Thrombosed External Hemorrhoids

The external hemorrhoids are a plexus of vessels under the skin just outside the anal opening. When a blood clot develops inside one of these vessels it is said to be thrombosed and causes the overlying skin to swell suddenly. The hallmark of this condition is a hard marble-shaped, often blue in color, lump at the edge of the anal opening. It is usually moderately to severely painful.

Thrombosed hemorrhoids often occur with chronic constipation, diarrhea, after a period of heavy lifting or exercise, or during pregnancy. Often there is no identifiable event that led to the thrombosis.  At times the clot causes enough tension on the skin that it may erode through the skin and lead to sudden, rather disconcerting bleeding.

Treatment

If left untreated the thrombosis will, eventually, resolve on its own.  The swelling will go down and the pain subside, but this may take a few weeks to completely resolve.  The most efficacious treatment is excision of the clot under local anesthetic.  The doctor will examine the area first to determine the size of the swelling and the status of the thrombosis. If it is judged that the worst of the pain is already over or the clot has already eroded through the skin, the surgeon may recommend simple evacuation of the remaining clot or conservative treatment with warm baths and a low dose anesthetic ointment.  If the patient is still in acute pain at the time of the examination, then excision of the external hemorrhoid vein and its clot is usually recommended. Simply lancing the skin to relieve the pressure is ineffective and the swelling will often recur after the blood clots again. To excise the hemorrhoid, a tiny needle is used to inject numbing medicine and then the skin over the clot is removed along with the clotted hemorrhoid. This is not a full hemorrhoidectomy. The wound is left open and will heal on its own over the next week or two. A dressing is placed over the wound as it is normal to have some slight bleeding after the procedure.

Fairfax Colon Rectal Surgery’s Approach

The sooner the patient is seen after the onset of their symptoms the sooner the patient will begin to feel relief of their pain.  At Fairfax Colon and Rectal Surgery we make every effort to promptly see you within 24 hours of your call so that you can be relieved of this problem as quickly as possible.  If you suspect you have a thrombosed hemorrhoid, we recommend you call the office and tell the receptionist that you are in acute pain.  If at all possible you will be seen that day for treatment.

After Treatment Symptoms and Care

There will be some pain after the local anesthetic wears off. It may be moderately strong. Your doctor will prescribe something to relieve it. You may also take acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®, for example). Do not take aspirin or products containing aspirin for at least seven days as they promote bleeding.

A small amount of bleeding is normal. Leave the dressing in place for 12 to 24 hours; then take your first sitz bath. If the dressing is difficult or painful to remove, do it after soaking in the bath. If the wound is still bleeding, cover it with a pad or gauze. When there is no longer a discharge you no longer need the pad.

It takes about two or three weeks for the wound to heal. Don't worry if some bleeding, discharge, or itching occur during this time; they are part of the normal healing process.

Anal hygiene is important. Wash or sit in the tub after bowel movements or at least twice a day for the first few days.

You may have been asked to return to the office in 7 to 14 days for a wound check. Your doctor will let you know if this is necessary and if you need further treatment or tests.

Diet

It is important to keep your bowel movements soft and regular. Eat foods high in fiber and drink lots of water (6-8 glasses a day). If you are constipated, take a fiber supplement (for example, Metamucil® or Konsyl®). Prune juice or small doses of milk of magnesia may also be used.

Activity

Avoid strenuous activity for the rest of the day. Tomorrow you can go back to your normal activities.

Causes For Concern

Call your doctor if you have any of the following problems:

  • Excessive pain unrelieved by your pain medication
  • Increasing pain several days after treatment
  • Fever or chills
  • Difficulty urinating
  • Severe bleeding that won't stop with direct pressure using Kleenex or gauze
  • Severe constipation (no bowel movement for three days)
  • Diarrhea (more than three watery bowel movements within 24 hours)
  • Nausea and vomiting

If your doctor is unavailable, the on-call doctor is available 24 hours a day, every day of the year. After hours, call any of our offices and the answering service will locate one of our doctors on call. In an emergency try to contact us for advice before you go to the hospital.