoculars (anoscopy). This examination is carried out to rule out other causes of anal bleeding, such as malignancy.

 What are the risk factors for hemorrhoids?

The incidence of hemorrhoids tends to increase with age, with a peak age of 45–65 years. The risk factors that cause someone to suffer from hemorrhoids include:

1. Constipation

Constipation is a defecation disorder characterized by hard and dry feces, difficulty defecating or straining, or a decrease in the frequency of defecation. The habit of pushing causes increased pressure in the digestive tract, causing pressure on the veins so that the veins become enlarged. Straining also increases the risk of hemorrhoids appearing to come out of the anus. Constipation itself is caused by several things, for example, a low-fiber diet, psychological stress, and a lack of physical activity.

2. Obesity

As many as 75% of internal hemorrhoid patients are obese. The relationship between hemorrhoids and obesity is actually unclear. It was later discovered that obesity can increase pressure in the digestive tract, which plays a role in compressing the veins in the anus. Excess fat in the body also has the potential to cause chronic inflammation, which causes abnormalities in the veins and lining of the anus. In addition, someone who is obese tends to consume a low-fiber diet.

3. Effects of Physical Activity

Lack of physical activity causes a high incidence of hemorrhoids. Sufficient physical activity affects the activity of the diaphragm, stomach, and pelvic muscles so that peristaltic activity or bowel movements become better and facilitate the defecation process. On the other hand, physical activity that is too heavy can cause increased pressure on the hemorrhoidal plexus veins, for example, lifting weights, rowing, cycling, and horseback riding.

4. Pregnancy

Pregnancy has the potential to increase the incidence of hemorrhoids. In pregnant women, abdominal pressure increases due to fetal growth and hormonal changes, which result in the widening of the veins. Generally, hemorrhoids in pregnancy include temporary hemorrhoids, which will disappear some time after giving birth.

5. Genetic Factors

Studies regarding the influence of genetic factors on the incidence of hemorrhoids are still very minimal. A study shows that there are abnormalities in genes that cause disorders of the intestinal mucosal lining, blood vessels, and anus in patients with hemorrhoids.

Hemorrhoid Management

The management of hemorrhoids is divided into non-surgical therapy and surgical therapy. 

Non-surgical therapy includes lifestyle modifications, for example, avoiding excessive straining, avoiding a sedentary lifestyle, and exercising that is too heavy. Apart from that, it is recommended to consume lots of fibrous foods and drink enough to facilitate bowel movements so that you don't have to strain excessively. Using medication through the anus and anal ointment is less effective but can reduce pain and the risk of infection. Hemorrhoid patients can also be given laxatives to facilitate and soften bowel movements.

Other non-surgical therapies aimed at preventing the worsening of hemorrhoids include ligation or binding with rubber, sclerotherapy, and infrared photocoagulation. 

• Ligation is generally used to treat grade II and III internal hemorrhoids. The protruding hemorrhoid is pulled with a suction tube, and then the rubber is pushed and placed tightly around the hemorrhoid. This binding causes the death of the protruding tissue, which can eventually fall off on its own. 
• Sclerotherapy is usually applied as a treatment for grade I and II internal hemorrhoids. This procedure involves injecting a chemical solution into the intestinal lining, which causes the death of hemorrhoidal tissue.
• Photocoagulation utilizes exposure to infrared light, which results in the clumping of intracellular proteins and the evaporation of intracellular fluid so that the cells in the hemorrhoids shrink.

Surgical therapy is generally used for grade IV internal hemorrhoids, hemorrhoids that interfere with activities, and if the hemorrhoids do not improve with non-surgical therapy. Surgical therapy includes excisional hemorrhoidectomy, stapled hemorrhoidectomy, and hemorrhoidal artery ligation.

Excisional hemorrhoidectomy is the act of cutting hemorrhoids with a scalpel. Scars can be closed with stitches or left open for the tissue to heal. The most common post-operative effect is bleeding one week after surgery.

Stapler hemorrhoidectomy involves installing ring-shaped staples to prevent prolapse of internal hemorrhoids and fix the hemorrhoids to the intestinal wall. This procedure generally does not cause post-operative pain.

Hemorrhoidal artery ligation-rectoanal repair (HAL-RAR) is a new method for managing hemorrhoids. This method utilizes ultrasound to detect which blood vessels are experiencing dilation, then ties the blood vessels to stop the blood supply to the part experiencing hemorrhoids. The network anal cushion and the descending mucosal layer are repaired with sutures. This method causes very little pain and a quicker post-operative healing time.

If you and your family experience symptoms that lead to hemorrhoids, immediately have yourself and your family examined by a specialist in digestive surgery and surgery at Hermina Pasteur Hospital for the most appropriate, complete treatment for you and your family. Hermina Pasteur: Prioritizing Service Quality and Patient Safety!

Compiled by Dr. Andika Trya

Curated by Dr. Nova Oktoria Putri Saragih, SpB, FINACS

Reference :

De Marco S., Tiso D. Lifestyle and risk factors in hemorrhoidal disease. Front Surg. 2021; 8: 729166. Diakses pada: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416428/

Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician. 2011;84(2):204–210. Diakses pada: https://www.aafp.org/pubs/afp/issues/2011/0715/p204.html

Dinata IGS, Pradiantini KHY. Diagnosis and management of hemorrhoids. Gan Med J. 2021; 1(1): 38–47. Accessed at: https://ejournal.undiksha.ac.id/index.php/GM/article/view/31704/

Jakubauskas M., Poskus T. Evaluation and management of hemorrhoids. Dis Colon Rectum 2020; 63: 420–426

https://cme.lww.com/ovidfiles/00003453-202004000-00004.pdf

Lawrence A., McLaren ER. External hemorrhoids. Statpearls [Internet]; 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK500009/