Haemorrhoids / Piles
In this article
What are haemorrhoids?
Haemorrhoids, also known as piles, are soft fleshy lumps just inside the back passage (anus). They have a rich blood supply and bleed easily, usually causing fresh bright-red bleeding when you have had a bowel movement. They do not usually cause pain but can cause itching around the anus. When large, they can pass through the anus (prolapsed pile), feeling like a lump when you clean yourself.
How do you know if you have piles?
Symptoms can vary depending on the size, position and grade of the pile.
- Grade 1 are small swellings on the inside lining of the anal canal. They cannot be seen or feel from outside the opening of the back passage (anus). Grade 1 piles are common. In some people they enlarge further to grade 2 or more.
- Grade 2 are larger. They may be partly pushed out from the anus when you go to the toilet, but quickly spring back inside again.
- Grade 3 hang out from the anus when you go to the toilet. 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.
- Strangulated or thrombosed piles are uncommon but usually very painful. They cause severe pain and stay swollen outside the anal canal.
How do haemorrhoids happen?
Haemorrhoids develop gradually, often over a long period of time. Being overweight increases your risk of developing piles. They are associated with constipation, particularly if you need to strain to open your bowels. They often run in families and can be made worse by pregnancy. The tissues in the lining of the anus may become less supportive as we become older therefore, piles become common with aging. Other possible causes of piles include heavy lifting or a persistent (chronic) cough.
Do I need any tests?
If you think that you may have piles, or have bleeding or pain from your back passage (anal canal), you should visit your surgeon.
Piles are usually diagnosed after your doctor asks you questions about your symptoms and performs a physical examination. The examination usually includes an examination of your back passage. Wearing gloves and using a lubricant, your surgeon will examine your back passage with their finger to look for any signs of piles or other abnormalities. The surgeon may perform a further examination called a proctoscopy. In this procedure, the inside of your back passage is examined using an instrument called a proctoscope. You may be prepared for a more detailed bowel examination (colonoscopy) to help rule out other conditions.
How are piles treated?
For grade 1-2 hemorrhoids
A soothing cream, ointment, or suppository may ease discomfort. 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).Various preparations and brands are commonly used. They do not cure piles. However, they may ease symptoms such as discomfort and itch.
Avoid constipation and straining at the toilet and keep the stools (faeces) soft, and don't strain on the toilet. You can do this by:
- Eating plenty of fibre (for example, fruit, vegetables, cereals and wholegrain bread).
- Have lots to drink. Most sorts of drink will do but too much alcohol and caffeine should be avoided.
- 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. However, simple painkillers such as paracetamol may help.
- Toileting. Go to the toilet as soon as possible after feeling the need. Do not strain on the toilet.
- Regular exercise helps to reduce constipation.
Grade 2-4 hemorrhoids:
- Banding of heamorrhoids
- Injection sclerotherapy
- Infrared/laser coagulation
- Diatherymy coagulation
Banding of haemorrhoids
Banding is the most commonly used procedure, especially for grade 2 and 3 piles. It may also be done to treat grade 1 piles which have not settled with the simple advice and treatment outlined above.
This procedure is usually done by a surgeon in an outpatient clinic / after colonoscopy. A rubber band is 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 piles 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.
In about 8 in 10 cases, the piles are cured by this technique. In about 2 in 10 cases, the piles come back at some stage. (However, you can have a further banding treatment if this occurs.) Piles are less likely to come back after banding if you do not become constipated and do not strain on the toilet (as described above).
A small number of people have complications following banding, such as bleeding, infection or ulcers forming at the site of a treated haemorrhoid, or urinary problems.
Phenol in oil is injected into the tissues at the base of the piles. This causes a scarring (fibrotic) reaction which obliterates the blood vessels going to the piles. The piles then die and drop off, similar to after banding.
Infrared coagulation/Laser coagulation
This method uses infrared energy/laser to burn and cut off the circulation to the haemorrhoid, which causes it to shrink in size. It seems to be as effective as banding treatment and injection sclerotherapy for first- and second-degree piles.
This uses heat energy to destroy the piles. They appear to have similar success rates as infrared coagulation and the risk of any complications is low.
Haemorrhoidectomy (the traditional operation)
An operation to cut away the haemorrhoid(s) is an option to treat grade (some grade 2) 3 or 4 piles or for piles not successfully treated by banding or other methods and strangulated haemorrhoids. The operation is done under general or spinal anaesthetic and is usually very successful. However, it can be quite painful in the days following the operation.
A circular stapling gun is used to cut out a circular section of the lining of the back passage (anal canal) above the piles. This has the effect of pulling the piles back up the back passage. It also has the effect of reducing the blood supply to the piles and so they shrink as a consequence. Because the cutting is actually above the piles, it is usually a less painful procedure than the traditional operation to remove the piles.
Haemorrhoidal artery ligation
The small arteries that supply blood to the piles are tied (ligated). This causes the haemorrhoid(s) to shrink. However, long term outcome may not meet the levels of a traditional surgery.