Can Hemorrhoids Cause Vulvar Pain?

Overview

Hemorrhoids and vulvar pain are conditions that can affect the anal and groin area. Despite the proximity, there is no link between hemorrhoids and vulvar pain. Therefore, according to current knowledge, hemorrhoids cannot cause vulvar pain.

What are hemorrhoids?

Hemorrhoids, also known as piles, are a common condition that affect the anal/rectal canal, mainly affecting adults. A study found that 38.93% of the general population are suffering from hemorrhoids.¹ The condition is described as a symptomatic enlargement and distal displacement of the normal anal cushions. Anal cushions are vascular structures that are related to the control of continence in the anal canal. Connective tissue surrounding these cushions deteriorates allowing destructive changes to the cushions, causing hemorrhoids. In addition, abnormal dilation and distortion of the vascular channel is found. This leads to uncomfortable symptoms of rectal bleeding and anal discomfort which will be examined further in this article.²

For diagnostic purposes, hemorrhoids are also graded based on their location and degree of prolapse. The location at which hemorrhoids occur can range from the inferior hemorrhoidal venous plexus (above the dentate line) or the dilated venules of this plexus (below the dentate line). Hemorrhoids in these areas are called internal hemorrhoids, characterised as painless and bright red bleeding, and external hemorrhoids, characterised by pain and swelling around the anus, respectively. There are also mixed hemorrhoids which occur in both areas. This grading allows better choosing of treatments and a comparison of therapeutic outcomes between the grades. 

There are four grades that range from the least severe, at grade I, to the most severe, at grade IV. Grade I involves anal cushions bleeding but not prolapsing. Grade II involves anal cushion prolapsing on straining but reduce when at rest. Grade III involves anal cushion prolapsing on straining or exertion and require manual replacement into the anal canal. Grade IV involves permanent anal cushion prolapsing and is irreducible.²

Once hemorrhoids have been clinically evaluated, treatment can take place which can involve four approaches: dietary and lifestyle modification, medical treatment, non-operative treatment and operative treatment. These approaches will be discussed in greater detail in a later section.²

Causes 

There is no known cause for hemorrhoids, but there are two causes thought to likely be involved. The first cause is constipation and straining when defecating, as hard stool and increased pressure are thought to damage the anal cushions. This damage eventually leads to the development of hemorrhoidal tissue. There is evidence to support this thinking, as a relationship between constipation and haemorrhoids is consistently found.³ 

Secondly, a link to diarrhoea has also been suggested, though this link is more tentative.² These are all conditions related to the anal canal which can affect the cushions, but there are other causes which can affect the cushions.

Pregnancy is also linked to hemorrhoids. Due to the locality of the vaginal canal to the anal canal, damage can occur to the cushions, which results in hemorrhoids. This usually occurs during the last trimester of birth and immediately after birth. One study found hemorrhoids occurred in relation to births of a baby greater than 3900g, and excessive straining during birth.⁴ In addition, dietary factors such as low fibre, spicy foods, and alcohol intake have been proposed. However, evidence for these factors is tenuous.²

To recap, there are several risk factors and causes related to hemorrhoids which include:

• Constipation and excessive straining
• Diarrhoea
• Pregnancy
• Low dietary fibre

Symptoms

The symptoms of hemorrhoids depend on the severity of the disease and type (internal or external). They can be painful or painless, and visible or not. However, the most common symptom of hemorrhoids is painless, bright red bleeding after visiting the toilet. This blood is bright red as the anal cushion tissue has direct contact with the arteries and veins in the body. The severity of symptoms can then increase from there.²

A prolapsing hemorrhoid may cause irritation or anal itching. As the tissue is mucosal, there can also be a production of mucus that can leave residue on underwear. These symptoms can be uncomfortable for patients and affect a person’s ability to sit down. A feeling of still needing to go to the toilet after defecating is also reported in patients with large hemorrhoids. 

To recap, there are several symptoms of hemorrhoids that can be painful:

• Bright red blood after pooing
• An itchy anus
• Feeling of still needing to poo, even if you have just been to the toilet
• Mucus production from the anus
• Presence of external hemorrhoids around the anus
• Pain around the anus

How is vulvar pain linked to hemorrhoids?

It has been established that pain can occur when suffering from hemorrhoids, but there is another type of pain in the same area that can occur in people assigned female at birth. This pain is known as vulvodynia which is a chronic pain or discomfort around the vulva, and the pain affects 7-15% of women.⁵ This can have no identifiable cause and last for at least 3 months. It can make sitting for long periods or having sex very difficult. In addition, the pain can be localised or generalised and can be constant or occasional. 

