An anal fissure is a small tear or open sore in the anus. It can cause pain and bleeding when you…
What are haemorrhoids?
Haemorrhoids (piles) are swollen, painful varicose veins in the anus or rectum that often hang down outside your anus. They can look like small grapes and are often caused by constipation, obesity, heavy lifting or pregnancy. While they are not life-threatening, they can cause great discomfort and embarrassment.
Haemorrhoids are a very common condition and occur when there is a prolonged increased pressure on the veins inside your anus. This leads to varicose veins developing and forming haemorrhoids.
There are several health conditions and lifestyle factors that may put you at greater risk of developing haemorrhoids, these include:
- Having a family history of haemorrhoids;
- Already having an inflammatory bowel condition such as Crohn's disease, irritable bowel syndrome (IBS) and ulcerative colitis;
- Constipation - the excessive straining associated with constipation puts great pressure on the blood vessels in and around your anus, which can cause the blood vessels to become swollen and develop into haemorrhoids;
- Pregnancy - haemorrhoids are very common during pregnancy and soon after childbirth, due to increased pressure on your abdominal blood vessels. You may become constipated during pregnancy if you are taking iron supplements, which can further increase your chance of haemorrhoids;
- Obesity - this increases the pressure on your pelvic region;
- Heavy lifting - straining to lift heavy objects or doing heavy manual labour can increase pressure on your anal region;
- Anal sex - this can cause tears and increase pressure on your anal veins;
- Ageing - as you get older haemorrhoids become more common, especially after 45 years of age;
- Laxatives and enemas - using too many of these can make you more prone to developing haemorrhoids, and;
- Ignoring the urge to go to the toilet and sitting for long periods of time.
There are two main types of haemorrhoids: internal and external:
These form higher inside your rectum and usually don't cause any pain. These haemorrhoids aren't usually noticed unless they bleed. Mucus and faecal incontinence sometimes occur with this type of haemorrhoid.
If they protrude outside your anus, they are called prolapsed haemorrhoids. You can sometimes push them back inside. They tend to protrude or hang down and can be very painful.
These are small lumps that form underneath the skin around your anus. If they develop a blood clot (thrombosed haemorrhoid) they will swell up and turn into hard painful lumps. The pain usually last two to three days, but the swelling may remain for weeks. Pain and itching are a common symptom and if ruptured, external haemorrhoids can bleed. Once they heal, a skin tag may remain.
Signs and symptoms
The signs and symptoms of haemorrhoids will depend on whether they are internal or external. If you have internal haemorrhoids, you may not be aware of them unless you become constipated and need to strain to pass a bowel motion. This straining puts pressure on the anal passage and can force internal haemorrhoids outside your anus. These prolapsed haemorrhoids can be itchy and quite painful.
Thrombosed external haemorrhoids can also be quite painful. They commonly appear as purplish, tender lumps around the anus.
Other symptoms of haemorrhoids include:
- Bleeding or mucus - a common sign of haemorrhoids is bright red blood, either on your toilet paper or in the toilet bowl. Bleeding from the rectum can also be a sign of a more serious condition, so always get it checked out with your doctor;
- Itchiness, irritation and inflammation around the anus;
- Pain when passing a stool or sitting for any length of time, or straining to pass a stool;
- Hard lumps around or near the anus, and;
- Faecal incontinence - internal haemorrhoids can cause faecal matter to leak from your anus, especially if they become quite large.
Methods for diagnosis
Haemorrhoids are a very common complaint and your doctor will have diagnosed many cases, so do not feel embarrassed about discussing this issue. Anal bleeding can also be a sign of a more serious underlying condition, so it is essential to have it checked out. Your doctor will need to take a full medical history, examine you and may perform some tests. Make sure to mention any unusual symptoms you are experiencing such as weight loss or change in bowel movements. A visual examination will be enough for your doctor to diagnose external or prolapsed haemorrhoids. Internal haemorrhoids may require additional procedures to be diagnosed.
Digital rectal examination (DRE)
A digital rectal examination involves your doctor putting a lubricated, gloved finger in your anus to feel for an internal haemorrhoid or to detect bleeding.
