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Haemorrhoids (Piles)
Logan Voss, edit. M.Chitgopeker, A.TanDisclaimer If you are concerned about your health or treatment, always see your own doctor.
These health guides are no substitute for proper diagnosis and treatment from your own health professional.
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What are haemorrhoids?
Haemorrhoids are swollen veins (haemorrhoidal veins) in the lining of the anus. While there is no firm evidence indicating what the cause is, they are thought to be associated with an increase in pressure in the abdomen due, for example, to straining to pass hard faeces or heavy physical work. It is probable that there is an inherited component in some cases of haemorrhoids, particularly in those with a congenital (in-born) weakness of the anal veins, making them susceptible to swelling under pressure.
Symptoms
Haemorrhoids are classified according to their site, size and symptoms. They are termed external when they occur close to and around the anal opening and internal when they occur higher in the anal canal.
Internal haemorrhoids
Are further classified as 1st degree to 4th degree according to symptoms and size:
- 1st degree: these are small and do not prolapse (displace such that they visibly protrude out of the anus). They are often associated with no symptoms at all. When symptoms occur, bleeding following a bowel movement is the most common complaint.
- 2nd degree: are slightly larger such that they often prolapse with a bowel movement, but spontaneously retract (reduce) back inside the anal canal. Symptoms are bleeding, mucous discharge and irritation.
- 3rd degree: are associated with essentially the same symptoms as 2nd degree haemorrhoids, except that when they prolapse, they require manual reduction.
- 4th degree: are of such a size that they are permanently prolapsed. Are also associated with bleeding, mucous discharge and discomfort.
3rd and 4th degree haemorrhoids may become strangulated or thrombosed (blocked with a blood clot), causing extreme pain. Otherwise, contrary to popular belief, pain is rarely a significant complaint with internal haemorrhoids, because haemorrhoidal tissue high in the anal canal does not contain any sensory (pain) fibres.
External haemorrhoids
The most common complaint is irritation and moisture around the anus. Like internal haemorrhoids, they can become thrombosed and painful, but do not usually bleed. External haemorrhoidal tissue has sensory fibres and are, therefore, generally more sensitive than internal haemorrhoids. Most "external haemorrhoids" are not true haemorrhoids (swollen veins) at all, but just flaps of skin ("skin tags").
Epidemiology
It has been claimed that "almost everyone" has haemorrhoids at some stage in life. At any one time, approximately 37% of the population has haemorrhoids, with equal distribution between men and women. They are particularly common in Western, industrialized countries, probably due, at least in part, to the low fibre diets of the people in these countries. Approximately 40% of pregnant women develop haemorrhoids, either during the pregnancy of following child birth.
Diagnosis
Diagnosis is made on the basis of a clinical history consistent with the above described symptoms. Examination of the lower rectum and anal canal should include palpation (touching) and viewing (proctoscopy or sigmoidoscopy) to confirm the diagnosis.
As rectal bleeding tends to be associated with other more serious conditions such as cancers, it is important that all patients who present with bleeding are appropriately examined to identify the cause. Proctoscopy is essential for internal haemorrhoids in particular, as they are not visible externally (unless they have become prolapsed).
Treatment and management
Treatment depends upon the classification of haemorrhoids as internal or external.
Internal
1st and 2nd degree haemorrhoids will often resolve without any treatment at all, or with a change in diet to increase fibre intake. Soothing creams containing local anaesthetic and hydrocortisone have been suggested as a help to ease swelling and irritation.
In those cases where symptoms persist, at least 80% of internal haemorrhoids can be effectively treated in an outpatient clinic without surgical removal. These treatments, which can be performed without the use of local anaesthetics because of the absence of sensory fibres in this tissue, include the following:
- injection sclerotherapy: with this technique, the haemorrhoids are injected with an irritant agent (usually 5% phenol in oil) which causes the haemorrhoidal tissue to shrivel and become fibrous and hard. This treatment is most effective for 1st and 2nd degree haemorrhoids. Complications are rare, as long as the injection is accurately placed. Imaging techniques (such as doppler sonography) can be used to help with accurate injection. This method has been said to be safe during pregnancy.
- rubber band ligation: this is the least expensive and probably the most widely used treatment. It has been suggested as a more effective treatment than injection sclerotherapy in terms of a better response and less need for subsequent treatment. The "binding gun" used for this procedure grasps or sucks the haemorrhoidal tissue into the hollow end of the instrument, which, when fired, inserts a rubber band around the base of the tissue. The tissue is strangulated and eventually "drops off". Because bleeding and discomfort is not uncommon in patients following this procedure, pain relief is the most important aspect of post-treatment management.
- cryosurgery: this involves the freezing of the haemorrhoidal tissue using liquid nitrogen. This is generally not a recommended technique as the size and depth of tissue destruction is difficult to accurately predict.
- laser treatment: the use of lasers to destroy the haemorrhoidal tissue has been promoted by some, but is considered by most to be of no proven benefit over and above other techniques and is more expensive.
- other techniques that are sometimes used include infrared and radiofrequency (electric current) coagulation to transform the tissue in to a fibrous, solid mass.
Approximately 90% of haemorrhoids (especially 1st and 2nd degree) will be treated effectively with one or other of the above non-surgical methods. Successful treatment, however, does not ensure against recurrence. Maintaining a high fibre diet, drinking plenty of fluids and employing healthy bowel habits (such as not deferring movements, avoiding excessive straining and careful cleaning of the anal area) will help to reduce the chance of symptoms returning.
In those patients with 4th degree internal haemorrhoids, or those with smaller haemorrhoids for which conservative treatments have been unsuccessful, surgical removal may be required. This is usually only required in 5-10% of patients. The procedure, known as haemorrhoidectomy, requires general or regional anaesthetic and is associated with significant postoperative pain. The operation is associated with a 3-4 week recovery period. Recurrence following surgical removal occurs in only 2-5% of patients.
External
Because external haemorrhoidal tissue contains sensory fibres, they are much more sensitive than internal haemorrhoids and cannot be treated with the above described non-surgical methods. For thrombosed external haemorrhoids, pain relief is the initial primary management consideration, as they will often resolve spontaneously. If they remain troublesome, they can usually be removed under local anaesthetic on an outpatient basis.
References
- Delco F; Sonnenberg A. Associations between hemorrhoids and other diagnoses. Diseases of the Colon and Rectum. 1998. 41: 1534-1542.
- Law W; Chu K. Triple rubber band ligation of haemorrhoids. Diseases of the Colon and Rectum. 1999. 42: 363-366.
- O’Regan P J. Disposable device and a minimally invasive technique for rubber band ligation of hemorrhoids. Diseases of the Colon and Rectum. 1999. 42: 683-685.
- Orkin B A; Schwartz A M; Orkin M. Hemorrhoids: what the dermatologist should know. Journal of the American Academy of Dermatology. 1999. 41: 449-456.
- Pfenninger J L. Modern treatments for internal haemorrhoids. British Medical Journal. 1997. 314: 1211-1212.
- Polylase A L. Haemorrhoids: a clinical update. Medical Journal of Australia. 1997. 167: 85-88.
- Robinson R; Arnold P; Smith T.
Reader’s Digest Encyclopedia of Family Health. Reader’s Digest: Sydney. 1994.
- Salvati E P.
Nonoperative management of hemorrhoids. Diseases of the Colon and Rectum. 1999. 42: 989-993.
- Stonelake P S; Hendrickse C W. Rubber band ligation is effective and efficient. British Medical Journal. 1997. 315: 881-882.
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