What are Haemorrhoids (piles)?

​

Haemorrhoids (Piles) are sacs consisting of blood vessel that are present in the lower part of the anus (back passage).  They are normal anatomical structures that help with continence and sensation and are important for differentiating between flatus and stool. Usually haemorrhoids are internal and therefore not visible, however they can enlarge and cause troublesome symptoms.  They can get large due to a combination of straining, pregnancy or constipation (hard stools).

​

The common symptoms are:

​

• Bleeding during bowel evacuation which is bright red. This generally drips or splashes in the bowl. It may be present on the toilet tissue only.

• Discharge from the back passage

• Prolapse: the piles slip out during bowel evacuation on straining. This is usually graded between 1 to 4.

• Pruritus i.e. itching around the back passage

• Pain: is a very uncommon feature of piles.

 

The bleeding can be alarming but is only rarely a large quantity.

 

What do I do if I have any bleeding?

 

It is important that you see your GP or inform your specialist. Bleeding may not be due to piles and therefore it is important to investigate and rule out other causes of bleeding before assuming a diagnosis of haemorrhoids and treating them.  

 

What treatment is available?

 

General Advice

 

• Increase the fibre in your diet: Increasing your intake of salads, fruit, fibre and bran (Porridge) will help to bulk and soften your stools as long as you also increase your fluid intake. Fybogel is a bulking agent that can also help. This bulks the stool and decreasing the need to straining on the toilet.

• More fluids: This is extremely important to help keep your stools soft. Fibre and bran intake alone will constipate without adequate fluid intake.

• Laxatives:  ½ - 1 sachet of Movicol/Laxido per day

• Toilet training/habit change:

  • Avoid sitting on the toilet for long periods and activities that may encourage this such as reading etc. as this can precipitate piles.

  • Avoid straining and rushing to evacuate in a hurry.

 

Alternatives to an Operation

 

These procedures that are usually carried out in the out-patient department work in about 7 out of 10 patients.

​

• Injections: Grade 1-2 haemorrhoids can be treated with an injection that is specifically injected to minimise pain and treat the haemorrhoid. This sclerosis the haemorrhoid causing it to shrink.  Sometimes may require to be repeated.

 

• Banding: Grade 2-3 haemorrhoids can have a rubber band placed around the pile in the outpatient clinic. This does not require anaesthesia. There should be little or no pain during the procedure. The band falls out in 8-10 days. There will be some discomfort for 48 hours after the banding and you will expect some bleeding after the procedure and on-off for around 4-5 days before settling. Please take paracetamol for the discomfort.

 

Potential Complications

​

1. A little discharge is normal.

2. When the bands fall-off you may have significant bleeding (1 in a 100 chance). This may require an operation to stop the bleeding

3. Any severe pain must be mentioned to your GP. There normally is a dull ache for 48 hrs.

 

What does an Operation Involve?

 

Sometimes your specialist may suggest an operation. This is usually done under a general anaesthesia (where you are asleep) but the best options will be discussed with the anaesthetist. The best operation depends on the individual patient after assessment and may include surgical excision (open haemorrhoidectomy), THD (Transanal Haemorrhoidal De-arterilisation), haemorrhoidopexy (Sutures), HALO (Haemorrhoidal Artery Ligation using a Doppler probe) Procedure or Rafaelo Procedure.  

 

Before the operation you will likely be advised to have laxatives to keep your stools soft before the operation. Ensure you tell your specialist and anaesthetist about all medication you take. You will usually also have a pre-assessment appointment to ensure you are optimised before your surgery.

 

General recommendations for all operation is to reduce or stop smoking as this decreases complications of wound infections, breakdown, chest infections and longer term health problems. Regularly exercising even leading up to your operation has shown to improve on outcomes post-operatively by leading to better ‘pre-habilitation’.

 

On the day operation day.  The procedure is usually done as a day case procedure and therefore be admitted and discharged from the hospital on the same day. After the anaesthetic, you will be given local anaesthetic to help with any pain post-operatively and may be given antibiotics.

 

 

Potential Complications

 

Complications can be both general for any operation and specific for the particular procedure.

Complications are rare but all of the potential ones are listed below.  Smaller haemorrhoids and ones amenable to THD, haemorrhoidopexy and Rafaelo Procedures have less potential complications. Your specialist will be able to go over specific ones with you.

 

General Complications:

​

1. Pain: This can be very painful following a haemorrhoidectomy (cutting away a pile), but may be the best way to treat a very large haemorrhoid. This can last 3-4 weeks and therefore following the use of local anaesthetics at the time of the operation, you should take regular pain killers and importantly keep your stools as soft as possible to avoid constipation.

2. Bleeding: Bleeding can happen for 1-2 weeks after the operation but if very large soon after the operation (less than 1 in 100 people), this may require a re-operation to stop this.

3. Infections: This usually causes a high temperature, pus from the anal passage, redness, swelling and increased pain. Antibiotics are used to treat this. It is safe to shower after 2 days following the operation.

4. Blood clots in the legs or lungs: Keeping mobile is important to prevent this along with the use of TED stockings.

 

Specific Complications:

​

1. Limited Treatment: If the haemorrhoids are very large or affecting the whole back passage area, it may be safe to only remove a limited number. This will reduce the risks of other complications outlined below.

2. Incontinence: This can happen temporarily due to swelling from healing around the back passage area. This is usually to very liquid stool or wind and usually settles after a few weeks. It is extremely rare to have more longer-term incontinence from damage to anal sphincters which the haemorrhoids have to be removed from at the time of surgery.

3. Anal Stenosis: This is narrowing of the back passage area and usually can result from too many haemorrhoids being removed at the same time.

4. Anal Fissure: This is a painful cut around the back passage area. If this occurs then usually this responds to medication and laxatives which your specialists can provide.

5. Skin Tags: This can occur after an open haemorrhoidectomy once healing has occurred.

6. Difficulty passing urine: The risks of this is higher if you already have problems passing urine before the operation. If this occurs then you may require a urinary catheter and may occur in 1 in 5 people. 

 

Recovery from the Operation

 

Following the operation, you will be wake up in recovery and usually go home the same day. You will require a responsible adult to be with you at home for the first 24hours and have access to a telephone in case you help or advice is required. It is important to continue to take regular pain killers and laxatives to avoid constipation and aid healing for several weeks. You may also be given antibiotics for 5 days following your operation.

 

Activities following surgery

For the first 24 hours following a general anaesthetic or sedation, do not drive, operative machinery, carryout dangerous activities, drink alcohol or sign legal paperwork. You can usually start driving once you can control and make an emergency stop.  It is important to be mobile to avoid blood clots and may need to wear stockings to prevent these. Depending on the type of work you do, you can usually return within 3-4 weeks.

 

You will usually have a follow-up after you operation between 4-12 weeks depending on the operation carried out.