Haemorrdoids (Piles)

Haemorrhoids (also known as piles), are swellings which contain enlarged and swollen blood vessels in or around the rectum and anus. In most cases, haemorrhoids are mild and some people do not experience any symptoms at all. However, in more severe cases, symptoms may include: 
  • bleeding after passing a stool (the blood will be bright red)
  • a pile may move down, outside of the anus (prolapse) and may need to be pushed back after passing a stool
  • itchiness around the anus



Haemorrhoids are sometimes caused by prolonged constipation. If you strain when you go to the toilet, it can put pressure on the blood vessels in and around your anus, causing them to swell. Things which increase the risk of piles include:
  • being pregnant
  • being overweight
  • being over 50 years old

Schematic diagram showing internal and external haemorrhoids (piles).


Should I see my doctor?

The symptoms of haemorrhoids often clear up on their own or treatment is available over-the-counter at pharmacies. However, you must speak to your doctor if your piles do not get better or if you experience any pain or bleeding. Haemorrhoids can be easily diagnosed by an internal examination of your back passage.


Treating piles

Haemorrhoid symptoms often settle down after a few days without treatment. However, creams and ointments are available to reduce any itching or discomfort. Making lifestyle changes to keep your stools soft and regular is usually the first recommendation for treating piles.

Eating wholegrain bread and cereal and fruit and vegetables will increase fibre in your diet and you should also drink plenty of water. If your haemorrhoid symptoms are severe, there are a number of treatment options available to remove them. For example, banding is a procedure where a very tight elastic band is put around the base of the haemorrhoid to cut off its blood supply. The haemorrhoid should fall off within seven days.
Surgery is also sometimes recommended to treat large haemorrhoids.


Causes of piles (haemorrhoids) 

Haemorrhoids (piles) are usually caused by excess pressure on blood vessels in and around the anus. If you are constipated and strain while trying to pass stools, it can put pressure on blood vessels in your back passage, making them inflamed and swollen.


Who is at risk of haemorrhoids (piles)?

Factors which increase your chances of getting haemorrhoids include:
  • being overweight 
  • prolonged constipation, often due to a lack of fibre in your diet 
  • prolonged diarrhoea 
  • regularly lifting heavy objects 
  • being pregnant – which can place increased pressure on your pelvic blood vessels, causing them to enlarge (the haemorrhoids will usually disappear after giving birth) 
  • being over 50 years old – as you get older, your body's supporting tissues get weaker, increasing your risk of developing haemorrhoids 
  • a family history of haemorrhoids – you may be predisposed (have an increased tendency) to developing haemorrhoids (e.g. due to having weak blood vessels).


Symptoms of piles (haemorrhoids)

Most cases of haemorrhoids (piles) are mild and the symptoms often disappear naturally after a few days. Some people may not even realise they have haemorrhoids, as they do not experience symptoms. However, where symptoms do occur they may include: 
  • bleeding after passing a stool (the blood will be bright red)
  • a pile may move down, outside of the anus (prolapse) and may need to be pushed back after passing a stool
  • a mucus discharge after passing a stool
  • itchiness around your anus (the opening where solid waste leaves the body)
  • soreness and inflammation around your anus
  • feeling like your bowels are still full and need to be emptied


Haemorrhoids are not usually painful unless they become 'strangulated' and bulge outside the anus. In this case, the muscles of the anus will tighten around the haemorrhoid, causing it to become hard and painful.


Other types of haemorrhoids

Haemorrhoids associated with external blood clots beneath the skin are known as perianal haematoma. A thrombosed external haemorrhoid is a hard lump made up of blood clots which develops around the anus. Both perianal haematomas and thrombosed external haemorrhoids are painful.


When to seek medical advice

You should see your doctor if your haemorrhoid symptoms are persistent and severe.
Also, seek medical advice if you notice blood or mucus in your stools. As well as being a symptom of haemorrhoids, it could also be a sign of other conditions.


Diagnosing piles (haemorrhoids) 

Haemorrhoids (piles) can be easily diagnosed by your doctor. They will examine your back passage to check for swollen blood vessels. It is important to tell your physician: 
  • if you have recently lost a lot of weight
  • if your bowel movements have changed
  • about the colour of your stools
  • if your stools contain blood
  • if there is mucus in your stools


Digital rectal examination

If you have internal haemorrhoids, your physician may carry out a digital rectal examination (DRE). During a DRE, your doctor will wear gloves and use lubricant. Using their finger (‘digit’), they will feel for any abnormalities in your back passage. A DRE should not be painful but you may feel some slight discomfort. 


Proctoscopy

If your doctor feels a closer examination is necessary, they may carry out a proctoscopy. This procedure involves examining the inside of your rectum using an instrument called a proctoscope (a hollow tube with a light on the end).

A proctoscope allows your doctor to see your entire anal canal (the last section of the large intestine). During the procedure your physician may also take a small tissue sample from inside your rectum so it can be tested in a laboratory.