Overall, the symptoms of vulvodynia include:

• Burning
• Soreness
• Stinging
• Rawness
• Painful intercourse
• Throbbing and itching

This pain can lead to several complications for a person, which include:

• Anxiety or depression
• Sleep disturbance
• Sexual dysfunction
• Relationship problems

But is vulvar pain linked to hemorrhoids? There is currently no research into this connection and there is no established link that hemorrhoids can cause pain specific to the vulva. However, external hemorrhoids could be considered as vulva pain due to their proximity.

Causes of vulvar pain

Although there can be no identifiable cause to vulvodynia, and sometimes no visible signs, there are possible contributing factors which create the pain. Generally these causes are related to a damaging of the nerves in the vulva. These causes include:

• Previous surgery
• Childbirth
• Trapped nerves
• Hormonal changes, such as low oestrogen
• Previous infections, such as HPV
• Pelvic floor dysfunction
• Psychological

Diagnosis

Hemorrhoids are diagnosed based on the patient's history and a clinical examination. Assessment would include a digital examination and anoscopy of the anus. The anal area would also be inspected for symptoms, such as the presence of external hemorrhoids, while the digital examination would be able to detect the presence of internal hemorrhoids. Diagnosis would then be able to lead to treatment.

Before diagnosis of vulvodynia, the doctor will ask questions to understand the pain. These questions can cover topics such as the patient’s medical, sexual, and surgical history. In addition to this, a doctor might perform a pelvic exam or cotton swab test. A pelvic exam is when a doctor visually examines the genitals for signs of infection or other causes for the symptoms. If there is no visual evidence, your doctor might take a sample of your cells for an infection analysis.

Treatments

For hemorrhoids, there are several treatment approaches.² These include:

• Creams to ease pain, itching and swelling of the hemorrhoids.
• Treatment to help constipation and soften poo.
• Colds packs to ease discomfort.
• Dietary and lifestyle modification.

If these treatments do not work then you can opt for hospital treatment for hemorrhoids. However, these treatments do not always prevent the hemorrhoids from re-occuring. Treatments can be performed without surgery and include:

• Rubber band ligation- this cuts off the blood supply causing the hemorrhoids to die and drop off.
• Sclerotherapy- injection of a liquid that reduces blood flow leading to a reduction in hemorrhoid size.
• Electrotherapy- gentle application of an electric current to shrink the hemorrhoids.
• Infrared coagulation- infrared light used to cut blood supply making the hemorrhoids shrink.

Treatments can also make use of surgery and include:

• Hemorrhoidectomy- surgical removal of the hemorrhoids.
• Stapled hemorrhoidopexy- hemorrhoids are stapled back into the anal canal.
• Hemorrhoidal artery ligation- stitches are used to cut blood supply to the hemorrhoids to make them shrink.

For vulvodynia, treatment approaches aim to relieve the pain and often take a holistic approach by using a combination of medicines. Treatment options can include:⁵

• Medications, such as antidepressants, to lessen pain
• Biofeedback therapy- aims to reduce pain by teaching you how to relax the pelvic floor and control response to symptoms.
• Cognitive behavioural therapy
• Local anesthetics such as lidocaine ointment, often recommended to be applied before sex.
• Nerve blocks- injection of agents that block the nerve to relieve pain.
• Pelvic floor therapy- exercises which relax the muscles surrounding the vulva.
• Other lifestyle options such as use of a cold-pack
• Surgery 

When to seek medical attention

For hemorrhoids, a person should seek medical attention if there has been no improvement after a week of home treatment, and the hemorrhoids frequently appear. If this is the case, you can make an appointment with your GP. However, if a fever accompanies your hemorrhoids or pus leaks from the hemorrhoids then you should seek medical attention at a hospital as soon as possible. 

For vulvodynia, medical attention can be sought when pain is persistent in the area and lasts for several days. 

Summary 

Hemorrhoids are caused by damage to the tissue surrounding the anal cushions. These can be within the anal canal or present externally, and can be painful or painless. A common symptom is bright red blood after going to the toilet. After diagnosis, it can be treated with surgical or non-surgical options.

Vulvar pain is a condition known as vulvodynia which affects the opening of the vagina. The cause of the condition is often unknown. Nonetheless, it can be a particularly uncomfortable condition which can be treated with home remedies such as pelvic floor therapy.

Despite the two conditions occurring in the similar area of the body, there is no relation between the two.