A proctoscopy is a common procedure that involves inserting a thin, hollow lubricated instrument (proctoscope) into your rectum. The instrument is lit and allows your rectum to be examined closely. If your doctor suspects that you are bleeding further up your colon, other tests may be suggested.
Sigmoidoscopy involves the insertion of a device called a sigmoidoscope into the bowel through the anus, allowing your doctor to see the lower part of your colon and rectum. Usually, you will need to use enemas to clean out the lower part of the colon and rectum, prior to having this procedure performed.
During a colonoscopy the entire length of the colon is examined using a long tube with a camera called a colonoscope. This is usually performed under light sedation, and generally requires cleaning out the colon and rectum with laxatives and/or enemas, prior to having this procedure performed.
Types of treatment
Many cases of haemorrhoids can be resolved with simple lifestyle changes. Avoiding constipation by eating a healthy diet that contains high-fibre, plenty of fruit, vegetables and whole grains, increasing your water intake and exercising regularly, can help treat and prevent haemorrhoids. Occasionally, laxatives may be needed to help keep stools soft to avoid straining.
With some cases though, you may need medications or surgery.
Thrombosed external haemorrhoids
Over-the-counter pain-relief medications such as paracetamol and ibuprofen can help manage the pain. Keeping stools soft using laxatives can also help reduce pain when passing stools.
Special haemorrhoid creams to reduce pain, itching and inflammation may be prescribed or bought over the counter to treat thrombosed external haemorrhoids. Hydrocortisone creams may be prescribed to help with localised irritation in the short-term, but can thin your skin with long-term use.
Sitting in a warm, hip-deep bath (sitz bath) two or three times per day can greatly reduce the pain associated with thrombosed external haemorrhoids.
Moist toilet paper
Using moist, unperfumed toilet paper or wipes will help keep the anal area clean and cause less irritation than dry paper.
Applying a cold compress or ice pack may help relieve severe inflammation and discomfort.
Incision of external haemorrhoid
If a blood clot appears in an external haemorrhoid, your doctor can drain it with a simple cut, providing immediate relief. However, this should generally be performed within 24-48 hours of the condition developing.
Recurrent or prolapsed internal haemorrhoids
Rubber band ligation
This procedure is performed by a surgeon or gastroenterologist (a specialist doctor) and involves placing specialised rubber bands around internal haemorrhoids to cut off their blood supply. The haemorrhoid and rubber band will eventually fall off. This procedure may be performed in the doctor's clinic.
This involves a special chemical being injected into your haemorrhoids, in order to shrink them.
Coagulation (Infrared coagulation)
This involves using infrared radiation to treat internal haemorrhoids, which may need to be over a series of sessions. An intense beam of radiation creates scar tissue, which cuts off the blood supply to the haemorrhoid. After about seven to 10 days you may notice bleeding as the haemorrhoid falls off.
This procedure involves the surgical removal of your haemorrhoids, usually under a general anaesthetic. Your surgeon will cut away or laser your haemorrhoids then close the wound with stitches. You may experience post-operative pain for a few weeks and may have to take laxatives to avoid constipation until you have healed completely. A haemorrhoidectomy may be necessary if you:
- Have external haemorrhoids which keep forming clots;
- Have tried banded ligation without success;
- Have constant bleeding, and;
- Have a prolapsed haemorrhoid which cannot be pushed inside.
There are always risks with any type of surgery. After a haemorrhoidectomy, potential complications may include pain, urinary retention, delayed bleeding, urinary tract infections, faecal incontinence, faecal impaction, infection and anal stricture.
This procedure involves removing enlarged haemorrhoidal tissue, then stapling the remaining tissue back into its normal position. This is considered less painful than haemorrhoidectomy.
If left untreated haemorrhoids can lead to faecal incontinence, anaemia and recurring thrombosis (clot formation within the haemorrhoid).
In general, the long-term outlook if you have haemorrhoids is positive. Lifestyle changes and a high fibre diet alone may be enough to keep symptoms at bay most of the time. If you do have a flare-up, self-care remedies can usually help.
If you try to avoid constipation by eating a healthy diet that contains high-fibre, plenty of fruit, vegetables and whole grains, increasing your water intake and exercising regularly, this will lessen the chance of your haemorrhoids returning.