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DEAR DOCTOR: Like a lot of older people, I suffer from hemorrhoids that cause some pain as well as intermittent bleeding after bowel movements. My doctor recommended surgery, but I've also found relief using a hemorrhoid cream. What's the best treatment?

DEAR READER: "Hemorrhoids" is the name given to a common condition in which veins in the tissues of the lower anus or the rectum become inflamed and swollen. They can be internal or external, and each type causes different symptoms.

Internal hemorrhoids occur within the rectum, which is the lowest portion of the colon, or large intestine. Although these can sometimes cause bleeding, they tend to be painless. External hemorrhoids present as visible bumps or swellings on and around the skin of the anus, which is the opening through which feces passes. External hemorrhoids often cause pain and intense itching around the anus, and they can bleed.

Both types of hemorrhoids can become thrombosed, which means that a blood clot has formed inside. Internal hemorrhoids can also prolapse, which means that they bulge beyond the anus. This is often quite painful, but it is usually not dangerous.

Although the exact reason someone develops hemorrhoids is often not known, causes include chronic straining during bowel movements due to constipation, sitting on the toilet for long periods of time, pressure due to pregnancy or weight gain and chronic diarrhea. Diagnosis is done via a visual or digital examination of the anus, or with an endoscopic device, which is a thin flexible tube that allows the physician to closely examine the anal canal.

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When it comes to treatment, we believe that the first approach should be adjustments to behavior and lifestyle. It's important to avoid sitting on the toilet for long periods of time, which puts pressure on the rectum and anus. Don't spend more time on the toilet than it takes to urinate or complete a bowel movement. For some people, a change of diet may be needed in order to deal with chronic constipation. This includes drinking plenty of water for adequate hydration, and eating lots of fresh greens, fruits and vegetables to get the insoluble fiber that makes stools softer and easier to pass. Using a Squatty Potty, a raised platform that turns the seated position on a toilet into a squat, can result in less straining during a bowel movement.

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As you've discovered, creams and ointments can help to ease symptoms like swelling and itching. However, they don't cause hemorrhoids to heal. Hemorrhoids often go away on their own. But when lifestyle methods aren't enough, or fail to adequately manage symptoms, then the conversation will turn to surgery, known as a hemorrhoidectomy, to address the affected tissues. Hemorrhoidectomies are usually done on an outpatient basis, which means you go home the same day.

One final note -- whenever you have anal bleeding, it is important to see your doctor for an exam. We recently had a patient who came to us with bleeding hemorrhoids. Thanks to additional testing, it was discovered to be a rectal cancer, and the patient was able to seek appropriate treatment.

Eve Glazier, M.D., MBA, is an internist and associate professor of medicine at UCLA Health. Elizabeth Ko, M.D., is an internist and assistant professor of medicine at UCLA Health.

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