To understand haemorrhoids and its treatment, one should appreciate certain aspects of the anal anatomy. The lining of the anus can be divided into 2 halves – deep and superficial.
The point of division is midway, in the anal canal marked by an irregular jagged line known as the dentate line. These are tooth-like projections in the lining, originated from the Latin word for teeth, dentatus. Above the dentate line, the lining is the same as that of the rectum. Below the dentate line, the lining is similar to skin.
What are Haemorrhoids?
Above the dentate line, there are 3 anal cushions under the lining. These cushions consist of specialised blood vessels that can rapidly fill up or decompress. This feature allows the anal cushions to prevent leakage of gas or faeces when there is sudden change of pressure, which can happen when we carry heavy things or when we sneeze. When these anal cushions over-expand (usually due to chronic straining from difficult bowel movement), they can prolapse out of the anus or cause bleeding. This is termed “internal haemorrhoids”.
Below the dentate line, the blood vessels are different from the anal cushions. The blood vessels here are prone to thrombosis, or clotting, when a person strains very hard during activities such as carrying heavy loads or passing motion due to chronic constipation. The thrombosed vessel appears as a painful hard lump at the edge of the anus. This is termed “external haemorrhoids”.
What is the difference between haemorrhoids and piles?
Haemorrhoids and piles mean the same thing. Both terms are used interchangeably although the term haemorrhoid is preferred in medical texts.
What are the symptoms?
There are 3 main symptoms of haemorrhoids: bleeding, prolapse and pain (from thrombosis). Sometimes, one may feel a burning discomfort or itch around the anus and this is due to the prolapsed haemorrhoid.
The bleeding pattern seen from haemorrhoids is unique. It is painless and occurs during bowel movement. Some patients notice a splatter of bright red, fresh blood before the stools are passed out. Others describe the dripping of fresh blood after bowel movement.
When the faeces are released, there is usually no blood at all. It is very rare to see blood clots from haemorrhoids because the bleeding stops immediately when the anus closes after bowel movement.
It is important to note that everyone has anal cushions and therefore, anyone can have some bleeding from haemorrhoids intermittently. This also means that haemorrhoids can co-exist with other diseases of the colon and rectum, such as colon cancer or colon infection (colitis).
Please do not ignore your symptoms and see a doctor if the problem persists.
How can haemorrhoids be treated?
Treatment of haemorrhoids depends on the symptom presented. The aim of treatment is to restore the anal cushions to their normal anatomy and function. The choices available for treatment are numerous and customised based on the patient’s symptoms and severity of haemorrhoids.
Here are some of the available treatment options:
Good dietary and toilet habits are necessary for the treatment of all patients suffering from haemorrhoids. Avoidance of constipation will help alleviate the symptom of bleeding.
Having regular bowel movements through a fibre-rich diet with adequate fluid intake can minimise the risk of constipation. Patients are also advised to avoid spending unnecessary time sitting on the toilet. They are advised to use the toilet only when they feel the urge to have a bowel movement and not to go according to a fixed time daily. They should not bring any reading materials, or smart devices such as gamepads or smartphones into the toilet either.
If bleeding persists, your doctor may prescribe oral medication to stop the bleeding. Small, bleeding haemorrhoids rarely require surgery. If there is itching or burning discomfort around the anus, use of topical creams help soothe the discomfort.
If there is prolapse of haemorrhoids, medication and dietary modification alone cannot adequately treat the problem. An outpatient treatment known as “rubber band ligation” can be used in conjunction with medication to remove the prolapsed haemorrhoid.
A small rubber band (diameter of 2mm) is applied to the base of the prolapsed haemorrhoid after it is reduced back to its original location in the anus. This rubber band stops blood flow to the tissue, causing the tissue to shrivel and die. The shrivelled tissue drops off and leaves a small ulcer which will heal spontaneously. Up to 3 rubber bands can be applied at a time and this procedure can be repeated. As the rubber band is applied above the dentate line, the patient usually feels no pain.