Preventing piles (haemorrhoids) 

It is not always possible to prevent getting haemorrhoids (piles), but a high-fibre diet will keep your stools soft and reduce your risk of becoming constipated. This will help you avoid straining to pass a stool, which is the main cause of haemorrhoids.

It is also recommended that you empty your bowels when you need to. Delaying going to the toilet can make your stools harder and drier. This increases the likelihood of pressure building up in the blood vessels of your rectum (the part of the large intestine where stools are stored) and anus (the end of the large intestine where solid waste leaves the body).


Self help

Ways of helping to prevent haemorrhoids include:
  • eating plenty of fresh fruit and vegetables – at least five portions a day
  • cutting down on fat – particularly fat in meat, sugary food, and refined and processed food
  • eating plenty of pulses, such as peas, beans and lentils
  • eating plenty of wholegrain foods, such as wholemeal bread, pasta and breakfast cereals
  • drinking plenty of fluid – you should drink at least one to two litres (six to eight glasses) of water a day to help keep your stools soft
  • drinking alcohol in moderation
  • losing weight – being overweight can be a contributing factor to having haemorrhoids; use the healthy weight calculator to find whether you are a healthy weight for your height
  • exercising regularly – can help prevent constipation, reduce your blood pressure, and help you lose weight
  • avoiding medication that causes constipation, such as painkillers that contain codeine


Fibre

If you already have haemorrhoids, eating a high-fibre diet can help ease your symptoms. Fibre, also known as roughage, is found in foods such as:
  • fruit
  • vegetables
  • nuts
  • cereals
  • seeds


A diet that does not contain enough fibre can cause constipation because the waste material produced is too hard. This can also lead to other problems such as:
  • appendicitis – which causes inflammation (redness and swelling) of the appendix (a small organ in the abdomen)
  • diverticular disease – where small, painful bulges form in the large intestine (colon).


Dietary fibre acts like a sponge, absorbing water to increase the bulk and softness of stools. This helps them to be passed easily from your body. If you increase your intake of fibre, it is also important you increase your fluid intake.

When increasing the amount of fibre you eat, you should do so gradually because your digestive system will need time to adapt. If you introduce too much fibre into your diet too quickly you may experience:
  • bloating
  • pain
  • constipation
  • excessive wind (flatulence)


Treating piles (haemorrhoids) 

Haemorrhoids (piles) often settle down after a few days without treatment. However, there are a number of treatments that can help reduce any itching and discomfort. Making simple lifestyle changes through diet and exercise is usually the first recommendation.


Dietary changes

If constipation is the cause of your haemorrhoids, you need to keep your stools soft and regular. This will help you avoid straining to pass stools. Increase the fibre in your diet and aim to eat 25-30g of insoluble fibre a day, such as wholegrain bread, cereal, and fruit and vegetables.


Foods such as fruits and vegetables, are particularly high in dietary fibre.


The body is unable to digest insoluble fibre, so it passes through the bowels and helps other food and waste move through more easily. Also drink plenty of water. Aim to drink at least six to eight glasses of fluid a day and avoid too much caffeine (found in tea, coffee and cola).


Self care

Follow the advice below when going to the toilet:
  • avoid straining to pass stools because it may make your haemorrhoids worse
  • after passing a stool, use moist toilet paper rather than dry toilet paper to clean your bottom
  • using baby wipes can help ease any discomfort that you have after passing a stool
  • pat the area around your bottom rather than rubbing it.


Creams, ointments and suppositories

Creams, ointments and suppositories, available over-the-counter from pharmacies, can be used to relieve any swelling and inflammation that you have around your back passage. However, they will only treat your symptoms and will not cure the haemorrhoids themselves.
These types of medicines should only be used for five to seven days at a time. If you use them for longer than this, they may irritate the sensitive skin around your anus. Any medication you use should be combined with the diet and self care advice above.

There is no evidence to show that one preparation is more effective than another. Ask your pharmacist for advice about which product is most suitable for you. Also, always read the patient information leaflet that comes with your medicine before using it. Do not use more than one product at the same time because they may contain similar ingredients.


Anusol cream that can provide symptom relief in patients with haemorrhoids
Corticosteroid cream.

If you have severe inflammation in and around your back passage, your doctor may prescribe corticosteroid cream. This cream contains powerful hormones called steroids. You should not use corticosteroid cream for more than a week at a time because it can make the skin around your anus thinner.


Painkillers

Painkilling medication, such as paracetamol, can relieve pain caused by haemorrhoids. Products that contain local anaesthetic (painkilling medication) may also be prescribed to treat painful haemorrhoids. They should only be used for a few days because they can make the skin around your back passage more sensitive.


Laxatives

If you are constipated, your physician may prescribe a laxative. This is a type of medicine that can help you empty your bowels. Laxatives can be:
  • bulk-forming – which contain fibre to make your stools heavier and softer
  • osmotic – which increases the amount of water in your bowels to make your stools softer.


