Haemorrhoids (piles) – A Guide

Also known as piles, haemorrhoids are enlarged and swollen blood vessels in or around the lower rectum and anus. Solid waste material (faeces or stools)is stored in the rectum before being passed out of the body through the anus

Introduction
Symptoms of haemorrhoids
Causes of haemorrhoids
Diagnosing haemorrhoids
Treating haemorrhoids
Going for surgery
Preventing haemorrhoids

See also: Piles – Haemorrhoids – Treatment Products

Introduction

Haemorrhoids can cause:

• bleeding when passing stools
• an itchy feeling around the anus
• pain

Blood vessels are a normal part of the anal canal (the last section of the bowel) and, along with other tissues in this area, help to keep the anus closed. However, the blood vessels can become swollen, often as a result of straining to pass a stool.

Types of haemorrhoids

Haemorrhoids vary in size and can occur internally (inside the anus) or externally (outside the anus). Internal haemorrhoids develop 2-4cm above the opening of the anus. External haemorrhoids (perianal haematoma) are less common and develop on the outside edge of the anus.

How common are haemorrhoids?

Estimates for how common haemorrhoids are vary, as often any symptoms to do with the anus, such as bleeding, are thought to be haemorrhoids, when it could be another condition. In the UK, it is estimated that between 4% and 25% of the population is affected by haemorrhoids.

Anyone at any age can be affected by haemorrhoids. However, they are usually more common during pregnancy and in people between 45 and 65 years of age.

Outlook

Haemorrhoids are not usually very serious and can be successfully treated with over-the-counter medicines and a high-fibre diet. In more severe cases, a number of surgical procedures can be used to treat or remove the haemorrhoids. Around 1 in 10 people with haemorrhoids may need surgery.

Symptoms of haemorrhoids

Haemorrhoids (piles) are usually mild and, in most cases, the symptoms will go away naturally within a few days. Most people may not even realise they have haemorrhoids as they do not experience any symptoms.

The symptoms of haemorrhoids include:

• itchiness around your anus (the opening at the end of the digestive system where solid waste leaves the body)
• discomfort around your anus, such as feeling sore or it being visibly red
• excessive straining when passing a stool
• bleeding after you have passed a stool (this will be bright red blood)
• discharge of mucus present after passing a stool
• pain while passing a stool
• feeling like your bowels are still full and need emptying

You may also get a hard lump around your anus. This lump is made up of blood clots forming in a small area (known as a thrombosed external haemorrhoid) and can become very painful.

Contact your GP if you experience pain or discomfort as a result of haemorrhoids. It is also best to contact your GP if you have blood or mucus in your stools, as this can be a sign of another health condition.

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Types of haemorrhoids

Haemorrhoids can be:

• internal haemorrhoids
• external haemorrhoids

These are explained in more detail below.

Internal haemorrhoids

Internal haemorrhoids are classified using a grading system from one to four.

• Grade one haemorrhoids are small swellings often inside the lining of your anus. They cannot be seen and are very common. In some cases, they will enlarge to grade two.
• Grade two haemorrhoids are larger in size but are still within your anus. Sometimes they become pushed out when you pass a stool, but will return inside immediately after.
• Grade three haemorrhoids appear outside your anus. You may be able to feel one or more small lumps hanging out. They are also referred to as prolapsed haemorrhoids. You will usually be able to push them back inside using your finger.
• Grade four haemorrhoids can become quite large and remain outside your anus permanently. They cannot be pushed back inside and will need to be treated by your GP.

External haemorrhoids

External haemorrhoids, also known as perianal haematoma, are small lumps that develop on the outside edge of the anus. They can become increasingly itchy. If a blood clot forms inside them (thrombosed external haemorrhoid), it can cause a lot of pain, requiring immediate treatment. This type of haemorrhoid is less common.

Causes of haemorrhoids

Haemorrhoids (piles) occur due to increased pressure in the blood vessels in your rectum (the storage area that holds the stools) and anus (the opening at the end of the digestive system where solid waste leaves the body).

This is often because of straining when trying to pass a stool. The blood vessels in and around your anus become inflamed (red and swollen).

Others factors that can increase your chances of having haemorrhoids include:

• being overweight
• being constipated (unable to empty your bowels) regularly, often due to a lack of fibre in your diet
• prolonged diarrhoea
• regularly lifting heavy objects
• pregnancy, where you experience increased abdominal pressure on your pelvic blood vessel, causing your blood vessels to enlarge (the haemorrhoids often disappear after giving birth)
• being over 50 years of age (ageing can make the support structures in your body tissues weaker, making haemorrhoids more likely)
• having a family history of haemorrhoids, for example you may have inherited something from your parents that makes haemorrhoids more likely, such as having weak blood vessels.

