Hemorrhoid

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Hemorrhoids
Other namesHaemorrhoids, piles, [1] hemorrhoidal disease [2]
Internal and external hemorrhoids.png
Diagram demonstrating the anatomy of both internal and external hemorrhoids
Pronunciation
  • UK: /ˈhɛmərɔɪdz/
Specialty General surgery
Symptoms Internal: Painless, bright red rectal bleeding [3]
External: Pain and swelling around the anus [4]
Usual onset45–65 years of age [5]
DurationFew days [3]
CausesUnknown [4]
Risk factors Constipation, diarrhea, sitting on the toilet for long periods, pregnancy [3]
Diagnostic method Examination, rule out serious causes [2] [3]
TreatmentIncreased fiber, drinking fluids, NSAIDs, rest, surgery, hemorrhoidal artery embolization [1] [6]
Frequency50–66% at some time [1] [3]

Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. [7] [8] In their normal state, they are cushions that help with stool control. [2] They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease. [8] The signs and symptoms of hemorrhoids depend on the type present. [4] Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating. [3] [4] External hemorrhoids often result in pain and swelling in the area of the anus. [4] If bleeding occurs, it is usually darker. [4] Symptoms frequently get better after a few days. [3] A skin tag may remain after the healing of an external hemorrhoid. [4]

Contents

While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved. [4] This may include constipation, diarrhea, and sitting on the toilet for long periods. [3] Hemorrhoids are also more common during pregnancy. [3] Diagnosis is made by looking at the area. [3] Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should not be ruled out. [2] Colonoscopy or sigmoidoscopy is reasonable to confirm the diagnosis and rule out more serious causes. [9]

Often, no specific treatment is needed. [9] Initial measures consist of increasing fiber intake, drinking fluids to maintain hydration, NSAIDs to help with pain, and rest. [1] Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence. [9] A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. [6] Surgery is reserved for those who fail to improve following these measures. [6]

Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives. [1] [3] Males and females are both affected with about equal frequency. [1] Hemorrhoids affect people most often between 45 and 65 years of age, [5] and they are more common among the wealthy, [4] although this may reflect differences in healthcare access rather than true prevalence. [10] Outcomes are usually good. [3] [9]

The first known mention of the disease is from a 1700 BC Egyptian papyrus. [11]

Signs and symptoms

An external hemorrhoid M 44 anus 22.jpg
An external hemorrhoid

In about 40% of people with pathological hemorrhoids, there are no significant symptoms. [4] Internal and external hemorrhoids may present differently; however, many people may have a combination of the two. [8] Bleeding enough to cause anemia is rare, [5] and life-threatening bleeding is even more uncommon. [12] Many people feel embarrassed when facing the problem [5] and often seek medical care only when the case is advanced. [8]

External

If not thrombosed, external hemorrhoids may cause few problems. [13] However, when thrombosed, hemorrhoids may be very painful. [1] [8] Nevertheless, this pain typically resolves in two to three days. [5] The swelling may, however, take a few weeks to disappear. [5] A skin tag may remain after healing. [8] If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus. [13]

Internal

Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. [8] The blood typically covers the stool (a condition known as hematochezia), is on the toilet paper, or drips into the toilet bowl. [8] The stool itself is usually normally coloured. [8] Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence. [12] [14] Internal hemorrhoids are usually painful only if they become thrombosed or necrotic. [8]

Causes

The exact cause of symptomatic hemorrhoids is unknown. [15] A number of factors are believed to play a role, including irregular bowel habits (constipation or diarrhea), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascites, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging. [1] [5] Other factors believed to increase risk include obesity, prolonged sitting, [8] [ dubious – discuss ] a chronic cough, and pelvic floor dysfunction. [2] Squatting while defecating may also increase the risk of severe hemorrhoids. [16] Evidence for these associations, however, is poor. [2] Being a receptive partner in anal intercourse has been listed as a cause. [17] [18] [19]

During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. [20] Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery. [1]

Pathophysiology

Gross pathology of hemorrhoids, showing engorged blood vessels Gross pathology of hemorrhoids.jpg
Gross pathology of hemorrhoids, showing engorged blood vessels

Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. [8] There are three main cushions present in the normal anal canal. [1] These are located classically at left lateral, right anterior, and right posterior positions. [5] They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle. [2] : 175  Sinusoids do not have muscle tissue in their walls, as veins do. [8] This set of blood vessels is known as the hemorrhoidal plexus. [2]

Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool. [8] When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure. [5] Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased. [12] Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms. [5] Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus. [5] The pectinate line divides the two regions. [5]

Diagnosis

Internal hemorrhoid grades
GradeDiagramPicture
1 Piles Grade 1.svg Haemorrhoiden 1Grad endo 01.jpg
2 Piles Grade 2.svg Hemrrhoids 04.jpg
3 Piles Grade 3.svg Hemrrhoids 05.jpg
4 Piles Grade 4.svg Piles 4th deg 01.jpg

Hemorrhoids are typically diagnosed by physical examination. [6] A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. [8] Visual confirmation of internal hemorrhoids, on the other hand, may require anoscopy, insertion of a hollow tube device with a light attached at one end. [5] A digital rectal exam (DRE) can also be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses. [8] This examination may not be possible without appropriate sedation because of pain, although most internal hemorrhoids are not associated with pain. [1] If pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid. [5]

Internal

Internal hemorrhoids originate above the pectinate line. [13] They are covered by columnar epithelium, which lacks pain receptors. [2] They were classified in 1985 into four grades based on the degree of prolapse: [1] [2]

External

A thrombosed external hemorrhoid Perianal thrombosis 01.jpg
A thrombosed external hemorrhoid

External hemorrhoids occur below the dentate (or pectinate) line. [13] They are covered proximally by anoderm and distally by skin, both of which are sensitive to pain and temperature. [2]

Differential

Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices, and itching have similar symptoms and may be incorrectly referred to as hemorrhoids. [1] Rectal bleeding may also occur owing to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia. [6] If anemia is present, other potential causes should be considered. [5]

Other conditions that produce an anal mass include skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae. [5] Anorectal varices due to portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition. [5] Portal hypertension does not increase the risk of hemorrhoids. [4]

Prevention

A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements and getting sufficient exercise. [5] [21] Spending less time attempting to defecate, avoiding reading while on the toilet, [1] and losing weight for overweight persons and avoiding heavy lifting are also recommended. [22]

Management

Conservative

Conservative treatment typically consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest. [1] Increased fiber intake has been shown to improve outcomes [23] and may be achieved by dietary alterations or the consumption of fiber supplements. [1] [23] Evidence for benefits from sitz baths during any point in treatment, however, is lacking. [24] If they are used, they should be limited to 15 minutes at a time. [2] : 182  Decreasing time spent on the toilet and not straining is also recommended. [25]

While many topical agents and suppositories are available for the treatment of hemorrhoids, little evidence supports their use. [1] As such, they are not recommended by the American Society of Colon and Rectal Surgeons. [26] Steroid-containing agents should not be used for more than 14 days, as they may cause thinning of the skin. [1] Most agents include a combination of active ingredients. [2] These may include a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine. [2] Some contain Balsam of Peru to which certain people may be allergic. [27] [28]

Flavonoids are of questionable benefit, with potential side effects. [2] [29] Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery. [30] Evidence does not support the use of traditional Chinese herbal treatment. [31]

The use of phlebotonics has been investigated in the treatment of low-grade hemorrhoids, [26] [32] [33] [34] although these drugs are not approved for such use in the United States or Germany. [35] [36] The use of phlebotonics for the treatment of chronic venous diseases is restricted in Spain. [37]

Procedures

A number of office-based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur. [6]

  1. Rubber band ligation is typically recommended as the first-line treatment in those with grade I to III disease. [6] It is a procedure in which elastic bands are applied onto internal hemorrhoid at least 1 cm above the pectinate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the pectinate line, intense pain results immediately afterwards. [1] The cure rate has been found to be about 87%, [1] with a complication rate of up to 3%. [6]
  2. Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is about 70%. [1]
  3. A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually used only when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery, [1] or cryosurgery. [38] Infrared cauterization may be an option for grade I or II disease. [6] In those with grade III or IV disease, reoccurrence rates are high. [6]

Hemorrhoidal artery embolization (HAE) is an additional minimally invasive procedure performed by an interventional radiologist. [39] HAE involves the blockage of abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or microparticles to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding. [40] HAE is very effective at stopping bleeding related symptom with success rate of approximately 90%. [41]

