Haemorrhoids (Piles)

Haemorrhoids (Piles) 

Patient Information

Colorectal Department

• Author ID: MH/NM
• Leaflet Ref: Surg 050
• Version: 5
• Leaflet title: Haemorrhoids (Piles)
• Last review: May 2021
• Expiry Date: May 2023

What are haemorrhoids (Piles), and what causes them?

Haemorrhoids (piles) are swellings that develop from the lining of the anus and lower rectum (back passage).  There is a network of small veins (blood vessels) within the inside lining of the anus and lower rectum. These veins sometimes become wider and fill up with more blood than usual. The veins and the overlying tissue may then form into one or more small swellings called haemorrhoids.

Symptoms range from temporary and mild, to persistent and painful.  In many cases, haemorrhoids are small and symptoms settle down without treatment.  If required, treatment is usually effective.  There are various treatment options.

The exact reason why these changes occur and lead to haemorrhoids forming is not clear. Some haemorrhoids seem to develop for no apparent reason. However, it is thought that the pressure in and around the anus can, in many cases, be a major factor. If the pressure in and around the anus is increased, then it is thought that this can lead to haemorrhoids developing.

About half the people in the UK develop one or more haemorrhoids at some stage. Certain situations increase the chance of haemorrhoids developing:

• Constipation: passing hard stools (faeces), and straining at the toilet. These increase the pressure in and around the veins in the anus and seem to be a common reason for haemorrhoids to develop. 
• Pregnancy: Haemorrhoids are common during pregnancy. This is probably due to pressure effects of the baby lying above the rectum and anus, and the affect that the change in hormones during pregnancy can have on the veins. 
• Ageing: the tissues in the lining of the anus may become less supportive as we get older. 
• Hereditary factors: some people may inherit a weakness of the wall of the veins in the anal region. 

What are the symptoms of haemorrhoids?

Internal haemorrhoids

These form in the back passage about 2 to 4 cm above the rim (opening) of the anus. Their severity and size are classified into grades 1 to 4.

• Grade 1 are small swellings on the inside lining of the back passage. They cannot be seen or felt from outside the anus. Grade 1 haemorrhoids are common. In some people they enlarge further to grade 2 or more. 
• Grade 2 are larger. They may be partly pushed out (prolapse) from the anus when you go to the toilet but spontaneously disappear back inside again. 
• Grade 3 hang out (prolapse) from the anus. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger. 
• Grade 4 permanently hang down from within the anus and you cannot push them back inside. They sometimes become quite large. 

Symptoms can vary. Small haemorrhoids are usually painless. The most common symptom is bleeding after going to the toilet. Larger haemorrhoids may cause a mucus discharge, some pain, irritation and itch. The discharge may irritate the skin around the anus.  When haemorrhoids are large, they can make you feel as though you have not fully emptied your rectum when you go to the toilet.

A possible complication of haemorrhoids that hang down (grade 3 to 4) is a blood clot (thrombosis) which can form suddenly within the haemorrhoid. This is uncommon, but causes intense pain if it occurs. 

What is the treatment for haemorrhoids?

Avoid constipation and straining at the toilet

Keep the faeces (bowel motion) soft, and don't strain on the toilet. You can do this by the following:

Eat plenty of fibre

Such as fruit, vegetables, cereals, wholemeal bread, etc

Have lots to drink

Adults should aim to take in at least two litres of liquid per day. Some of this can be in drink form but the rest should be within the diet. You will pass much of the fluid as urine, but some is passed out in the gut and softens the faeces. Most sorts of drink will do, but alcoholic and caffeinated drinks can be dehydrating. 

Fibre supplements

If a high fibre diet is not helping, you can take bran, or other fibre supplements ('bulking agents') such as Fybogel or Movicol. In addition, there are stimulant laxatives available such as Senna which may also be of use. You can buy these at pharmacies or get them on prescription. 

Avoid painkillers that contain codeine

Co-codamol and Tramodol are painkillers which contain codeine and are a common cause of constipation. 

Toileting

Go to the toilet as soon as possible after feeling the need. Some people suppress this feeling and plan to go to the toilet later. This may result in harder faeces forming which are then more difficult to pass. Do not strain on the toilet. Haemorrhoids may cause a feeling of a lump in the rectum and it is tempting to strain at the end to try and empty the rectum further. Resist this. Do not spend too long on the toilet which may encourage you to strain, (for example, do not read whilst on the toilet). 

The above measures will often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small and non-prolapsing haemorrhoids (grade 1). Small grade 1 haemorrhoids often settle down over time. 

