Haemorrhoids (piles) are swellings that develop from the lining of the anus and lower rectum (back passage). Symptoms range from temporary and mild, to persistent and painful. In many cases, haemorrhoids are small and symptoms settle down without treatment. If required, treatment is usually effective.
What are haemorrhoids and what causes them?
Haemorrhoids are swellings that can occur in the anus and lower rectum (back passage).
There is a network of small veins (blood vessels) within the inside lining of the anus and lower rectum. These veins sometimes become wider and engorged with more blood than usual. These engorged veins and the overlying tissue may then form into one or more small swellings called haemorrhoids.
The exact reason why these changes occur and lead to haemorrhoids forming is not clear. Some haemorrhoids seem to develop for no apparent reason. However, it is thought that the pressure in and around the anus can be a major factor in many cases. If the pressure in and around the anus is increased, then it is thought that this can lead to haemorrhoids developing.
Certain situations increase the chance of haemorrhoids developing:
- Constipation, passing large stools (faeces), and straining at the toilet. These increase the pressure in and around the veins in the anus and seem to be a common reason for haemorrhoids to develop.
- Pregnancy. Haemorrhoids are common during pregnancy. This is probably due to pressure effects of the baby lying above the rectum and anus, and the affect that the change in hormones during pregnancy can have on the veins.
- Ageing. The tissues in the lining of the anus may become less supportive as we get older.
- Hereditary factors. Some people may inherit a weakness of the wall of the veins in the anal region.
How does haemorrhoids present?
These form in the back passage about 2-4 cm above the rim (opening) of the anus. Their severity and size are classified into grades 1 to 4:
Grade 1 are small swellings on the inside lining of the back passage. They cannot be seen or felt from outside the anus.
Grade 2 are larger. They may be partly pushed out (prolapse) from the anus when you go to the toilet, but quickly spring back inside again.
Grade 3 hang out (prolapse) from the anus. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.
Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.
Symptoms can vary. Small haemorrhoids are usually painless. The most common symptom is bleeding after going to the toilet. Larger haemorrhoids may cause a mucous discharge, some pain, irritation, and itch. The discharge may irritate the skin around the anus. You may have a sense of fullness in the anus, or a feeling of not fully emptying your rectum when you go to the toilet.
A possible complication of haemorrhoids that hang down (grade 3-4) is a blood clot (thrombosis), which can form within the haemorrhoid. This is uncommon, but causes intense pain if it occurs.
External haemorrhoid (sometimes called a perianal haematoma)
This is less common than internal haemorrhoids. An external haemorrhoid is a small lump that develops on the outside edge of the anus. Many do not cause symptoms. However, if a blood clot forms in the haemorrhoid (a thrombosed external haemorrhoid) it can suddenly become very painful and need urgent treatment. The pain due to a thrombosed external haemorrhoid usually peaks after 48-72 hours, and then gradually goes away over 7-10 days. A thrombosed external haemorrhoid may bleed a little for a few days. It then gradually shrinks to become a small skin-tag.
Some people develop internal and external haemorrhoids at the same time.
How is haemorrhoids treated?
- Avoid constipation and straining at the toilet
- Keep the faeces (sometimes called stools or motions) soft, and don't strain on the toilet. You can do this by the following:
- Eat plenty of fibre such as fruit, vegetables, cereals, wholemeal bread, etc.
- Have lots to drink. Adults should aim to drink at least two litres (10-12 cups) per day.
- Fibre supplements. If a high-fibre diet is not helping you can take fibre supplements (bulking agents) such as ispaghula, methylcellulose, bran or sterculia.
- Avoid painkillers that contain codeine such as co-codamol, as they are a common cause of constipation.
- Toileting. Go to the toilet as soon as possible after feeling the need. Some people suppress this feeling and plan to go to the toilet later. This may result in bigger and harder faeces forming which are then more difficult to pass. Do not strain on the toilet.
The above measures will often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small and non-prolapsing haemorrhoids (grade 1). Small grade 1 haemorrhoids often settle down over time.
- Ointments, creams, and suppositories Various preparations and brands are commonly used. They do not cure haemorrhoids. However, they may ease symptoms such as discomfort and itch.
- A bland soothing cream, ointment, or suppository may ease discomfort. Several brands are available without a prescription.
- One that contains an anaesthetic may ease pain better. You should only use one of these for short periods at a time (5-7 days). If you use it for longer, the anaesthetic may irritate or sensitise the skin around the anus. A pharmacist can advise.
- One that contains a steroid may be advised by a doctor if there is a lot of inflammation around the haemorrhoids. Steroids reduce inflammation and may help to reduce any swelling around a haemorrhoid. This may help to ease itch and pain. You should not normally use a steroid cream or ointment for longer than one week at a time.
- Very painful prolapsed haemorrhoids are uncommon. The pain may be eased by an ice pack pressed on for 15-30 minutes. Strong painkillers may be needed.
- Haemorrhoids of pregnancy usually settle after the birth of the child. Treatment is similar to the above.
- Banding treatment
Banding is a common treatment for grade 2 and 3 haemorrhoids. It may also be done to treat grade 1 haemorrhoids which have not settled with the measures described above (such as an increase in fibre, etc).This procedure is usually done by a surgeon in an outpatient clinic.
A haemorrhoid is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid which then dies and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.Banding of internal haemorrhoids is usually painless as the base of the haemorrhoid originates above the anal opening - in the very last part of the gut where the gut lining is not sensitive to pain. Up to three haemorrhoids may be treated at one time using this method.
In about 8 in 10 cases, the haemorrhoids are cured by this technique. In about 2 in 10 cases, the haemorrhoids recur at some stage. (However, you can have a further banding treatment if this occurs.) Banding does not work in a small number of cases.
A small number of people have complications following banding, such as bleeding, urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid.
The more commonly done procedures include the following:
- Injection sclerotherapy Phenol in oil is injected into the tissues at the base of the haemorrhoids. This causes a fibrotic (scarring) reaction which obliterates the blood vessels going to the haemorrhoids. The haemorrhoids then die and drop off, similar to after banding. However, this procedure is less widely used than banding because the success rate is not as good.
- Various methods that use heat to destroy the haemorrhoids There are various ways this can be done and include: infrared coagulation; photocoagulation; diathermy; electrotherapy. However, these procedures are less widely used than banding because their success rate is not as good.
- Haemorrhoidectomy (the traditional operation) An operation to cut away the haemorrhoid(s) is an option to treat grade 4 haemorrhoids, and for grade 2 and 3 haemorrhoids not successfully treated by banding or other methods. The operation is done under general anaesthetic and is usually successful. However, it can be quite painful in the days following the operation.
- Stapled haemorrhoidectomyAlthough the name of this procedure implies that the haemorrhoids are removed (cut out), this is not so. What happens in this procedure is a circular stapling gun is used to cut out a circular section of the lining of the anal canal above the haemorrhoids. This has an effect of pulling the haemorrhoids back up the anal canal. It also has an effect of reducing the blood supply to the haemorrhoids which shrink as a consequence. Because the cutting is actually above the haemorrhoids, it is usually a less painful procedure than the traditional operation to remove the haemorrhoids.
- Haemorrhoidal artery ligation Also known as transanalhaemorrhoidaldearterialisation (THD), in this procedure the small arteries that supply blood to the haemorrhoids are tied (ligated). This causes the haemorrhoid(s) to shrink. This procedure is not usually painful and is gaining in popularity as a treatment option.
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