What Is the Treatment for Combined Internal and External Hemorrhoids?

Medically reviewed by: Gary H. Hoffman, MD

There are two types of hemorrhoids, those that occur inside the anal opening and those that occur outside. In fact, the anatomy of hemorrhoids is rather complex.  But, inside and outside are reasonable ways to think about hemorrhoids.  Internal hemorrhoids are often asymptomatic. External hemorrhoids, however, are known for causing a wide variety of symptoms because they are located in a very sensitive area and are easily irritated.

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When both internal and external hemorrhoids occur at the same time, the condition is known as combined hemorrhoids. Combined hemorrhoids can lead to symptoms of both conditions, as well as additional complications.

What Causes Combined Hemorrhoids?

The causes of internal and external hemorrhoids are the same, so it is not surprising that some people develop inflammation in both areas at once. Increased pressure on the anus and straining to have a bowel movement are thought to be the primary causes of hemorrhoid flare ups. This pressure may occur in a number of ways, including being due to:

  • Pregnancy
  • Constipation
  • Diarrhea
  • Other irregular bowel habits
  • Spending too much time sitting on the toilet after a bowel movement

If the cause of inflamed hemorrhoids continues, the condition can worsen. Symptoms advance, and become difficult to ignore. Over time, complications including thrombosis (clotting) of external hemorrhoids or prolapsing (falling out or protruding) of internal hemorrhoids may occur.

What Are the Symptoms of Combined Hemorrhoids?

According to The American Society of Colon and Rectal Surgeons, only about 5 percent of people develop symptoms of hemorrhoids although they are actually very common. While it is more common to experience symptoms in conjunction with external hemorrhoids, patients with combined hemorrhoids can have symptoms of either type, or both.

These symptoms may include:

  • Burning and pain around the anus
  • Itching
  • Swollen area just outside the anus
  • Bright red blood, especially after bowel movements
  • Mucus-like discharge
  • Prolapse of tissue out of the anus
  • Feeling like you cannot completely evacuate your bowels

If you experience any of these symptoms, schedule an appointment with your colon and rectal specialist, also know as a proctologist.. The sooner you can confirm a diagnosis of combined hemorrhoids, the sooner you can get the pain and discomfort under control.

How Are Combined Hemorrhoids Diagnosed?

Many people assume any anal symptoms are hemorrhoids, and begin using over-the-counter creams in hopes of reducing symptoms. However, this is not a good idea. Because life threatening conditions can cause similar symptoms and hemorrhoid complications can be serious, it is necessary to visit an experienced  colon and rectal specialist for a diagnosis.

Your doctor will talk to you about your health history, symptoms and bowel habits. This will be followed by a physical exam that consists of a visual exam, manually feeling for internal inflammation using a lubricated finger, and viewing any internal hemorrhoids with a special tool called an anoscope.

With this exam, your doctor will confirm your diagnosis of combined hemorrhoids and rule out other conditions with similar symptoms, including:

  • Anal fissures
  • Skin tags
  • Fistulas
  • Pruritus ani
  • Colon cancer

How Are Most Cases of Combined Hemorrhoids Treated?

In most cases of combined hemorrhoids, symptoms can be alleviated and inflammation reduced with only conservative treatments. Pairing dietary and lifestyle changes with at-home treatment to soothe your symptoms is usually effective in providing comfort from hemorrhoids.

Your doctor will most likely recommend taking a few steps to reduce your symptoms, including:

  • Increased fiber intake
  • Drinking plenty of fluids
  • Sitting less and moving around more
  • Regular sitz baths until symptoms disappear

Many doctors recommend that patients with combined hemorrhoids get between 20 and 35 grams of fiber each day, which requires eating a well-rounded diet with plenty of fruits and vegetables. Your doctor or pharmacist may recommend a fiber supplement to help regulate your bowel habits and ensure your stool is easily passed. Exercise also helps keep your bowels moving properly.

At the same time, you’ll need to drink plenty of water and other fluids to keep your body well-hydrated. Be aware of the fact that caffeine and alcohol both dehydrate the body, meaning you will need to drink even more water if you have beer or soda on a regular basis.

Sitting in a warm, shallow bath several times a day can reduce hemorrhoid symptoms and encourage faster healing. This is especially useful after a bowel movement. Just be sure to avoid using any other-the-counter hemorrhoid treatments unless they are specifically recommended by your doctor.

What if First Line Treatments Aren’t Effective?

More than 90 percent of patients who have symptomatic hemorrhoids see their symptoms resolve without surgery, and this is the best option for some people with combined hemorrhoids. When non-invasive treatments are not effective at treating combined hemorrhoids, a hemorrhoidectomy may be considered.

During this procedure, the surgeon will remove the involved hemorrhoidal tissue. It is typically performed in an operating room under general anesthesia. Most people can go home a few hours after surgery, although an overnight stay is occasionally necessary.  There are several methods to remove hemorrhoidal tissue.  Methods include (PPH (surgical stapling), THD (transanal hemorrhoidal dearterialization and traditional surgical hemorrhoidectomy.  PPH usually returns patients to their daily routines quicker than a traditional hemorrhoidectomy.  THD involves ligating the hemorrhoidal arteries, thus depriving the hemorrhoid of its blood supply.  It is less painful than a traditional hemorrhoidectomy.

Hemorrhoidectomies can be painful, but the pain is usually easily managed with prescription medication for a few days following surgery. Most people return to work and their regular activities within two to four weeks. Hemorrhoidectomies are highly effective, both in providing symptom relief and in reducing the chance of recurrence.

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