Hemorrhoids

 

Alexander Liss

 

11/11/04

 

 

 

     Symptoms of Hemorrhoids were identified long ago, sufferers are ready to pay well for its cure, but neither cure nor a satisfactory explanation of this phenomenon is known.

     Many describe Hemorrhoids as bulging of veins in anal area; when it is inside (internal Hemorrhoids), it is not painful, but outside (external Hemorrhoids) it could be painful. The picture could be complicated with prolapse of the rectum. During defecation, these bulged veins could be damaged.

     Bulged veins expand during defecation and often shrink soon after that. It is not clear what causes such expansion and contraction. If it is high blood pressure in them, then why it does not cause immediate outflow of blood via system of veins?

Hemorrhoids sufferers sometimes observe arterial blood in their stool, which should not be in veins.

Hence, limiting explanation to veins is unrealistic.

Some define Hemorrhoids as dilated arteriovenous complexes and explain it with the vascular cushion theory:

"Anatomically, anal cushions exist within the submucosa of the anal canal; they contain blood vessels (e.g. arterioles, venules, arteriolar-venous shunts), muscle, and connective tissue. These vascular cushions, found at the anorectal junction above the dentate line, are anatomically normal. The vascular cushions are present in adults, in children, and even in the embryo. Apparently, the distal displacement of these cushions by loss of their supportive structure leads to hemorrhoids, which may prolapse, bleed, or thrombose."

"Loss of the supportive structure" is a theme of some other current theories.

Symptoms of Hemorrhoids often appear and disappear for awhile only to come back later. Sometimes they disappear for good, especially when they appear as a side-effect of pregnancy. How could this be with a permanent disorder of veins or supportive structure?

     One crucial element is absent in currently accepted theories of Hemorrhouids.

There are (circular) sphincter muscles, which are present in anorectal area. When sphincter squeezes the rectum, it squeezes arteries and veins.

     Many questions can be answered from analysis of dynamics of blood flow in presence of arteriovenous complexes in a sphincter area, when a part of arteriovenous complex is cut off the rest of it by muscle fibers of the sphincter.

The phenomena could not be explained only with actions of veins. Let say, a contracted sphincter cuts off a part of the network of veins from the rest of veins. While blood in this cut-off part of the network should be under elevated pressure, which could cause some bulging, this causes only insignificant bulging. To explain large bulging one needs a source of high blood pressure – arteries.

The phenomena could not be explained with static model either. If one adopts a static model, then there should be no blood flow in a cut-off area and hence no bulging.

Note that when the strength of the sphincter’s squeeze is large, the static model describes situation well enough ant there should be no bulging.

However there is an important example, which shows that there are cases, where bulging appears and this bulging has to be explained not with static but with dynamic model of blood flow.

Sphincter muscles cut blood flow to a penis and this causes erection - bulging of arteries and veins, not absence of blood flow, as the static model would suggest.

How does cutting off a part of an arteriovenous complex by pressing muscles leads to pumping of blood in this cut-off area?

There are pressure waves in arteries. When pressure of blood can overcome squeeze of the muscles, blood is pushed into the segregated area of the arteriovenous complex. This critical condition could occur in some periods during the cycle of arterial heartbeat, when the strength of muscles squeeze is in a particular range.

What about blood outflow from this cut-off area?

There are pressure waves in veins also. When difference in pressure of blood in the segregated area and in outside veins can overcome the squeeze of the muscles, the blood outflow occurs. This could occur in some periods during the cycle of arterial heartbeat, when the strength of muscles squeeze is in a particular range.

When overall blood inflow exceeds blood outflow, the bulging occurs. The degree of bulging is limited by the maximum level of blood pressure in a pressure waves in arteries.

In anal area there is one exacerbating factor. One group of veins in this area leads to the liver and blood in them has higher pressure.

When this type of veins drains the segregated area, it is less likely that blood outflow from segregated area occurs.

This dynamic model, which takes in consideration various pressure waves in blood vessels and their interaction with muscles, explains many phenomena of Hemorrhoids:

·        bulging of vessels,

·        arterial blood in stool,

·        worsening of symptoms of Hemorrhoids with elevation of arterial blood pressure (with higher pressure, more blood is pumped into the segregated area),

·        temporary worsening of symptoms of Hemorrhoids with strenuous physical activity (it temporary increases blood pressure).

It explains also increase in bulging of vessels during defecation. First, muscles of sphincter partially relax and in some areas this could lead to emergence of the critical condition, where strength of muscles contraction is less than peak of arterial blood pressure wave. In turn, it leads to emergence of bulging, where it was not present before. Second, there is additional squeezing of vessels by the waste mass from inside the channel, which could cause bulging in new areas.

