We are are finally breaking the stigma and talking about mental health. Men grow moustaches in November to raise awareness and talk about prostate health. It is time to move past embarrassment to talk about rectal health —and ways to reduce the incidence of some very painful conditions. This article opens that conversation.
Hemorrhoids are usually thought of as painful sores on the anus that are resolved with a few days of over-the-counter ointment, and that are frequently (pardon the pun) the butt of jokes. These are external hemorrhoids, but there are also internal hemorrhoids located on the lining of the rectum and that remain entirely painless, until they aren’t. In fact, they can be excruciatingly painful and while previously thought to be preventable mainly through dietary changes, diet is only part of reducing the likelihood of getting hemorrhoids. More than two-thirds of Canadians and Americans engage in a daily habit that significantly increases the risk of developing hemorrhoids and simple lifestyle changes can help reduce that risk.
Internal hemorrhoids are normal structures that are aligned in three columns in the rectum and function like bubble wrap —cushioning the rectum against irritation from the stool until a bowel movement[1]. Internal hemorrhoids are in the upper two thirds of the rectum, above what’s called the dentate line and since they don’t have nerve endings, they are painless and remain that way until one becomes irritated — or worse, becomes inflamed and protrudes from the rectum like a large, angry grape.
While internal hemorrhoids are totally normal, the term is usually used to refer to one (or more) that is inflamed and symptomatic, and the term will be used that way in this article.
Half of adults will have had hemorrhoids by age fifty yet it’s rare for people to talk about them. Only 4% of people go to their doctor for help because they’re embarrassed, and the last thing they want is to have someone having a look “down there” and poking around. They just want their hemorrhoids to stop hurting and to go away— and the faster, the better. Most people will self-treat with Epsom salt sitz baths and over the counter topical creams or wipes, and only seek medical help if the symptoms persist, or get worse.
As a Dietitian, I have routinely asked my clients about their bowel function, including how often they poop and its texture — and most are fine with answering these questions because they know this is within my scope of practice. Even though I was taught that part of what can help people avoid hemorrhoids is dietary, until recently I never asked anyone whether they’ve been experiencing hemorrhoids. This has changed. While getting enough of the right type of fiber and drinking sufficient water is important, there are also two lifestyle factors that are thought to contribute to the development of hemorrhoids, and these are the focus of this article.
Hemorrhoids, sometimes called “piles,” are swollen, inflamed veins in the rectum or on the anus that can be painful, itchy and may bleed.
External hemorrhoids form under the skin around the anus, and can easily be felt.
Internal hemorrhoids are natural structures on the lining of the lower rectum. Most people are unaware that they are there until they get irritated and swollen, or worse — prolapse, and protrude from the anus.
There are four grades of internal hemorrhoids based on the degree of prolapse.
Grade 1: Not at all prolapsed.
Grade 2: Prolapses with a bowel movement, but retracts by itself.
Grade 3: Prolapses with a bowel movement and has to be manually pushed it back in.
Grade 4: Prolapsed but can’t be pushed back in, or only with a lot of pain.
Internal hemorrhoids are located on the left lateral side, the right anterior side, and the right posterior side [1,2]. If they become inflamed or prolapsed, sitting becomes very painful, and sleeping on one side, or on one’s back becomes painful, too. Furthermore, a blood clot may form within a hemorrhoid, causing it be become thrombosed and if this causes the blood supply to get cut off, a strangulated hemorrhoid results, which is excruciatingly painful.
The pain of hemorrhoids ranges considerably. It’s only once an internal hemorrhoid becomes irritated, swollen and inflamed that they become painful. If they prolapse, an internal hemorrhoid can go from a 1-3 on a Likert pain scale of 1- 10 (with 10 being the worst) to an 8 or 9 on 10 — and this can occur suddenly, without warning. A person can literally go from having no awareness of having internal hemorrhoids, to having a Grade 3 prolapsed hemorrhoid and experiencing significant pain. As a result, learning what leads to the development of inflamed internal hemorrhoids is essential to avoid experiencing this.
Most external hemorrhoids and Grade 1 and 2 internal hemorrhoids will clear up by themselves after a week or so of self-treatment, however a Grade 1 or 2 hemorrhoids that does not get better, or gets worse, as well as Grade 3 hemorrhoids requires intervention —usually with rubber band ligation (RBL) which is the most common first line treatment [3]. This is where a very small rubber band is applied to the base of the internal hemorrhoid which cuts off the blood supply to it. In essence, this is a planned strangulated hemorrhoid. Over a week or two (depending on the hemorrhoid’s size), the walls will thicken, and the overall size of it will shrink. After approximately 10-14 days, the rubber bands fall off the hemorrhoid, leaving an ulcer. The ulcer may bleed a bit with bowel movements over a few days, as it heals [3]. Finally, what will remain is a bit of scar tissue on the rectum wall and that may continue to bleed lightly during bowel movements, until it heals over completely over the following few weeks. While the banding procedure itself is painless when done properly, and is usually performed without anesthesia, the pain from the hemorrhoid its self can be significant until it finally falls off after ligation, and heals.
If the inflamed internal hemorrhoid is located on the left lateral side, it may be too painful to sleep on that side, and if it is located on the right posterior side it may be too painful to sleep on one’s back. Regardless where it’s located, a Grade 3 or 4 hemorrhoid may make it too uncomfortable to sleep much at all — and since people are generally too embarrassed to talk about hemorrhoids, this pain is largely endured in silence.