Surgery

A number of surgical techniques may be used if conservative management and simple procedures fail. [6] All surgical treatments are associated with some degree of complications, including bleeding, infection, anal strictures, and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder. [1] Also, a small risk of fecal incontinence occurs, particularly of liquid, [2] [42] with rates reported between 0% and 28%. [43] Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). [44] This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse. [44]

  1. Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases. [1] It is associated with significant postoperative pain and usually requires two to four weeks for recovery. [1] However, the long-term benefit is greater in those with grade III hemorrhoids as compared to rubber band ligation. [45] It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours. [6] [13] Evidence to support this is weak, however. [25] Glyceryl trinitrate ointment after the procedure helps both with pain and with healing. [46]
  2. Doppler-guided transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy. [1]
  3. Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy , involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids. [1] However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy, [47] so it is typically recommended only for grade II or III disease. [6]

Epidemiology

It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider. [12] [15] However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time. [1] Both sexes experience about the same incidence of the condition, [1] with rates peaking between 45 and 65 years. [5] Some studies have found that they are common in people of higher socioeconomic status, [2] however this may reflect differences in healthcare access rather than true prevalence. [10]

Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes. [12] Only a small proportion of persons end up needing surgery. [2]

History

An 11th-century English miniature. On the right is an operation to remove hemorrhoids. 11th century English surgery.jpg
An 11th-century English miniature. On the right is an operation to remove hemorrhoids.

The first known mention of this disease is from a 1700 BC Egyptian papyrus, which advises: "Thou shouldest give a recipe, an ointment of great protection; acacia leaves, ground, titurated and cooked together. Smear a strip of fine linen there-with and place in the anus, that he recovers immediately." [11] In 460 BC, the Hippocratic corpus discusses a treatment similar to modern rubber band ligation: "And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not foment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of Hellebore." [11] Hemorrhoids may have been described in the Bible, with earlier English translations using the now-obsolete spelling "emerods". [5]

Celsus (25 BC – 14 AD) described ligation and excision procedures and discussed the possible complications. [48] Galen advocated severing the connection of the arteries to veins, claiming it reduced both pain and the spread of gangrene. [48] The Susruta Samhita (4th–5th century BC) is similar to the words of Hippocrates, but emphasizes wound cleanliness. [11] In the 13th century, European surgeons such as Lanfranc of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene made great progress and development of the surgical techniques. [48]

In medieval times, hemorrhoids were also known as Saint Fiacre's curse after a sixth-century saint who developed them following tilling the soil. [49] The first use of the word "hemorrhoid" in English occurs in 1398, derived from the Old French "emorroides", from Latin hæmorrhoida, [50] in turn from the Greek αἱμορροΐς (haimorrhois), "liable to discharge blood", from αἷμα (haima), "blood" [51] and ῥόος (rhoos), "stream, flow, current", [52] itself from ῥέω (rheo), "to flow, to stream". [53]

Notable cases

Related Research Articles

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Anal fissure</span> Medical condition

An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they are painful after defecation, but with chronic fissures, pain intensity often reduces and becomes cyclical.

<span class="mw-page-title-main">Rectal prolapse</span> Protrusion of the walls of the anus outside the body

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Colorectal surgery</span> Field in medicine for disabilities in the rectum

Colorectal surgery is a field in medicine dealing with disorders of the rectum, anus, and colon. The field is also known as proctology, but this term is now used infrequently within medicine and is most often employed to identify practices relating to the anus and rectum in particular. The word proctology is derived from the Greek words πρωκτός proktos, meaning "anus" or "hindparts", and -λογία -logia, meaning "science" or "study".

In medicine, the ileal pouch–anal anastomosis (IPAA), also known as restorative proctocolectomy (RPC), ileal-anal reservoir (IAR), an ileo-anal pouch, ileal-anal pullthrough, or sometimes referred to as a J-pouch, S-pouch, W-pouch, or a pelvic pouch, is an anastomosis of a reservoir pouch made from ileum to the anus, bypassing the former site of the colon in cases where the colon and rectum have been removed. The pouch retains and restores functionality of the anus, with stools passed under voluntary control of the person, preventing fecal incontinence and serving as an alternative to a total proctocolectomy with ileostomy.

