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Updated 13 February 2013

Haemorrhoids - piles

Haemorrhoids, also known as piles are enlarged veins around the anal canal and can be internal or external.

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Description

Haemorrhoids, also known as piles are very common and have been afflicting humans for centuries. They develop when the veins in the anal canal become abnormally swollen and inflamed. Haemorrhoids result from increased pressure in the veins of the anus, causing the veins to bulge and expand, making them painful - particularly when sitting.

The most common cause of haemorrhoids is straining during bowel movements brought on by constipation, sitting for long periods of time, and anal infection. Other contributing factors include pregnancy, ageing, chronic constipation or diarrhoea, natural birth, and anal intercourse. In some cases, they can also be caused by other diseases, such as liver cirrhosis.

Haemorrhoids can develop inside the anal canal or near the opening of the anus – these types are classified as internal or external.

External haemorrhoids develop below the dentate line (a line that separates the two types of anal skin), and are generally painless. They rarely need medical treatment, unless a vein bursts, blood pools under the skin and a painful lump develops (this is called a clotted or thrombosed haemorrhoid).

Internal haemorrhoids develop above the dentate line. They can range in size from a slight swelling under the wall of the canal to large, sagging veins that protrude from the anus at all times. For treatment purposes, internal haemorrhoids are graded according to their size:

  • Grade I: The vein bulges and may bleed during bowel movements.
  • Grade II: The vein comes out of the anus during bowel movements, but goes back by itself.
  • Grade III: The vein comes out during bowel movements, but doesn't go back by itself. It has to be replaced by hand.
  • Grade IV: The vein protrudes from the anus at all times and cannot be replaced.

Classification of haemorrhoids

It is possible for a person to have both internal and external haemorrhoids at the same time.

Cause

Haemorrhoids result from increased pressure on the veins in the pelvis and rectal area that causes the veins to bulge and expand. The increase in pressure is commonly related to:

  • Poor bowel habits – straining from long-term constipation or diarrhoea;
  • Overweight, which often leads to straining to pass stools;
  • Standing or sitting for long periods of time;
  • Breathing improperly while lifting heavy weights (inhaling rather than exhaling while pushing against the weight);
  • Pregnancy, which results in increased blood flow to the pelvic area;
  • Pushing and pressure of natural childbirth
  • Medical conditions, such as long-term (chronic) heart and liver disease, which causes blood to pool in the abdomen and pelvic area;
  • Anal infections;
  • Coughing, sneezing or vomiting;
  • Genetic (inherited) factors.

Symptoms

The most common symptoms of both internal and external haemorrhoids include bleeding during bowel movements (you may see streaks of bright red blood might on toilet paper after you strain to have a bowel movement); itching; and rectal pain.

Anatomy of the anal canal

External and internal haemorrhoids manifest as follows:

External haemorrhoids

  • External haemorrhoids may appear as slight swelling of the veins near the anus, and generally go unnoticed. It may only feel like extra skin around the anus.
  • These skin tags can become inflamed, causing a feeling of pressure in the anus. They can also make it hard to keep the anal area clean, which can lead to skin irritation, itching and burning. If a vein becomes quite large, it may cause discomfort, especially during bowel movements. The discomfort may discourage you from cleaning the anal area as well as you should, which can also lead to skin irritation.
  • A clotted haemorrhoid can be extremely painful, even inhibiting you from sitting or walking. The skin covering the lump may be blue (because of the collection of blood under the skin) and shiny due to stretching of the skin.
  • If the lump is not removed within 24 to 48 hours, the pain will gradually lessen over the following four to five days. The skin covering the lump may break open on its own, causing mild bleeding. With good self-care, pain and bleeding will stop within two weeks.

Internal haemorrhoids

  • The most common symptom of internal haemorrhoids is painless rectal bleeding. You may notice bright red streaks of blood on toilet paper after having a bowel movement or blood on the surface of stools. If you strain to pass stools, blood may spurt (spraying the sides of the toilet bowl) or trickle (colouring the water in the toilet bowl) from your anus.
  • You may have an uncomfortable feeling of fullness after passing stools because of the bulging of the haemorrhoid in the anal canal.
  • Haemorrhoids that are large enough to protrude from the anus (grade III and IV) may secrete mucus, causing mild skin irritation and itching.
  • You may see or feel protruding haemorrhoids as moist pads of skin sticking out. It may recede into the rectum on its own or can be pushed back into place.
  • Very large haemorrhoids may become painful if they swell and are squeezed by the muscles (anal sphincters) that control the opening and closing of the anus.
  • At their worst, large internal haemorrhoids protrude from the anus at all times.
  • In rare cases, the opening and closing of the anus may cut off the blood supply to the swollen veins. This causes tissues inside the rectum to die, and emergency surgery is required to prevent serious damage.