Diagnosing haemorrhoids

Haemorrhoids (piles) are easily diagnosed by your GP. They will examine your anus (the opening at the end of the digestive system where solid waste leaves the body) to check for swollen blood vessels.

It is important to tell your GP:

• if you have recently lost a lot of weight
• if your bowel movements have changed
• what colour your stools are
• if your stools contain any blood
• if there is any mucus present in your stools

Digital rectal examination

If your haemorrhoids are internal (see Haemorrhoids – symptoms for an explanation), your GP may perform a digital rectal examination (DRE). Wearing gloves and using lubricant, they will use their finger (‘digit’) to feel for any abnormalities in your anus and rectum (the storage area that holds the stools).

Proctoscopy

If a closer examination is necessary, your GP may perform a proctoscopy. This is an examination of the inside of your rectum. Your GP may use an instrument called a proctoscope, which is a hollow tube fitted with a light on the end.

A proctoscope makes it possible for your GP to see your entire anal canal (the last section of the bowel). It also allows your GP to take a small tissue sample from inside your rectum, which may be necessary if any laboratory tests need to be carried out.

It is important to see your GP if you experience any bleeding from your anus. You can also call 111 for advice.

Treating haemorrhoids

Haemorrhoids (piles) usually settle down in a few days without any treatment. However, there are a number of treatments that will reduce the itching and discomfort that haemorrhoids can cause. Lifestyle changes are usually the first step of treatment.

Dietary changes

If your haemorrhoids are a result of constipation (being unable to empty your bowels), try to keep your stools soft and regular. By making changes to your diet, you can avoid straining while on the toilet:

• Increase the amount of fibre in your diet. Aim to eat 25-30g of insoluble fibre every day (insoluble fibre is fibre that the body cannot digest, so it passes through the bowels and helps other food and waste move through more easily), such as wholegrain bread and cereal, and raw fruits and vegetables.
• Drink lots of water. Aim to drink six to eight glasses of fluid every day and avoid too much caffeine (which is found in tea, coffee and coca-cola).

Self care

Follow the advice below when passing stools:

• Avoid straining to pass a stool as this may make your haemorrhoids worse.
• After passing a stool, clean your anus (the opening where solid waste leaves the body) with moist toilet paper instead of dry toilet paper.
• Using baby wipes can ease any discomfort that occurs after passing a stool.
• Pat, rather than rubbing, the area.

Creams, ointments and suppositories

Over-the-counter (OTC) creams and medicines can be used to soothe any inflammation (swelling and redness) around your anus. These will only treat the symptoms of haemorrhoids, and will not cure the haemorrhoids themselves.

These products should only be used for five to seven days at a time. If they are used for longer than this, they may irritate the sensitive skin around your anus. Combine taking any medication 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 about which product may suit you best, and 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, as they may contain similar ingredients. Your pharmacist should be able to advise you about which products you can safely use.

Corticosteroids

Creams containing corticosteroids (medication that contains powerful hormones called steroids) can also be prescribed to reduce the inflammation around your anus. These should not be used for longer than a week as they can make the skin around your anus thinner.

Painkilling medication

Painkillers, such as paracetamol, can be taken to relieve the pain caused by haemorrhoids. Some are available OTC, or they may be prescribed by your GP.

Products containing local anaesthetic (a painkilling medication) may also be prescribed to treat the pain that haemorrhoids cause. They should only be used for a few days, as they can make the skin around the anus more sensitive.

Laxatives

If you are constipated, your GP may prescribe a laxative (a type of medicine that can help you to empty your bowels). This could either be:

• a bulk-forming laxative, which contains fibre to make your stools heavier and softer
• an osmotic laxative, which increases the amount of water in your bowels to make your stools softer

Banding

Banding involves your GP putting a very tight elastic band around the base of the haemorrhoid inside your anus. This cuts off the blood supply. Within seven days of having the treatment, the haemorrhoids should fall off.

This is a common treatment for grade two or three internal haemorrhoids. See Haemorrhoids – symptoms for an explanation of the different types and grades of haemorrhoids.

Banding is usually done as a day procedure and you can 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 your GP can prescribe something stronger if necessary.

You may not notice that the haemorrhoids have fallen off as they should pass out of your body with a bowel movement. Some people notice some mucus discharge within a week of the procedure, which usually means the haemorrhoid has fallen off.

Directly after the procedure, it is normal to see some blood on the toilet paper, but you should not bleed a lot. If you start to pass a lot of bright red blood or pass clots (solid lumps of blood), go to your nearest accident and emergency (A&E) department immediately.

Infections or ulcers (open sores) can also occur where the banding took place. However, these complications are rare and can be easily treated.

Injections (sclerotherapy)

Sclerotherapy is a common treatment for grade two or three internal haemorrhoids. It is often used as an alternative to banding.

A chemical solution can be injected around the blood vessels in your anus. 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 can resume your normal activities, including work, the day after. You may experience some minor pain for a while and may bleed a little.