The very fact that arteriovenous complex occurs together with sphincters in different places in the body leads to a reasonable suspicion that bulging of vessels generally plays a useful role. A sphincter alone cannot provide tight closing of a channel. Bulging complements it and provides needed tight closing. Muscle fibers of a sphincter contract and relax either randomly or periodically temporarily cutting off small areas of arteriovenous complex and small bulging appears and disappears complementing actions of the sphincter.

This is an efficient mechanism, which should be present in many places of the body: between esophagus and stomach, between stomach and intestine, at opening of urethra, at opening of glands, etc.

However, it works on small bulging existing for short periods. A long-term cutoff and creation of a segregated area of arteriovenous complex is impossible under a continuous band of active muscle fibers of a sphincter.

It occurs, when there is a gap in a band of muscle fibers of sphincter, vessels caught in this gap are prone to bulging.

This could be a real gap or some fibers could be inactive or less active, the result is the same.

In addition, it could occur at the edge of a sphincter.

This explains why various treatments beyond pain relief, ointments helping defecation or physical removal of parts of arteriovenous complex do not work.

In addition, it shows that strenuous activity in small doses is not dangerous in the majority of cases of Hemorrhoids. Hence, people do not need to stop physical exercises, because of Hemorrhoids. This is good news, because often it is recommended to limit physical activity in the case of the Hemorrhoids.

Understanding of the nature of Hemorrhoids leads to new venues of easing suffering associated with this disorder.

As it was mentioned above, during defecation, sphincter relaxes. Sometimes, this relaxation is only partial, and that could be not sufficient to decrease existing bulging, and even could cause bulging of vessels in new areas.

In such case, the channel is still obstructed and there are difficulties of defecation. When a person pushes waste in spite of obstruction, it sometimes damages bulged vessels and causes pain. Such damage and pain causes anxiety and the person increases period between defecations. In turn, waste mass grows large and dryer and this causes even more damage and pain.

Eventually, this vicious cycle settles into a persistent combination of Hemorrhoids and constipation.

 One has to make efforts to break this vicious cycle, where it is most controllable - one has to maintain a normal period between defecations and has to make process of defecation fast with ointments.

A radical improvement comes with learning full relaxation of sphincter muscles.

There are two obstacles on this way - one is anxiety caused by painful experiences during defecation and another is an objective feeling that on initial stages of relaxation of sphincter muscles effect is just the opposite - vessels bulge.

One has to learn how to go beyond initial stages of relaxation to full relaxation in spite of these negative experiences.

This requires regular muscle relaxation exercises performed, when the rectum is empty.

These exercises could be combined with muscle contraction exercises.

These exercises could be done, because sphincter in anus is consciously controllable. More precisely, there is an external layer of muscle fibers in the sphincter – External Sphincter, which has separate innervations and is consciously controllable. Actions of these muscles trigger by reflex actions of other muscles.  

Benefits of such exercises could go well beyond what is expected.

First, regular exercises give the body experience of behavior, which it will use automatically, when needed. If there are weakened muscle fibers in the sphincter, which cause problems, as if there is a gap in a band of muscle fibers, then these exercises should energize them, and this should improve overall condition of the Hemorrhoids.

Second, an exercise of an anal sphincter causes an exercise in other sphincters of the body. There is a reasonable suspicion that when there are problems with the sphincter mechanism in the anus there are similar problems in other sphincter mechanisms of the body. Hence, such exercise could improve state of the body well beyond its anal area.

As it was mentioned above, sphincter mechanisms are controlling flow of liquid through a channel in many areas, and when they do not open sufficiently, it is manifested in seemingly unrelated symptoms.

It could be difficulty of urination, because there is a sphincter mechanism at opening of the urethra. This is a common symptom in aging males.

It could be difficulties of ejaculation, which is also a common symptom in aging males (not everyone sees it as a problem, though).

It could be difficulty of passing processed food and gases from the stomach to the intestine. This causes movement of gases into the esophagus (burping), and excessively long stay of food in stomach, which in turn leads to transformation of sugars into toxins and possibly to other problems.

Channels of many glands are controlled by sphincters, and when sphincters do not open well, when needed, this should cause problems.

Only two sphincters have conscious control - anal and urethral and usually contraction and relaxation of the urethral sphincter is triggered by similar actions of the anal sphincter. Hence, exercise of the anal sphincter is a main way to exercise other sphincters.

Such exercise makes sense, especially with age.