Prevalence

Haemorrhoids are common in both men and women. About half of the population has haemorrhoids by age 50. Haemorrhoids are also common among pregnant women. The pressure of the foetus on the abdomen, as well as hormonal changes, cause the haemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, haemorrhoids caused by pregnancy are a temporary problem.

When to see a doctor

A visit to a doctor is indicated when:

  • Rectal bleeding occurs for no apparent reason and is not associated with trying to pass stools.
  • Rectal bleeding continues for more than one week.
  • Stool becomes more narrow than usual.
  • A lump near the anus gets bigger or becomes more painful.
  • Pain and/or swelling due to haemorrhoids are severe.
  • Moderate pain lasts longer than one week after home treatment.
  • Any unusual material seeps from the anus.
  • Tissue from inside the body sticks out of the anus and does not return to normal after three to seven days of home treatment.
  • Rectal bleeding becomes heavy and/or changes in colour from bright red to dark red or if stools change in colour.

Diagnosis

A number of ailments that affect the anal canal, rectum, and colon (large intestine) can cause bleeding, discharge, itching, and discomfort. Most people who have these symptoms assume they have haemorrhoids, but this is often not the case.

The purpose of a visit to the doctor is to evaluate the symptom, rule out life-threatening conditions, and to make a diagnosis of haemorrhoids. The diagnosis is based on the following:

  • The patient's medical and social history, including personal habits such as diet.
  • Symptoms.
  • Visual examination of the anus and rectum.
  • Digital rectal examination, where the doctor feels inside the rectum with a lubricated gloved finger for abnormalities.
  • With an anoscopy, the doctor uses a small, hollow lighted tube to help view internal haemorrhoids inside the anal canal and lower part of the rectum.
  • A proctoscopy is similar to the anoscopy, but provides a more thorough rectal examination.
  • A faecal occult blood test may be done if internal haemorrhoids cannot be detected with a digital rectal examination or anoscopy.
  • A sigmoidoscopy may be done to check for cancer of the colon and/or rectum (colorectal cancer), this procedure may be undertaken to view the lower colon and so rule out other causes of rectal bleeding, even if haemorrhoids are evident.
  • Further examination of the entire colon with colonoscopy, when indicated.
  • A barium enema/X-ray can also be done which will show the colon's interior.

Common anorectal conditions

Treatment

If the haemorrhoids diagnosis is confirmed, a treatment plan can be initiated.

Treatment of haemorrhoids depend on the degree of prolapsed and the extent of symptoms.

Home treatment and medication

Lifestyle changes are an integral part of treatment and can be used by patients with all stages of haemorrhoidal disease as a preventative measure. Here are some home-treatment techniques and remedies for small haemorrhoids:

  • Do not sit for long periods of time. Take frequent breaks.
  • Insert petroleum jelly on the inside rim of the anus to make bowel movements less painful.
  • Stool softeners can reduce straining and constipation during bowel movements.
  • Be gentle when wiping after a bowel movement. If toilet paper is irritating, try dampening it first, or use cotton balls or alcohol-free baby wipes. You may prefer washing yourself and then dabbing the area dry.
  • It is important to keep the anal area clean and regular bathing is suggested. But be careful, excessive scrubbing, especially with soap, can intensify burning and irritation. Use soaps that contain no perfumes or dyes.
  • Resist the temptation to scratch the area as this irritates the inflamed veins more, damages the surrounding skin and intensifies the itchiness.
  • Ointments that contain hydrocortisone may help decrease inflammation and speed healing.
  • Non-prescription pain relievers and nonsteroidal anti-inflammatory medicine can help with pain and swelling.
  • To relieve pain and itching, apply ice several times a day for 10 minutes at a time. Follow this by placing a warm compress (such as a warm, damp towel) on the anal area for another 10 to 20 minutes.

External haemorrhoids

  • External haemorrhoids usually do not need surgical treatment, unless an enlarged vein near the anus bursts, forming a hard and extremely painful lump under the skin (thrombosed haemorrhoid).
  • If the pain is not too severe, stool softeners, topical pain-relieving creams and Sitz baths (sitting in a bathtub of warm water for 15 minutes several times a day, especially after a bowel movement) may be sufficient.
  • If pain is severe, surgical treatment may be required. If the lump is not removed within 24 to 48 hours, the pain will gradually lessen over the next four to five days. The skin covering the lump may break open on its own, causing mild bleeding. With good self-care, pain and bleeding stop within two weeks (although the lump may remain for several weeks).

Internal haemorrhoids

  • Anaesthetising creams and suppositories to reduce inflammation may relieve irritation and pain due to internal haemorrhoids.
  • Internal haemorrhoids that continue to bleed after a trial of home treatment or become so large that they stick out of the anus may require professional treatment.

Surgery and fixative procedures

This section discusses surgery and fixative procedures for internal and external haemorrhoids.

