Dr Lim Jit Fong
Haemorrhoids is a condition where the veins in the anus and lower rectum become inflamed or swollen. It is a common condition which many adults would experience at some point in their lives.
Haemorrhoids and piles mean the same thing. Both terms are used interchangeably although the term haemorrhoid is preferred in medical texts.
The lining of the anus is divided into two parts, marked by the dentate line. Above, the anal lining is the same as that of the rectum, while the lining below is similar to skin. This distinction is important in determining the type of haemorrhoids you are experiencing, and the type of treatment that would be suitable.
External haemorrhoids occur below the dentate line, where the blood vessels are prone to thrombosis, or clotting. This is more likely to occur due to increased pressure during activities such as heavy lifting or straining due to difficult bowel movement or chronic constipation. This causes the thrombosed blood vessels to appear as a painful, hard lump at the edge of the anus.
Internal haemorrhoids occur when the anal cushions, which contain specialised blood vessels that compress and decompress, are placed under sudden or chronic pressure. These anal cushions function to prevent leakage of gas or faeces when there is a sudden change in pressure, which occurs when we sneeze or lift a heavy object.
However, with prolonged pressure, they can prolapse and protrude from the anus, or start to bleed.
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.
The symptoms of haemorrhoids are different depending on the type of haemorrhoids you have.
If you have external haemorrhoids, you may experience:
External haemorrhoids sometimes progress to become thrombosed haemorrhoids, which happens when the blood pools and forms a clot known as a thrombus. This can lead to:
If you have internal haemorrhoids, you may not see or feel them. However, if you have difficulty or straining with bowel movement, you may experience:
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.
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.
In haemorrhoids or 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.
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.
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.
As haemorrhoids can recur, it is best to adopt a preventive approach. These lifestyle adjustments can help.
Dr Lim adds, "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 costs. One's posture in the toilet also makes a difference. Ideally, we should be sitting forward with our elbows or 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. If you're unsure about getting surgery for piles or haemorrhoids, you can read more about it here.