Sometimes, the amount of prolapsed haemorrhoids may be too large for rubber band ligation. Patients with large prolapsed haemorrhoids usually describe a prolapse that can only be reduced back into the anus manually with their fingers. Some may be permanently prolapsed and cannot be reduced back into the anus. In such cases, surgery will be necessary.
As there are many difference surgical techniques that may be applied, your specialist will be able to describe the most appropriate option.
Treatment of thrombosed haemorrhoids
In thrombosed haemorrhoids, the treatment is usually for pain. If a patient presents soon after the thrombosis or is in severe pain, the blood clot can be removed with a small cut. The release of the clot will provide immediate relief.
If the patient presents when the thrombosis is several days old, it may be partially resorbed by the body (just like any bruise under the skin) already and treatment is usually with medication to treat the symptoms. Surgery would not be necessary then.
In certain cases, the thrombosis may get infected or show signs to suggest infection. If that is so, surgery is recommended to prevent any secondary infections of the anus.
Does surgery cure me of piles?
In piles surgery, the guiding principle for surgeons is to restore the anal cushions to their original and ideal position in the upper anal canal. This means that surgery is not aimed at removing all of the piles, but only to reduce it back to its normal size and location.
Removing all of the piles will mean a person can lose bowel control as they may leak stools when coughing or jumping. Therefore while surgery will restore normal anal anatomy, there remains a small chance of recurrence of piles.
Do I need any tests before surgery?
The diagnosis of haemorrhoids is made on clinical assessment alone. No further tests are required before surgery. However, if there is a suspicion of a concomitant colorectal problem, a colonoscopy may be required before surgery. In the rare instance that a cancer is detected, the treatment of the cancer takes precedence over the haemorrhoids.
What do I need to look out for after surgery?
Depending on the type of operation done, there can be some variations to your post-operative recovery. There is usually no dietary restriction after surgery. You will however, have some have a tendency to pass gas more frequently. That will stop when the wounds heal.
After excisional haemorrhoidectomy, the wounds may take up to 4 weeks to heal. There is minimal pain at rest, but having a bowel movement can be painful unless oral and topical medications are used. After stapled haemorrhoidectomy, there may be a persistent urge to pass motion as the pain from the staple line pain is similar to the urge we have when there’s a need for bowel movement. This discomfort usually lasts for 10 days. For haemorrhoidal artery ligation, the discomfort is the least and lasts only 2 – 3 days.
Whichever technique is used for surgery, there is a risk of bleeding, which can happen 5 – 10 days post-surgery. Visit your specialist immediately as this could be due to an infection of the wound or staple line. This bleeding can be easily stopped with an injection into the bleeding site and a re-operation is very rarely needed.
As the aim of surgery is to return the anus to its normal function, there may be a risk of recurrence of haemorrhoids. This is not a failure of surgery as the normal anal cushions cannot be removed completely. Each of the operations can be repeated if necessary but repeat operations are very uncommon within the first 10 years of surgery.
What are the risks if I leave my haemorrhoids alone?
Haemorrhoids are anal cushions that have developed problems and become symptomatic. They do not predispose you to develop colorectal cancer. It is common for patients who have been diagnosed with prolapsing haemorrhoids to choose to leave it alone once colorectal cancer is ruled out.
How do we prevent the recurrence of haemorrhoids?
In order to prevent recurrence after treatment of haemorrhoids, you should try to avoid excessive straining during bowel movement as well as bad toilet habits.
Drink adequate amounts of fluid, at least 1 litre a day, to avoid constipation and having the need to strain in order to pass motion. Constipation with hard stools can be overcome by taking more fibre in your diet. Constipation with soft stools will require the aid of laxatives.
Many people have poor toilet habits without realising it. This includes spending unnecessary time sitting on the toilet bowl engaging in activities such as reading, playing games or smoking. You should avoid that at all cost.
One other thing is to improve one’s posture in the toilet. Ideally, we should be sitting forward with our elbows/ hands on our knees with a straight back. This improves the passing of motion.
Always consult your doctor should you have any doubts about your symptoms experienced, especially if there is bleeding or pain.
Article contributed by Dr Lim Jit Fong, general surgeon at Gleneagles Hospital