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What are Haemorrhoids?
Haemorrhoids or ‘piles’ as they are commonly known, are vascular cushions at or just inside the opening of the bottom. Straining to pass hard stools can cause the haemorrhoids to swell and the direct trauma of passing the stool can make them bleed.
What are the symptoms of Haemorrhoids?
Haemorrhoids cause a wide range of symptoms including;
- Itching around the bottom
- Swelling and discomfort
- Bleeding from the bottom (usually bright red)
- Problems with perianal hygiene
- Passing mucus from the bottom
- Prolapse (when a haemorrhoid/haemorrhoids protrude out of the bottom either after opening the bowels or all the time)
- Incontinence (faecal soiling) – Usually this is mild, but in some cases it can be severe. Usually this means that the haemorrhoid has either developed a blood clot that is expanding within the haemorrhoid tissue or a thrombosis. These are exquisitely painful and the haemorrhoid will usually prolapse out of the bottom.
What are the causes of Haemorrhoids?
Many people suffer from haemorrhoids at some point in their life. Common times for them to occur include during pregnancy and in the post-partum period, during periods of erratic bowel habit, when using strong painkillers that cause constipation and after long haul flights. Simple measures can reduce the chance of suffering from haemorrhoidal symptoms.
How are Haemorrhoids diagnosed?
Many patients will present with symptoms of rectal bleeding. Because of this, patients at OneWelbeck will often be investigated to make sure there are no other causes of bleeding.
Your surgeon will need to examine you. This allows the doctor to assess the severity of the haemorrhoid and rule out other causes of bleeding. He or she may use a plastic telescope in the clinic to properly visualise the haemorrhoid and this is important for planning treatment.
Many patients will have a telescopic examination of the rectum or colon as part of their investigation.
How are Haemorrhoids treated?
Treatment for haemorrhoids is different for each patient. We make a personalised decision based on your symptoms and the type of haemorrhoids you have.
The best treatment is prevention and this means that you should try to:
- Avoid straining or spending too long on the loo.
- Treat constipation by increasing the amount of fibre in your diet
- Make sure you drink enough fluid during the day and that you avoid dehydration
- Laxatives are often required to help soften the stool and prevent straining.
Topical creams and suppositories
These should be tailored to the symptom. If haemorrhoids are causing swelling or discomfort, topical preparations containing steroids can be used for a short period of time. For itching, barrier creams can be used on the perianal skin. Or pain and burning preparations containing local anaesthetic are soothing.
Injection of sclerosant via the anal canal into the haemorrhoids causes the blood vessels in the haemorrhoids to become blocked and the scarring reduces the size of the haemorrhoids and the potential for them to bleed. This can be performed in the clinic setting without anaesthetic and repeated as many times as required. It is also sometimes used to treat mucosal prolapse caused by chronic straining.
Rubber band ligation
This is the most effective nonsurgical method for treating haemorrhoids and can be performed either in clinic without sedation or under general anaesthetic in the operating theatre depending on patient/surgeon preference.
The procedure involves the insertion of a lubricated proctoscope to visualise the haemorrhoids and then application of suction and a band to the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid causing it to shrivel up and fall off. The haemorrhoid(s) are then usually passed in the stool and many patients will not notice this happening. Several bands can be applied at a time and the technique can be repeated as many times as required. The bands cause an initial discomfort often felt as the need to pass stool or something in the rectum that they cannot pass. Bleeding can occur when the bands are applied and when they fall off, which is usually within a week.
The bleeding usually stops on its own. If you are taking anti-coagulants (medications to thin the blood such as warfarin, apixiban, rivaroxaban or clopidogrel) these drugs will need to be stopped for banding to be performed.
Radiofrequency treatment for haemorrhoids (Rafaelo Procedure)
This new treatment for haemorrhoids is usually done under local or general anaesthesia. Its advantage is that it causes less discomfort than removal of the haemorrhoid . A lubricated proctoscope is inserted into the anus to allow good visualisation of the anal canal and to expose the haemorrhoids. Local anaesthetic is injected into the tissue surrounding the haemorrhoid. A specially designed instrument applies radiofrequency energy waves to the haemorrhoid tissue, which produces heat and shrinkage of the haemorrhoid. The haemorrhoids may be treated in several sessions, each taking up to 20 minutes.
Haemorrhoidal Artery ligation (HALO) or transanal haemorrhoidal dearterialization (THD)
This technique is usually performed under a general anaesthetic using a specialised proctoscope to identify branches of the blood vessels feeding the haemorrhoids and a stitch is used to tie them off. The haemorrhoid is pulled into the bottom and it shrinks. However, if you have tags of skin around the bottom these are not treated with this technique. Like the Rafaelo, this approach is less painful than surgical excision of the haemorrhoids but there is a greater chance the haemorrhoid will return than with traditional surgery.
Open (excisional) Haemorrhoidectomy
This involves excision of the haemorrhoids under general anaesthetic. After excision the wounds on the bottom are left open to prevent infection. It is an uncomfortable procedure but it still has the lowest long term chance of the haemorrhoids coming back. Antibiotics, laxatives, local anaesthetic and creams to reduce spasm in the sphincter muscles after surgery which are all helpful in reducing discomfort.
A circumferential line of staples are placed around the lining of the rectum. The aim is to staple across the blood vessels that supply the haemorrhoids and to any redundant mucosa (the lining of the bowel) inside the anal canal. The procedure is performed under general anaesthetic. Because the staples are placed inside the rectum, no skin is cut and this reduces the pain typically found after traditional surgery.