Upon examination, the family physician (FP) noted an external hemorrhoid. The patient indicated that she’d had large hemorrhoids during her last pregnancy. Hemorrhoids are cushions of highly vascular structures found within the submucosa of the anal canal. They become pathologic when swollen or inflamed.
There are 3 hemorrhoidal cushions in the anal canal and they have several functions, including maintaining fecal continence by engorging with blood and closing the anal canal and protecting the anal sphincter during defecation. Hemorrhoidal tissue provides important sensory information, enabling the differentiation between solid, liquid, and gas and subsequent decision to evacuate. External hemorrhoids arise distal to the dentate line. They are covered by stratified squamous epithelium and receive somatic sensory innervation from the inferior rectal nerve.
Patients with hemorrhoids should be encouraged to increase dietary fiber and/or add a fiber supplement to reduce severity and duration of symptoms. In this case, the FP encouraged the patient to take in adequate amounts of fluid and increase her dietary fiber. He also prescribed a stool softener because of the patient's history of constipation. Since the hemorrhoid was external, no suppositories were prescribed. Also, the FP did not recommend sitz baths because of a lack of data supporting their use.
Photo and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Hemorrhoids. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:414-418.
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