Hemorrhoids and Varicose Veins: A Review of Treatment Options

Alternative Medicine Review,  April, 2001  by Douglas MacKay

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Abstract

Hemorrhoids and varicose veins are common conditions seen by general practitioners. Both conditions have several treatment modalities for the physician to choose from. Varicose veins are treated with mechanical compression stockings. There are several over-the-counter topical agents available for hemorrhoids. Conservative therapies for both conditions include diet, lifestyle changes, and hydrotherapy which require a high degree of patient compliance to be effective. When conservative hemorrhoid therapy is ineffective, many physicians may choose other non-surgical modalities: injection sclerotherapy, cryotherapy, manual dilation of the anus, infrared photocoagulation, bipolar diathermy, direct current electrocoagulation, or rubber band ligation. Injection sclerotherapy is the non-surgical treatment for primary varicose veins. Non-surgical modalities require physicians to be specially trained, own specialized equipment, and assume associated risks. If a non-surgical approach fails, the patient is often referred to a surgeon. The costly and uncomfortable nature of treatment options often leads a patient to postpone evaluation until aggressive intervention is necessary. Oral dietary supplementation is an attractive addition to the traditional treatment of hemorrhoids and varicose veins. The loss of vascular integrity is associated with the pathogenesis of both hemorrhoids and varicose veins. Several botanical extracts have been shown to improve microcirculation, capillary flow, and vascular tone, and to strengthen the connective tissue of the perivascular amorphous substrate. Oral supplementation with Aesculus hippocastanum, Ruscus aculeatus, Centella asiatica, Hamamelis virginiana, and bioflavonoids may prevent time-consuming, painful, and expensive complications of varicose veins and hemorrhoids.

(Altern Med Rev 2001;6(2):126-140)

Introduction

Every general practitioner sees a large number of patients who suffer from problems associated with venous insufficiency. Two of the most common manifestations of venous insufficiency are varicose veins and hemorrhoids. The prevalence of these two conditions is astonishing. In population studies the prevalence of varicose veins has been reported to be 10-15 percent for men and 20-25 percent for women.[1] In a recent cross-sectional study, the age-adjusted prevalence of varicose veins was 58 percent for men and 48 percent for women.[2] Over three-quarters of individuals in the United States have hemorrhoids at some point in their lives, and about half of the population over age 50 requires treatment.[3]

The Merck Manual defines hemorrhoids as "Varicosities of the veins of the hemorrhoidal plexus, often complicated by inflammation, thrombosis, and bleeding."[4] It has been suggested this is an oversimplification of the nature of hemorrhoids. A more recent definition is, "Vascular cushions, consisting of thick submucosa containing both venous and arterial blood vessels, smooth muscle, and elastic connective tissue."[5] While everyone has this tissue, it is the enlargement, bleeding and protrusion that create pathology. The crossroads to the development of varicose veins and hemorrhoids is the loss of vascular integrity. Considering the combined prevalence of varicose veins and hemorrhoids, venous insufficiency and its manifestations are an extremely common medical problem that every physician should be prepared to treat.

Hemorrhoids

Historical Perspective on Hemorrhoids

Hemorrhoids are mentioned in ancient medical writings of every culture, including Babylonian, Hindu, Greek, Egyptian, and Hebrew. The word "hemorrhoid" is derived from the Greek "haema" = blood, and "rhoos" = flowing, and was originally used by Hippocrates to describe the flow of blood from the veins of the anus.[6] Prior to the 1800s hemorrhoids were treated simply by poultice, bed rest, or, in difficult cases, by the application of a red hot poker. A simpler method was prayer to the patron saint of hemorrhoid sufferers, St. Fiacre, an Irish priest who lived in the seventh century.[7] Injection therapy was begun in 1869 by Morgan of Dublin using iron persulfate, and was a relief to many who had endured the medical treatment of the time.[8] As late as 1888 the only other recommended treatment (apart from the above mentioned) was abstinence from alcohol, sitting in cane chairs, and half a pint of cold spring water injected into the rectum after a morning fast.[9] The founding of St. Mark's Hospital in 1935 by Fredrick Salmon, who is given credit for the first ligation of hemorrhoids, marked a turning point in the treatment of hemorrhoids.[10]

Hemorrhoid Histology

As mentioned, there are variant definitions of the histology of the hemorrhoid tissue, but they are universally classified according to anatomical origin. Internal hemorrhoids consist of redundant mucus membrane of the anal canal with the origin above the dentate (ano-rectal) line. Extemal hemorrhoids have an epithelial component and originate below the dentate line.[7] Internal hemorrhoids are further graded based on the extent to which the tissue descends into the anal canal (Table 1).