Piles, medically known as haemorrhoids, is a condition that patients often find embarrassing. But the fact is, they’re incredibly common, with anywhere up to a third of the UK population affected. One of the first symptoms you’ll notice may be bleeding from your back passage or a lump. So what’s going on? When should you seek medical help? And what can be done to treat your haemorrhoids?
To understand haemorrhoids, it helps to get an idea of the anatomy of your back passage.
There are two muscles around your back passage responsible for keeping your stools in. To prevent anything leaking out when your stools are loose, your back passage has an added level of security — anal cushions that sit above these muscles.
When the cushions become enlarged, they cause haemorrhoids. As the anal cushions contain lots of blood vessels, the main symptom of haemorrhoids is bleeding, usually without any pain. As everyone has anal cushions, anyone can develop haemorrhoids at any age.
Haemorrhoids can be internal, where they sit inside your back passage, or they can be external where they protrude out of your back passage. Sometimes haemorrhoids only pop out when you open your bowels. They may go back in on their own or you may need to push them back in. In some cases, they can’t be pushed back and are constantly hanging out of your back passage (Grade 4 haemorrhoids).
As we’ve already discussed, the main symptom is bleeding. Blood is usually bright red but can also be darker. Depending on the size and position of your haemorrhoids, you may feel lumps in and around the entrance to your back passage.
If your haemorrhoids protrude, you may also experience itching and discomfort. Pain is not a common symptom of haemorrhoids but may occur if the blood clots within the haemorrhoid (thrombosed haemorrhoids). This occurs when the muscles around your back passage clamp down. It can cause severe pain that may result in seeing a doctor. However, pain usually resolves after around two weeks.
Although haemorrhoids can occur in anyone of any age, there are risk factors for the condition. The two main risk factors are straining to pass stools and pregnancy when the womb pushes down on the pelvis. Other conditions that push down on the pelvis can also increase your risk of haemorrhoids, such as a pelvic tumour.
The short answer is no. This is why it’s so important to see your GP if you notice any anal bleeding. It could be a sign of another condition, perhaps more serious, which may need treatment.
You may have a tear in the skin around your anus (anal fissure). In addition to bleeding, anal fissures are usually very painful, especially when passing stools or within an hour of passing stools.
You may have a peri-anal haematoma, where blood vessels in the skin around your anus burst causing an olive-shaped lump at the entrance to your back passage.
Other conditions that cause anal bleeding include anal fistulas, rectal ulcers, diverticular disease, polyps (growths, usually non-cancerous) and bowel cancer. Bowel cancer is the third most common cancer in the UK and may cause anal bleeding.
If you have noticed persistent blood in your stools or when you wipe your bottom, you should see your GP. You may have haemorrhoids or you may have another condition that needs treatment.
The older you are, the more important it is to seek medical attention as early as possible. This is because the incidence of bowel cancer, where anal bleeding is a common symptom, increases significantly after age 50.
If you’re diagnosed with haemorrhoids, you may not need any medical intervention or surgery. Making certain lifestyle changes is often enough to resolve your symptoms.
Try to avoid straining when passing stools. You can pass stools more easily by sitting on the toilet with your knees bent at around 90° and making certain changes to your diet.
Eat more dietary fibre (fibre from plants) by including more fruits, vegetables, oats, lentils, seeds, nuts and whole grains in your diet. Dietary fibre makes your stools larger and softer so they are easier to pass. However, don’t go overboard with dietary fibre — too much can make your stools uncomfortably bulky. Also, make sure you stay well hydrated by drinking more water.
To ease your discomfort, you can also try over-the-counter topical creams that contain local anaesthetic and a low dose of steroids to reduce swelling.
While lifestyle changes are usually enough to resolve bleeding caused by haemorrhoids, you may need medical treatment if your symptoms are persisting or if you have external haemorrhoids. Your GP will refer you to a specialist.
As an experienced Consultant Colorectal and General Surgeon, I often see patients referred for haemorrhoids treatment. However, surgery is not the only treatment option available. The treatment you receive will depend on the severity of your haemorrhoids. This will factor in whether your haemorrhoids are internal or external, whether they are protruding some or all of the time, and whether and how much discomfort they are causing you.
Haemorrhoids can often be treated in an outpatient clinic, either with banding or sclerotherapy.
Banding can be used to tie off internal haemorrhoids. A tiny rubber band is placed around the haemorrhoid, which cuts off its blood supply, causing it to shrivel up and fall off.
Sclerotherapy is an alternative treatment. This is where the haemorrhoid is injected with a chemical called phenol, which causes scar tissue to form. This stops the bleeding associated with haemorrhoids.
