Haemorrhoids (Piles)

Haemorrhoids (piles) are 'anal cushions' present in the anal canal. For a variety of reasons, these cushions can enlarge and then protrude through the anal opening. The following conditions can predispose to the development of haemorrhoids:

• Irregular bowel movements: constipation or diarrhoea
• Low fibre diets
• Chronic cough
• Straining to pass urine
• Pregnancy
• Obesity and lack of exercise

Haemorrhoids can occur internally (inside the anus) or externally (outside the anus). Internal haemorrhoids develop 2-4cm above the opening of the anus. They can be classified depending on their size and severity. Internal haemorrhoids are classified as follows:

• First degree
  small swellings that develop on the inside lining of the anus and are not visible from outside the anus
• Second degree
  larger swellings that may come out of your anus when you go to the toilet before disappearing inside again
• Third degree
  one or more small, soft lumps that hang down from the anus and can be pushed back inside
• Fourth degree
  larger lumps that hang down from the anus and cannot be pushed back inside

Haemorrhoids that are external andassociated with blood clots beneath the skin are known as perianal haematomas. They are less common than internal haemorrhoids and develop on the outside edge of the anus. They can also be severely painful.

What are the symptoms of haemorrhoids?

Haemorrhoids can lead to the following symptoms/complications:

• Feeling of a mass protruding through the anus
• Mucous (slimy) discharge
• Itchiness / redness around the anus (pruritis ani)
• Faecal incontinence (inability to control stool)
• Bleeding: usually bright red blood that coats outside of normal stool (hematochezia) or blood on toilet paper. Many other conditions of the colon and rectum (such as cancer) can also cause rectal bleeding which makes it imperative for the surgeon to investigate all cases of rectal bleeding thoroughly taking into account your age and other symptoms
• Pain that occurs when passing stool. This is the most common reason why a surgeon would be consulted. Usually secondary to a blood clot forming in a pile (thrombosis)

What does the treatment of haemorrhoids entail?

Treatment of haemorrhoids depends on the size of the haemorrhoids and the symptoms they produce. To treat haemorrhoids, Dr Cooper may recommend the following:

• Conservative/medical management:
  Conservative treatment typically consists of a diet rich in dietary fiber, increased intake of oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID’s), saltwater baths and rest. The surgeon may also prescribe ointments and creams such as “Anusol”, “Preparation H” or “Sheriproct” for relief of symptoms.
• Local non-operative therapy:
  
  • Sclerotherapy is reserved for early (1st and 2nd degree) haemorrhoids and involves Dr Cooper injecting a substance that causes shrinkage of the piles.
  • Rubber band ligation involves the surgeon placing a rubber band around the base of the pile and cutting off the blood supply. This is indicated in all degrees of internal haemorrhoids (Grade 1&2) and should be virtually painless if done correctly. Bleeding can occur on day 7-10 when the necrotic pile sloughs off.
• Operative therapy:
  
  • Excisional:
    These procedures are done in theatre, usually under full anaesthetic. They involve Dr Cooper removing all haemorrhoidal tissue (internal and external). The wounds can then be left open or closed with a suture. These procedures lead to painful wounds, and patients generally take 2 – 4 weeks to recover fully. Historically these have been the most commonly performed procedures for haemorrhoids following the failure of conservative management. However, with the introduction of Doppler-guided minimally invasive procedures such as the THD (discussed later) into Dr Cooper’s practice, the use of excisional surgery has greatly decreased and is nowadays seldomly indicated.
  • Non-excisional:
    Transanal Haemorrhoidal Dearterialization (THD) uses a doppler probe to locate the terminal branches of the haemorrhoidal arteries. Once the artery is located, the surgeon uses an absorbable suture to ligate or "tie-off" the arterial blood flow. The venous "outflow" remains to "shrink" the cushion. This is done without excision of tissue. The surgeon will then also perform a hemorrhoidopexy to repair the prolapse of the anal canal/anal cushions. Again, this is done with suture, and no excision of tissue is done. This repair restores and "lifts" the tissue back to its anatomical position. Dr Cooper performs this entire procedure above the dentate line (an area with no sensation) so that there is markedly less discomfort than with exsicional procedures. The procedure takes about 40 minutes and is offered as a day case surgery. Learn more about the procedure by watching these videos.
    The THD procedure is as effective as excisional surgery but avoids to a large extent the postoperative pain and prolonged period of wound healing associated with excisional surgery. Postoperative complications are rare and may include temporary mucous discharge and urinary retention (inability to pass urine). No serious complications have so far been reported with the THD procedure.

Video: https://www.youtube.com/watch?v=gGlvctwJVI8