Infrared coagulation

Infrared coagulation (also know as infrared light) can also be used to treat your haemorrhoids. A special device is used to burn the tissue of the haemorrhoid. 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 often used to treat internal haemorrhoids that are either very large or are grade three or four. See Haemorrhoids – surgery for more information on surgical procedures to treat haemorrhoids.

Going for surgery

If other treatment has not worked on your haemorrhoids (piles), you may be referred to a surgeon. There are several different surgical procedures you can have. These are explained in more detail below.

Haemorrhoidectomy

If injections or banding have not treated your haemorrhoids successfully, or if your haemorrhoids are large and causing you a lot of pain and discomfort, you may be referred for a haemorrhoidectomy. This is an operation to remove the haemorrhoids and is usually done under a general anaesthetic (a painkilling medication that makes you unconscious).

A traditional haemorrhoidectomy involves gently stretching the anus (the opening at the end of the digestive system where solid waste leaves the body) while the haemorrhoids are cut away.

It is less likely that the haemorrhoids will come back after surgery than it is with injections or banding, but a high-fibre diet is always recommended as a preventative measure.

This is a major operation and you will need to take a week or so off work while the wounds heal.

It is common to have pain after this procedure, but you will be given painkillers to help you deal with it. You may still have some pain for a few weeks afterwards, but this can be controlled with painkillers. If the pain goes on for longer, seek medical advice.

If you start to pass a lot of bright red blood or pass clots, go to your nearest accident and emergency (A&E) department immediately.

Alternative procedures

Some alternative surgical procedures are explained below.

Stapling

Stapling, also known as stapled haemorrhoidopexy, is an alternative to a traditional haemorrhoidectomy. It is usually only done to treat prolapsed haemorrhoids (when the haemorrhoids are hanging out of your anus) and is carried out under general anaesthetic.

The haemorrhoids are stapled to the wall of the anal canal (the last section of the bowel), which reduces their blood supply and makes them smaller.

Stapling has a shorter recovery time than the traditional haemorrhoidectomy, and you can usually return to work in around a week. Stapling also tends to be less painful than a haemorrhoidectomy. However, after stapling, more people experience a further prolapsed haemorrhoid than after a haemorrhoidectomy.

Haemorrhoidal artery ligation

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

The Doppler probe is used to locate all the areas in the bowel where an artery (blood vessel) supplies blood to a haemorrhoid. A stitch is placed in these arteries so that the blood supply to the haemorrhoid is blocked. This causes the haemorrhoid to shrink over the following days and weeks.

Guidance from the National Institute for Health and Clinical Excellence (NICE) says that haemorrhoidal artery ligation is an effective alternative to a haemorrhoidectomy or stapled haemorrhoidopexy. It causes less pain after the operation and people have reported a high level of satisfaction with the results.

The Specialist Advisers for NICE, who are experts that provide informed opinions about medical procedures, found that haemorrhoidal artery ligation was effective for relieving symptoms such as bleeding, itching, swelling and pain. One study that looked at the progress of patients four weeks after having haemorrhoidal artery ligation found that 9 out of 10 said their symptoms had cleared up.

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

A few other options are available, but only a few surgeons carry them out on the NHS or in private clinics. These include freezing and laser treatment.

Preventing haemorrhoids

There is no guaranteed way to prevent haemorrhoids (piles), but a high-fibre diet will keep your stools (faeces) soft, reducing your risk of becoming constipated (when you are unable to empty your bowels). This will ensure that 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. If you delay passing your stool, it could become harder and drier. This increases the likelihood of pressure building up in the blood vessels in your anus (the opening at the end of the digestive system where solid waste leaves the body) and rectum (the storage area that holds the stools).

Possible ways 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 1-2 litres (six to eight glasses) of water every day to keep your stools soft
• drinking alcohol only in moderation
• losing weight if you need to. Being overweight can be a contributing factor to having haemorrhoids.
• exercising regularly, which can prevent constipation, reduce the pressure in your blood vessels 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 plant foods, such as:

• fruit
• vegetables
• cereals
• nuts
• seeds

A diet too low in fibre can cause constipation because the waste material is too hard. This can lead to other problems such as:

• appendicitis, which causes inflammation (redness and swelling) of the appendix (a small pocket in the abdomen with no known purpose)
• diverticular disease, when small pouches form that stick out of the side of the large intestine (colon) and cause pain

Dietary fibre acts like a sponge, absorbing water to increase the bulk and softness of stools. This ensures that they are eliminated easily from the body. If you increase your intake of fibre, it is also important that you increase your fluid intake.

Gradually increase the amount of fibre you eat, as your digestive system will need time to adapt. If you introduce too much fibre into your diet too quickly, you may experience:

• bloating
• constipation
• excessive wind (flatulence)
• pain