The latest non-surgical approaches
If your haemorrhoids are larger and hanging out (prolapsed), you may need more involved treatment. At Spire Healthcare, an innovative treatment called the Rafaelo® procedure is available. It uses radiofrequency technology to shrivel up haemorrhoids and takes around 15 minutes. Although it can be carried out as an outpatient procedure under a local anaesthetic with sedation, it is usually performed as a day case under general anaesthetic as it can be uncomfortable.
Another new treatment for haemorrhoids is laser treatment. As with the Rafaelo® procedure, it can be carried out under local anaesthetic but is usually performed under general anaesthetic. As this treatment is relatively new, it is not yet widely available in the UK.
Both laser treatment and the Rafaelo® procedure are thought to be less painful during recovery than traditional surgical treatments for haemorrhoids.
If your haemorrhoids are very large or severely prolapsed, you will most likely need surgery under general anaesthetic. You may be recommended HALO or a haemorrhoidectomy.
A common surgical procedure for haemorrhoids is called haemorrhoidal artery ligation operation (HALO). This is carried out as a day case under general anaesthetic. First, an ultrasonic probe is used to identify the blood vessels supplying your haemorrhoids. These blood vessels are then stitched to cut off the blood supply to your haemorrhoids so they will shrivel up.
HALO is often performed alongside rectal anal repair — this is called HALO-RAR. After the blood vessels supplying your haemorrhoids are stitched, any haemorrhoidal tissue hanging out of your back passage is then stitched to hold it up.
In the most severe cases of haemorrhoids, that is, very large, prolapsed haemorrhoids or haemorrhoids that haven’t responded to other treatment, a haemorrhoidectomy is usually needed. This surgery removes your haemorrhoids and is carried out under general anaesthetic usually as a day case procedure.
A haemorrhoidectomy can be performed using a laser or by electrocautery where an electric current is used to destroy tissue. Recovering from this surgery is painful — patients often describe the pain as similar to having an astroturf burn but on their bottom. The pain usually resolves after about two weeks.
To find relief from your post-surgery pain, you can sit in a warm saltwater bath, apply warm water from a showerhead or place ice cubes in your underwear. Although you may want to take strong painkillers, such as codeine or opiates, these can cause constipation (hard stools), which will worsen your pain. It is, therefore, preferable to take laxatives to help avoid straining and apply a topical anaesthetic. If you’re still in considerable pain, your doctor may also prescribe co-codamol — this contains paracetamol mixed with a lower dose of an opiate.
As with any surgery, there are risks involved in having a haemorrhoidectomy. Removing large haemorrhoids can cause your anal canal to narrow, which makes it difficult to open your bowels. Your surgeon may, therefore, leave behind some haemorrhoidal tissue to reduce this risk. But this comes with the risk of milder but recurrent symptoms. There is also a very small risk of damage to the muscles in your back passage.
Thrombosed haemorrhoids are very painful and if the enlarged blood vessels burst, you may experience lots of bleeding. Consequently, you may be referred to a hospital for urgent treatment. However, surgery is not always recommended. This is because the pain caused by surgery for haemorrhoids can be just as severe as the pain caused by your thrombosed haemorrhoids.
What’s more, both types of pain usually resolve in a similar time frame of around two weeks. So rather than swapping one pain for another equally bad pain, you may instead be offered non-surgical treatments to ease your haemorrhoids pain.
Whether your haemorrhoids are mild or severe, it is important to continue to avoid straining when passing stools after your treatment. Make sure you stay well-hydrated and follow a diet rich in fibre. These lifestyle changes will reduce your risk of developing haemorrhoids in the future.
Spire Healthcare offers a range of haemorrhoids treatments, including banding, sclerotherapy, HALO, the Rafaelo® procedure and haemorrhoidectomy. What’s more, you won’t have to wait months to see a specialist, with easy access to appointments and your own dedicated, experienced consultant who you’ll see every time.
Mr Prateesh Trivedi is a Consultant Colorectal and General Surgeon, specialising in bowel cancer, laparoscopy, colonoscopy, anal conditions (eg haemorrhoids, fissures, fistulas), inflammatory bowel disease, pelvic floor problems and hernia surgery. He practices at both Spire Gatwick Park Hospital and at NHS Ashford & St Peter's Hospital. He graduated from Guy's and St Thomas' Medical School and was awarded a Doctor of Medicine (MD) from UCL for his research into bowel dysfunction and pelvic floor problems in those with spinal injury. Currently, Mr Trivedi is also an Honorary Senior Research Associate at UCL.