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Anorectal problems cause untold misery for at least half of the population at one time or another.1 Because of embarrassment, many patients choose simply to suffer in silence. Others delay consulting a pharmacist or physician until the symptoms become unbearable. Unfortunately, many patients who initially seek relief through the use of a nonprescription product will require referral to a physician.
Prevalence
Discovering the true incidence of Hemorrhoids is problematic because many patients use the term as a catch-all for any anorectal symptom, including itching. For this reason, some estimates of
Hemorrhoids incidence in the U.S. are deceivingly high at 80%?0%.2 Only about half of those who experience anorectal symptoms have true
Hemorrhoids.1 Therefore, the actual incidence is more likely to be about 40% of U.S. residents.2
Epidemiology
The study of Hemorrhoidsal epidemiology has been marked by many theories, but remains largely unsupported by credible research.
Diet: One determinant of Hemorrhoids may be diet. In the early 1970s, proponents of fiber created the theory that low-fiber diets are responsible for
Hemorrhoids.3 Industrialized nations tend toward a highly refined low-residue diet. This diet yields harder stools that patients will often strain to pass, which can cause bowel smooth muscle hypertrophy and injure the tissues of the anal canal.1
Toilet Habits: Medical wisdom has held for decades that straining to pass stool throughout one's life is the primary etiologic factor for
Hemorrhoids. However, more recent research has demonstrated that the cause may be prolonged sitting on the toilet. In this position, the perineum is relaxed and the anal cushions are unsupported.4
Constipation/Diarrhea: The theory that low-fiber diets cause Hemorrhoids
naturally leads to the assumption that constipation would also be a primary etiologic factor. However, when researchers compare the occurrence of
Hemorrhoids and constipation in regard to the ages, genders, ethnic groups, and social classes in which they are more common, there are marked differences in epidemiology.3 Also, patients with symptomatic
Hemorrhoids do not experience constipation more often than patients who do not have them. Diarrhea seems to be more strongly linked to
Hemorrhoids than constipation, particularly when the patient has a history of alcoholism.2
Genetics: Research has yielded sparse support for a genetic link to
Hemorrhoids.4 It is unknown whether there is a true underlying genetic disorder that predisposes a person to
Hemorrhoids or whether a child merely mimics the parents' Hemorrhoids-inducing toilet behaviors.
Gender: Hemorrhoids do not discriminate markedly between men and women, although it is known that men seek treatment in greater numbers than women. Pregnancy is a prominent risk factor.2
Age: Hemorrhoids gradually increase in prevalence with age.2 This continues until the seventh decade of life, when the prevalence begins a slow decline.
Medical Conditions: Hemorrhoids are positively correlated with the presence of hernia or genitourinary prolapse.4 The common cause of all three conditions may be a connective tissue disorder, although it may also be the fact that all three can be brought about by chronic straining to expel stool. Chronic straining may also be the underlying reason why
Hemorrhoids are also more common in patients with prostate enlargement, chronic cough, and pregnancy.2 Portal hypertension is also correlated with
Hemorrhoids.
Other Factors: Anecdotal evidence suggests that Hemorrhoids are caused by prolonged sitting or standing, and lifting heavy objects. Evidence of these activities as primary causes of
Hemorrhoids is nonexistent. Rather, it is probable that each can worsen asymptomatic
Hemorrhoids that are already present. This might cause the patient to initially notice the
Hemorrhoids after such activity and wrongly attribute their occurrence to the activity itself.
Anatomy
The actual anal opening is also known as the anal verge. Approximately 2? cm above the anal verge is an anatomic landmark known as the dentate or pectinate line. This is distinguished by a circular row of glands that secrete mucus, which acts to lubricate the anal canal. Groups of normal submucosal vascular beds composed of supportive connective tissue, smooth muscle and blood vessels surround the anal canal. When these beds enlarge, the result is
Hemorrhoids. Those who support the straining theory assert that straining interrupts the tissues that support the vascular bundles, displacing the tissues and leading to their congestion.
Classifications of Hemorrhoids
The standard Hemorrhoids classification is dependent on the point of origin of the problem. If the
Hemorrhoidsal tissue originates above the dentate line, it is classified as an internal
Hemorrhoids, even if some of the tissue reaches below the dentate line. External
Hemorrhoids originate below the dentate line.
Manifestations
The degree of discomfort experienced by the patient is dependent on the type of
Hemorrhoids and their severity. Internal Hemorrhoids lack nerves and are painless. When they bleed, the blood is usually bright red and seen on the outer part of stools after defecation. The patient does not usually bleed at other times. The internal tissues may enlarge and push below the dentate line to protrude from the anal opening, especially after defecation. The patient may describe this protrusion to the pharmacist as a soft bit of tissue that shrinks back to normal shortly after defecation or that requires the patient to manually push the tissue back to its normal position above the dentate line after each bowel movement (in more severe cases).
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