<span class="mw-page-title-main">Blood in stool</span> Medical condition

Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.

Rectal bleeding refers to bleeding in the rectum, thus a form of lower gastrointestinal bleeding. There are many causes of rectal hemorrhage, including inflamed hemorrhoids, rectal varices, proctitis, stercoral ulcers, and infections. Diagnosis is usually made by proctoscopy, which is an endoscopic test.

<span class="mw-page-title-main">Lower gastrointestinal bleeding</span> Medical condition

Lower gastrointestinal bleeding (LGIB) is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). It is estimated that UGIB accounts for 100–200 per 100,000 cases versus 20–27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the large intestine, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3–5% involve the small intestine.

<span class="mw-page-title-main">Anal fistula</span> Disease of the anus

Anal fistula is a chronic abnormal communication between the anal canal and the perianal skin. An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus. Anal fistulae commonly occur in people with a history of anal abscesses. They can form when anal abscesses do not heal properly.

<span class="mw-page-title-main">Diosmin</span> Chemical compound

Diosmin, a flavone glycoside of diosmetin, is manufactured from citrus fruit peels as a phlebotonic non-prescription dietary supplement used to aid treatment of hemorrhoids or chronic venous diseases, mainly of the legs.

<span class="mw-page-title-main">Stapled hemorrhoidopexy</span>

Stapled hemorrhoidopexy is a surgical procedure that involves the cutting and removal of anal hemorrhoidal vascular cushion, whose function is to help to seal stools and create continence. Procedure also removes abnormally enlarged hemorrhoidal tissue, followed by the repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. Severe cases of hemorrhoidal prolapse will normally require surgery. Newer surgical procedures include stapled transanal rectal resection (STARR) and procedure for prolapse and hemorrhoids (PPH). Both STARR and PPH are contraindicated in persons with either enterocele or anismus.

<span class="mw-page-title-main">Rectum</span> Final portion of the large intestine

The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about 12 centimetres (4.7 in) long, and begins at the rectosigmoid junction at the level of the third sacral vertebra or the sacral promontory depending upon what definition is used. Its diameter is similar to that of the sigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla. It terminates at the level of the anorectal ring or the dentate line, again depending upon which definition is used. In humans, the rectum is followed by the anal canal, which is about 4 centimetres (1.6 in) long, before the gastrointestinal tract terminates at the anal verge. The word rectum comes from the Latin rēctumintestīnum, meaning straight intestine.

<span class="mw-page-title-main">Human anus</span> External opening of the rectum

In humans, the anus is the external opening of the rectum located inside the intergluteal cleft. Two sphincters control the exit of feces from the body during an act of defecation, which is the primary function of the anus. These are the internal anal sphincter and the external anal sphincter, which are circular muscles that normally maintain constriction of the orifice and which relax as required by normal physiological functioning. The inner sphincter is involuntary and the outer is voluntary. Above the anus is the perineum, which is also located beneath the vulva or scrotum.

Transanal hemorrhoidal dearterialization (THD) is a minimally invasive surgical procedure for the treatment of internal hemorrhoids.

Rectal discharge is intermittent or continuous expression of liquid from the anus. Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of fecal incontinence but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge.

Solitary rectal ulcer syndrome or SRUS is a chronic, benign disorder of the rectal mucosa. It commonly occurs with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation. Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

<span class="mw-page-title-main">Anorectal disorder</span> Medical condition

Anorectal disorders include conditions involving the anorectal junction as seen in the image. They are painful but common conditions like hemorrhoids, tears, fistulas, or abscesses that affect the anal region. Most people experience some form of anorectal disorder during their lifetime. Primary care physicians can treat most of these disorders, however, high-risk individuals include those with HIV, roughly half of whom need surgery to remedy the disorders. Likelihood of malignancy should also be considered in high risk individuals. This is why it is important to perform a full history and physical exam on each patient. Because these disorders affect the rectum, people are often embarrassed or afraid to confer with a medical professional.

<span class="mw-page-title-main">Hemorrhoidal artery embolization</span> Non-surgical hemorrhoid treatment

Hemorrhoidal artery embolization is a non-surgical treatment of internal hemorrhoids.

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