Ointments, creams, and suppositories

Various preparations and brands are commonly used: they do not 'cure' haemorrhoids but may ease symptoms such as discomfort and itch.

• A bland soothing cream, ointment, or suppository may ease discomfort. Several brands are available without a prescription. Ask a pharmacist to advise. Follow the instructions on the packet on how to use. 
• One that contains an anaesthetic may ease pain better. You should only use one of these for short periods at a time (5-7 days). If you use it for longer, the anaesthetic may irritate or sensitise the skin around the anus. A pharmacist can advise. 
• One that contains a steroid may be advised by a doctor if there is a lot of inflammation around the haemorrhoids. Steroids reduce inflammation and may help to reduce any swelling around a haemorrhoid. This may help to ease itch and pain. You should not normally use a steroid cream or ointment for longer than one week at a time. 
• Very painful prolapsed haemorrhoids are uncommon. The pain may be eased by an ice pack pressed on for 15-30 minutes. Strong painkillers may be needed. 
• Haemorrhoids of pregnancy usually settle after the birth of the child. Treatment is similar to the above. 

Banding treatment

Banding is a common treatment for grade 2 and 3 haemorrhoids. It may also be done to treat grade 1 haemorrhoids which have not settled with the measures described above (such as an increase in fibre).

This procedure is usually done by a surgeon in an outpatient clinic. A haemorrhoid is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid which then 'dies' and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.

Banding of internal haemorrhoids is usually painless as the base of the haemorrhoid originates above the anal opening - in the very last part of the gut where the gut lining is not sensitive to pain. Up to three haemorrhoids may be treated at one time using this method.

In about 8 in 10 cases, the haemorrhoids are 'cured' by this technique. In about 2 in 10 cases, the haemorrhoids recur at some stage. You can, however, have a further banding treatment if this occurs. Haemorrhoids are less likely to recur after banding if you do not become constipated and do not strain on the toilet (as described above).

A small number of people have complications following banding such as bleeding, urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid.

Banding does not work in a small number of cases and you may be offered an operation. This is usually carried out under some form of anaesthetic which your surgeon will discuss with you.

Haemorrhoidectomy (the traditional operation)

An operation to cut away the haemorrhoid(s) is an option to treat grade 4 haemorrhoids, and for grade 2 and 3 haemorrhoids not successfully treated by banding or other methods. The operation is done under general anaesthetic and is usually successful; however, it can be quite painful in the days following the operation.

Haemorrhoidal artery ligation, HALO procedure

In this procedure, the small arteries that supply blood to the haemorrhoids are tied (ligated). This causes the haemorrhoid(s) to shrink. The lining of the lower bowel, (rectum) is then stitched up inside to stop the pile prolapsing through the anus. This procedure is not usually painful and is gaining in popularity as a treatment option.

Stapled haemorrhoidectomy

Although the name of this procedure implies that the haemorrhoids are removed, (cut out), this is not so. What happens in this procedure is a circular stapling 'gun' is used to cut out a circular section of the lining of the anal canal above the haemorrhoids. This has an effect of pulling the haemorrhoids back up the anal canal. It also has an effect of reducing the blood supply to the haemorrhoids which shrink as a consequence. Because the 'cutting' is actually above the haemorrhoids, it is usually a less painful procedure than the traditional operation to remove the haemorrhoids.

Benefits of surgery

Surgery is usually recommended when other measures have failed. It is often reserved for Grade 3 or 4 haemorrhoids which tend to cause more symptoms or where bleeding is regular and heavy.

Risks of surgery

The commonest symptom after surgery is pain. Occasionally bleeding can occur within the first 48 hours and if it is heavy, a return to theatre may be necessary. Other, much less frequent complications can include:

• Infection less than 2%
• Stenosis, (narrowing of the anus), less than 1%
• Incontinence (lack of control due to damage of the muscle around the anus),  less than 1%
• Recurrence of the haemorrhoids; about 1 in 20 people will develop haemorrhoids again after surgery

After surgery

You will be advised to avoid constipation and straining. An antibiotic, Metronidazole, is often prescribed to help relieve the pain along with simple painkillers and a laxative.

You will be followed up in the outpatient clinic at 6 – 8 weeks and examined to ensure that the site of surgery has healed.

Contact information

If you have any questions or queries please do not hesitate to telephone either:

Ward 2 01942 264256 

or 

Ward 3 at Leigh Infirmary 01942 264260

Or if you were admitted to RAEI, Wigan, contact the ward you were admitted to by telephoning the switchboard 01942 244000.