External haemorrhoids

  • The most effective treatment for thrombosed external haemorrhoids (an external haemorrhoid that causes a painful lump) is to surgically drain it, as this provides immediate relief from pain. It is best if it is removed during the first 24 to 48 hours after formation of the lump. This procedure is easily performed in the doctor's office using a local anaesthetic to numb the skin.
  • Conservative treatment for thrombosed external haemorrhoids include sitz baths, mild analgesics, and stool softeners to relieve the symptoms. The thrombus will slowly be absorbed during the course of several weeks, the pain usually will subside after two or three days, and the mass will resolve within seven to 10 days.
  • Surgical removal (haemorrhoidectomy) is only considered for external haemorrhoids when the veins are so large that they cause significant discomfort and make it difficult to keep the anal area clean. If skin tags cause repeated problems, they can be removed surgically.

Internal haemorrhoids

  • Non-surgical treatments are used to cure most smaller (grade I and II) and some larger (grade III) internal haemorrhoids. The goal of most non-surgical procedures is to cut off the flow of blood to the enlarged vein, causing the vein to fall off and a scar to form in its place on the wall of the anal canal. These are called fixative procedures because the scar keeps nearby veins from drooping into the anal canal. Fixative procedures include the following:
    • Rubber band ligation: a tiny rubber band is tied around a prolapsed haemorrhoid, shutting off its blood supply. The haemorrhoid withers away within a few days. This method is painless and has a 75% success rate.
    • Coagulation or cauterisation: using an electric probe, laser beam or infrared light, a tiny burn painlessly seals the end of the haemorrhoid, causing it to close off and shrink.
    • Sclerosant injection: haemorrhoids are injected with chemicals that create a scar and closes off the haemorrhoid. With a success rate of 90%, this is often the first choice. Results are not permanent, however, and repeat injections may be needed every two or three years.

Most internal haemorrhoids respond to non-surgical treatment. When compared to surgery, these procedures involve less risk and are less painful.

  • Surgical removal of haemorrhoids (haemorrhoidectomy) is most successful for treating larger (grade III and IV) internal haemorrhoids. Smaller internal haemorrhoids are only treated surgically when they cause severe problems (usually when a person has several haemorrhoids; when bleeding cannot be controlled with other treatments; or when a person has both internal and external haemorrhoids).
  • Other non-surgical treatment include bipolar diathermy and direct-current electrotherapy, cryotherapy, laser therapy, and more.
  • Surgery may be done under general, spinal or local anaesthetic. It can be done with a scalpel, cautery device or laser. The choice as to which is the most appropriate varies from patient to patient and is best left to the judgement of the surgeon.

Complete healing from this operation can take two to four weeks. However, after one week most patients are able to return to their usual activities with minimal or no discomfort. The success rate of haemorrhoid removal approaches 95%, but unless dietary and lifestyle changes are made, haemorrhoids are likely to recur.

Prevention

Initial treatment for haemorrhoids begins at home. Since haemorrhoids are made worse by straining to pass stools, changing some of your daily habits to promote regular, smooth bowel movements may help relieve symptoms and keep haemorrhoids from worsening. Half of all haemorrhoid sufferers find relief with dietary changes alone.

  • Avoid constipation by eating high-fibre foods (fruits, vegetables, whole grain breads, beans, and legumes) and avoiding refined and "junk" food. If this cannot be accomplished with diet alone, adding bulk laxatives may be necessary.
  • Drink plenty of liquids such as water, fruit juice and other beverages that don't contain caffeine – at least eight glasses of water a day.
  • Limit alcohol consumption to one drink per day. Alcohol causes dehydration, which can lead to constipation.
  • Monitor your salt intake. Excess salt in the diet causes fluid retention, which will cause swelling in all veins, including haemorrhoids.
  • Regular exercise is important, especially if you have a sedentary job. Exercise helps by keeping weight down, decreasing constipation and enhancing muscle tone. Exercise often to promote regular, smooth bowel movements.
  • Practice good bowel habits. Go to the bathroom as soon as you have the urge to move your bowels. Try to set up routine times when you can go to the bathroom without feeling as if you have to rush or strain. Once on the toilet, don't sit there any longer than necessary, because this can put additional pressure on the haemorrhoidal veins. Don't strain to pass stools. Be relaxed and give yourself time to let things happen naturally. Never hold your breath while passing stools.
  • Modify your daily habits. Avoid prolonged sitting and/or standing at work or during leisure time. Take frequent short walks. If possible, avoid frequent lifting of heavy objects. If you must do heavy lifting, always exhale as you are lifting the weight; don't hold your breath when you lift.
  • If you are pregnant, sleeping on your side will lower pressure on the blood vessels in your pelvis. This can help keep haemorrhoids from getting bigger.

(See images of haemorrhoids - WARNING: graphic images)

Reviewed by Prof Don du Toit (M.B.Ch.B) (D.Phil.) (Ph.D) (FCS) (FRCS).

 
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