The good news is that by adopting a few simple dietary changes and modifying two lifestyle habits the risk of developing hemorrhoids occurring, or reoccurring after treatment can be reduced.
Most people know that avoiding constipation is important to reduce the risk of getting hemorrhoids and think that drinking enough water and eating lots of “roughage” is the way to accomplish that. What few realize is that some types of fiber can make constipation worse — especially if there is insufficient water intake. But, reducing the risk of hemorrhoids involves more than diet. The length of time that we sit on the toilet, as well as the position that we sit on it both play a significant role in the risk of developing hemorrhoids.
Squatting versus Sitting Toilet
In much of Asia, South East Asia and Africa, the squatting toilet is the norm. The user positions themselves in a squat position over a floor-level porcelain bowl which results in the colon and rectum being positioned in a straight line. This enables bowel movement to occur significantly faster and without straining than what occurs when using a western-style pedestal toilet. These are more than “holes in the ground” but are real toilets with a flush mechanism that the user engages to empty the bowl — just like on a Western toilet.
In Europe and most of the West, the pedestal toilet is the norm which is used in a sitting position. This type of toilet results in a bend in the alignment between the colon and the rectum, causing it to take longer to have a bowel movement, and frequently requiring more than one “visit” to accomplish it. Of importance, the seat design of a pedestal toilet results in increased pressure on the rectum and anus which significantly increases the risk of developing hemorrhoids.
Middle Eastern and North African countries have both squatting and pedestal toilets, depending on the region.
There are various types of squatting platforms available for purchase that can be placed over a standard Western pedestal toilet, converting it into a squatting toilet. These are popular with people who have emigrated from countries where squatting toilets are the norm.
Also available online are various types of squatting footstools that are placed in front of a standard Western pedestal toilet and enable the user to sit in a semi-squatting position. These squatting stools allows for better alignment of the colon and the rectum, and are frequently recommended to people recovering from hemorrhoids, hemorrhoid ligation (banding), and hemorrhoid surgery. These squatting stools allow for less pressure on the anus and pelvic floor, and as a result, may help reduce the development of hemorrhoids or deterioration of unknown internal hemorrhoids.
The Length of Time Sitting on a Pedestal Toilet
Due to the shape of the seat on a Western-style pedestal toilet, the length of time that one sits on it increases the risk of developing hemorrhoids. This is due to the increased pressure on the pelvic floor, lower rectum, and anus resulting from the seat’s shape.
Think of a single hole paper punch.
The pressure exerted over a small hole is what makes a one-hole paper punch so effective. Good for paper, not good for rectums.
To limit pressure on the rectum and anus, it is recommended to limit “seat time” to 3-5 minutes at a time, 10 minutes maximum in 24 hours [1].
Washrooms as Phonebooths
In the early 1950s, most houses only had one washroom or bathroom, so multiple members of the same household had to do what they needed to in a limited time, and get out. It was rare to have the luxury of being able to sit on the toilet for extended period of time, reading the newspaper. Now, 97% of new home construction has more than one washroom or bathroom [4] — most often having two full washrooms, plus an additional 1/2 bathroom containing a toilet and a sink.
With three toilets per house for an average family size of three in Canada [5] means that each member of the average household has access to a toilet on demand, and can — and does spend inordinate amounts of time sitting on it.
A recent study found that 2/3 of Canadians and even more Americans are on their smartphones while sitting on the toilet [6]. The washroom is the new phone booth. It is one of only places in the house that many can have time alone — and all this increased sitting on the toilet scrolling on the phone is thought to be related to the increased rates of hemorrhoids seen in younger and younger adults.
Final Thoughts
There are simple things we can do to lower the risk of developing hemorrhoids.
We can drink more water and eat enough of the right types of fiber.
A squatting stool can help align our colon, making defecation time shorter, while reducing the amount of pressure on our rectum.
It is recommended to limit “seat time” to 3-5 minutes. Not scrolling on the phone while sitting on the toilet will make it possible to do what is needed in the recommended amount of time—significantly reducing the risk of developing hemorrhoids.
Remembering how a one-hole punch works may be a helpful reminder.
For those who have never experienced the debilitating pain of a large, prolapsed hemorrhoid, implementing these changes may help avoid the experience.
For those who have, I hope that learning how to minimize the risk of another will be welcomed news.
To your good health.
Joy
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References
- UT Southwestern Medical Centre, Treating hemorrhoidal disease: Conservative vs. surgical approaches, April 14, https://utswmed.org/medblog/best-ways-to-treat-hemorrhoids/
- McKeown DG, Goldstein S. Hemorrhoid Banding. [Updated 2024 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK558967/
- Hawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1. 67 (5):614-623.
- Eye on Housing, Number of Bathrooms in New Homes in 2021, November 3, 2022, https://eyeonhousing.org/2022/11/number-of-bathrooms-in-new-homes-in-2021/
- Statistics Canada, Average Family Size in Canada, 2021 https://www.statista.com/statistics/478948/average-family-size-in-canada/
- Toronto Sun, Two-thirds of Canadians take smart phones into the bathroom: Survey, May 16, 2022, https://torontosun.com/news/national/survey-65-of-canadians-take-their-smart-phones-into-the-bathroom
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