External Hemorrhoid Symptoms & Treatment
What Are Hemorrhoids
External hemorrhoids are part of the normal anatomy of the anal canal. They are a complex of blood vessels located beneath the skin at specific areas along the anal opening. A column of internal and external hemorrhoids exists at the 9 o’clock position along the left side of the anal opening, and two additional columns of internal/external hemorrhoid blood vessels are located on the right side of the anal canal, at the 2 o’clock and 5 o’clock locations.
Hemorrhoids are normal vascular anatomy. Only when they become engorged and swollen and then cause symptoms do people become aware of their hemorrhoids. Some of the many conditions or behaviors that can stress and engorge the blood vessels of hemorrhoids and cause hemorrhoid symptoms include:
1) obesity,
2) constipated hard stools (that require repeated straining during bowel movements),
3) sometimes the frequency of diarrhea,
4) sitting too long on the toilet reading your phone or newspaper (even without straining),
5) pregnancy, and
6) jobs or activities that require frequent heavy lifting .
When hemorrhoids are only occasionally and infrequently stressed they will usually settle back down to a flat, quiet state. However, severe or repeated exertional pressure can cause the external hemorrhoids to become persistently engorged, varicosed, swollen or stretched. These conditions lead to chronic hemorrhoid skin tags.
Pictured: Left side is a normal Internal Hemorrhoid. On the right side is the anatomy of an engorged Hemorrhoid, both Internal and External.
Symptoms of External Hemorrhoids (Chronic And Sudden)
Symptoms of external hemorrhoids and hemorrhoid skin tags are sometimes long-standing, chronic or persistent and sometimes suddenly out of the blue.
The chronic symptoms and challenges of long-standing prominent external hemorrhoids or hemorrhoid skin tags include anal skin irritation, itching, ache or heaviness at the end of the day, increased clean-up after a bowel movement, unsightly appearance, and hygiene issues including fecal smearing.
Sudden symptoms of external hemorrhoids include the rapid appearance of a painful anal lump known as a thrombosed hemorrhoid. This occurs when a hemorrhoid blood vessel is injured and develops one or more blood clots. The thrombosis can often have the appearance of a purple lump the size of a peanut or grape immediately at the anal opening. Overstraining with bowel movements or vigorous physical activity can cause thrombosed hemorrhoids. In retrospect, people can often identify an event of increased anal pressure or pushing that preceded the appearance of the painful sudden anal lump.
Of course, other conditions can occur within the anal area that can mimic the symptoms of external hemorrhoids. If local symptoms are associated with systemic symptoms such as fever or chills, call your doctor, or our office, as these may be symptoms of an anal infection or abscess. Additionally, persistent symptoms (or a lump/mass) that do not go away or are getting progressively worse should also be evaluated by a doctor.
What is the Natural Course of a Thrombosed Hemorrhoid?
The initial days of a thrombosed external hemorrhoid blood vessel are a combination of pain/discomfort with associated anal lump. In many cases, after a few days, the pressure of the underlying blood clot on the overlying skin will lead to spontaneous splitting of the skin and a bloody drainage of the lump. This is Mother Nature’s way of decompressing the painful lump and relieving the pressure/pain. The appearance of this blood can be alarming, but should be self-limited. This drainage event is also associated with a decrease of the anal lump and improvement in the painful symptoms.
If the pressure of the underlying blood clot does not result in spontaneous drainage during the first several days, then the body will eventually re-absorb the clotted blood over the following ~10-30 days.
Sometimes after complete resolution of the painful thrombosis there may be a persistent floppy skin tag, the result of stretching of the overlying anal skin. This can lead to chronic symptoms, as described above.
What To Do During The Initial Days Of Sudden Thrombosed External Hemorrhoids
During the first 24 hours of a sudden painful anal lump, the application of an ice pack to the area can help limit the size of the clotted blood and associated discomfort. Apply a cold pack wrapped in a thin cloth towel to the area for ~20 minutes at a time, several times during the initial day.
After the first day, the blood clot should have established its ultimate size. Now it is time to apply gentle warmth to the area, in an attempt to “melt” the blood clot. This will aid the body in its efforts to disintegrate the clot and resolve the lump. Apply warmth through either a warm bath, or a warm pack for ~20 minutes, several times per day. You can use the warmth therapy for several days, or for as long as it brings symptomatic relief. You should be experiencing improvement by the third day. If the situation is worsening, please contact our office or your doctor.
Bowel movements may be more difficult during this time of anorectal pain. Be sure to drink plenty of water, perhaps also adding a stool softener or gentle laxative such as fiber or miralax (or generic) to your program. Avoid constipation as possible.
Over the counter (OTC) topical medications can bring temporary relief of symptoms. These products include creams and ointments. Your doctor may also prescribe additional steroid foams and suppositories. We are not big fans of suppositories during this time of a painful lump and pressure. All of these products have limited value, and none of them will eliminate the underlying cause, that being the blood clot. We often hear the story, “ … the cream didn’t start working until the third day…” . More often than not, this is the person experiencing Mother Nature's natural time-course of resolution. We believe the topical application of cold and warm, as described above, is as effective as most OTC products.
When To See a Doctor
Call our office at any time during this process. If we have the opportunity to see you during the immediate first days of the problem, we can often drain the clot in the office and bring immediate relief of pain, and shorten the time to full resolution.
We advise office examination also for conditions which are worsening over several days, or are persistent without complete resolution.
The majority of external hemorrhoid problems can be diagnosed through a combination of initial patient interview and anorectal physical exam. The elements of the exam include visual, digital rectal exam, anoscopy, and sometimes proctoscopy. We are very empathetic to the suffering these conditions can cause and always perform an exam tailored to the abilities of the patient.
Decisions on treatment include discussion of potential immediate procedures performed in the office setting, and/or discussion of definitive operative surgery, especially for severe or recurrent events.
Another time to see us is for chronic persistent annoying symptoms of anal skin irritation, itching, ache or heaviness at the end of the day, increased clean-up after a bowel movement, and subtle hygiene issues including fecal smearing. We offer both office and surgical therapy, tailored to the specific exam findings and desires of you, our patient. People will often avoid dealing with these chronic issues out of fear or embarrassment. We take great pride in providing an experience that alleviates physical and emotional suffering. Our goal is to exceed your expectations.