Banding

Banding is a procedure that is sometimes used to treat second and third degree haemorrhoids. Banding involves a very tight elastic band being placed around the base of your haemorrhoids to cut off their blood supply. The haemorrhoids should fall off within seven days of having the treatment.

Banding is usually carried out as a day procedure and you should be able to return to work the following day. However, you may feel some pain or discomfort for a day or so. Normal painkillers are usually effective but, if necessary, your doctor may prescribe something stronger.

You may not realise the haemorrhoids have fallen off because they should pass out of your body when you go to the toilet. If you notice some mucus discharge within a week of the procedure, it usually means that the haemorrhoid has fallen off.

Directly after the procedure, you may notice some blood on the toilet paper after going to the toilet. This is normal, but there should not be a lot of bleeding. If you pass a lot of bright red blood or blood clots (solid lumps of blood), go to your nearest Accident and Emergency department (A&E department) immediately. Infections or ulcers (open sores) can occur at the site of the banding. However, these complications are rare and can be easily treated.


Injections (sclerotherapy)

Sclerotherapy is another common treatment for internal haemorrhoids. It can be used as an alternative to banding. A chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the sensory nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so that a scar is formed. After about four to six weeks, the haemorrhoid should decrease in size or shrivel up.

After the injection, avoid strenuous exercise for the rest of the day. You may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.


Infrared coagulation

Infrared coagulation, also know as infrared light, can also be used to treat haemorrhoids. A special device is used to burn the haemorrhoid tissue. One or two bursts of infrared light can cut off the circulation to small internal haemorrhoids, such as grade one or two haemorrhoids.


Surgery

Surgery is sometimes recommended to treat large internal haemorrhoids, or those graded as three or four.


Surgery for piles (haemorrhoids) 

Surgery may be recommended if other haemorrhoid (piles) treatments have not been successful. There are a number of different surgical procedures for piles.


Haemorrhoidectomy

A haemorrhoidectomy is an operation to remove the haemorrhoids. It may be recommended if injections (sclerotherapy) or banding have not been effective, or if you have large haemorrhoids causing severe pain and discomfort.

Haemorrhoidectomies are usually carried out under a general anaesthetic. A traditional haemorrhoidectomy involves gently opening the anus so the haemorrhoids can be cut out. It is a major operation and you will need to take a week or so off work to recover.

It is likely you will experience significant pain after the operation, but you will be given painkillers to help. You may still have pain a few weeks after the procedure, which can also be controlled with painkillers. However, seek medical advice if you have pain that continues for longer.

If you begin to pass a lot of bright red blood or blood clots, contact your emergency doctor or go to your nearest Accident and Emergency (A&E) department immediately. After having a haemorrhoidectomy, there is less chance of the haemorrhoids returning compared with injections or banding. However, a high-fibre diet is always recommended as a preventative measure.


Stapling

Stapling, also known as stapled haemorrhoidopexy, is an alternative to a traditional haemorrhoidectomy. It is often used to treat prolapsed haemorrhoids (where the haemorrhoids hang out of your anus) and is carried out under general anaesthetic. Your haemorrhoids are stapled to the wall of the anal canal (the last section of the large intestine), which reduces their blood supply and makes them smaller.


Stapling has a shorter recovery time than a traditional haemorrhoidectomy, and you will usually be able to return to work about a week afterwards. It also tends to be a less painful procedure.

However, after stapling, more people experience another prolapsed haemorrhoid compared with having a haemorrhoidectomy, and there have been a very small number of serious complications following the stapling procedure.


Haemorrhoidal artery ligation

Haemorrhoidal artery ligation (HALO), also known as transanal haemorrhoidal dearterialisation (THD), is an operation to reduce the blood flow to your haemorrhoids. It's usually carried out under general anaesthetic and uses a small ultrasound device called a Doppler probe. Ultrasound is a procedure where high-frequency sound waves are used to create an image of the inside of the body.

The Doppler probe is used to identify areas in the bowel where an artery (blood vessel) supplies blood to a haemorrhoid. A stitch is then placed in each artery to block the blood supply to the haemorrhoid. This causes the haemorrhoid to shrink over the following days and weeks.

The National Institute for Health and Clinical Excellence (NICE) recommend haemorrhoidal artery ligation as an effective alternative to a haemorrhoidectomy or stapled haemorrhoidopexy. The procedure causes less pain and, in terms of results, a high level of satisfaction has been reported.

An expert panel of specialist advisers for NICE found haemorrhoidal artery ligation to be an effective method of relieving symptoms such as bleeding, itching, swelling and pain. A study that looked at the progress of patients four weeks after having the procedure reported that symptoms had cleared up in 9 out of 10 people.

A review of a number of different studies looked at the results of haemorrhoidal artery ligation a year or more after the procedure. It found that about 1 in 10 people experienced:
  • bleeding
  • pain when passing stools
  • a prolapsed haemorrhoid (where the haemorrhoid hangs out of the anus).


Other treatments


Other treatment options are available, including freezing and laser treatment. However, the number of NHS or private surgeons who perform these treatments is limited.

 Source: NHS Choices.