Doctor, I have hemorrhoids!!!

It's true!!! we all have them!!!

Pathology is often confused with normal anatomy. Hemorrhoids are, indeed, normal, even quite complex, anatomical structures that we all possess and that play a fundamental role in anorectal physiology, particularly in the physiology of defecation.

What are hemorrhoids?

Hemorrhoids, mucous prolapse, hemorrhoidal prolapse, mucohemorrhoidal prolapse, what are hemorrhoidsThe popular vulgate, often fueled even by us physicians, is that they are VENE. THEY ARE NOT. Then, what are hemorrhoids? They are actually Functional complexes consisting of arteries, capillaries, veins, connective and muscle fibers, and mucosa. Conventionally, we say that there are Three major hemorrhoid plexuses (which I, following the Spanish school, call front right, back right and side left; others, especially in Italy, enumerate them according to a "clockwise" criterion: "at one o'clock - at five o'clock - at nine o'clock"; to me this seems a tad farrago...) - although in reality, located among the main plexuses ACCESSORIES, smaller but equally important.

What are hemorrhoids for and how do they work?

Once we understand what hemorrhoids are, let's explain what they are for. Each hemorrhoid plexus is made up of a series of ARTERO-VENOSIC SHUNTS, i.e., veins and arteries that join together and form veritable VASCULAR CUSHIONS, the size of which can vary depending on the amount of blood they contain-which is, in turn, determined by arterial inflow and venous outflow into the "pads." These pads are covered by the mucous membrane of the last part of the rectum, and are, shall we say, "held in place" by a complex of connective and muscular fibers that ensure, moreover, their elasticity - and thus their ability to fill and empty with blood; in short, ultimately, VOLUME.

Thanks to their PLASTICITY, the hemorrhoid pads are able to perform their functions perfectly: which are to ACCOMPANY the feces toward their elimination, preventing the passage into the last part of the anorectal canal from being painful, and to PERFECT THE CLOSURE of the mouth of the anal canal, thus participating in the sphincter mechanisms of the anus. Alas, when the magnificent and complex fibrous scaffolding of the hemorrhoids becomes altered (and we will see the reasons for this another time) the problems begin... The connective and muscular fibers that constitute the support for the veins and arteries in the hemorrhoid pads can undergo alterations, which eventually cause them tostretch and/or rupture. The venous structures that make up the hemorrhoids then begin to "slide" downward, which causes them to become truly "deformed" (especially at the expense of the veins, which have, in contrast to the arteries, very little elasticity): the end result of this "degenerative" process (which, however, generally takes YEARS to develop) is HEMORROID PROLASSE.

The consequences, clinically speaking, are obvious: that valuable mechanism of accompanying stool and closing the anus that was regulated by hemorrhoids is broken; in addition, the elongated and deformed veins become more fragile, dilate, and can no longer empty. BLOODING (generally not painful) is the most frequent manifestation of hemorrhoidal pathology; the blood is "bright red," precisely because of its arterial origin, and may be noticed on toilet paper or, less frequently, in the toilet. Alteration of the sphincter mechanism may result in filtration of fecal matter, especially liquid, which causes IRRITATION and ANAL PRURITATION; finally, in the most important cases, there may be SOILING (i.e., minor fecal incontinence) or even STIPSI (the so-called "obstructed defecation syndrome"... a very complicated thing); not to mention the actual PROLAPSE, i.e., the outflow from the anus of a "mucous cylinder," consisting of the rectal mucosa, which sometimes no longer re-enters, which can ulcerate and bleed, and which for patients (who are often elderly, and therefore struggling with a thousand other conditions) is a huge problem.

Well, now we understand what hemorrhoids are, what they are for, and how they work. In a future article, we will see why they, from the normal structures that they are, turn into pathological entities. Stay tuned!