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Piles (haemorrhoids)

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Piles (haemorrhoids)



Introduction 

Haemorrhoids, also known as piles, are swellings that contain enlarged blood vessels that are found inside or around the bottom (the rectum and anus).

Most haemorrhoids are mild and sometimes don't even cause symptoms. When there are symptoms, these usually include: 



bleeding after passing a stool (the blood will be bright red)



itchy bottom



a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool



Should I see my GP?

The symptoms of haemorrhoids often clear up on their own or with simple treatments that can be bought from a pharmacy without a prescription (see below). However, you should speak to your GP if your symptoms don't get better, or if you experience pain or bleeding.

Haemorrhoids can be easily diagnosed by a simple internal examination of your back passage.

Some people with haemorrhoids are reluctant to see their GP. However, there’s no need to be embarrassed – all GPs are used to diagnosing and treating haemorrhoids.

What causes piles?

The exact cause of haemorrhoids is unclear, although they are associated with increased pressure in the blood vessels in and around your anus.

Most cases are thought to be caused by excessive straining on the toilet, due to prolonged constipation, often resulting from a lack of fibre in your diet.

Things that can increase your risk of haemorrhoids include:



being overweight



being over the age of 45



having a family history of haemorrhoids



Preventing and treating piles

Haemorrhoid symptoms often settle down after a few days without treatment. Haemorrhoids that occur due to pregnancy usually get better after you give birth.

However, making lifestyle changes to reduce the strain on the blood vessels in and around your anus is often recommended. These can include:



gradually increasing the amount of fibre in your diet – good sources of fibre include fruit, vegetables, wholegrain rice, wholewheat pasta and bread, seeds, nuts and oats



drinking plenty of fluidparticularly water, but avoiding or cutting down on caffeine and alcohol



not delaying going to the toilet – ignoring the urge to empty your bowels can make your stools harder and drier, which can lead to straining when you do go to the toilet



avoiding medication that causes constipation – such as painkillers that contain codeine



losing weight if you are overweight



exercising regularly– this can help prevent constipation, reduce your blood pressure and help you lose weight



These measures can also reduce the risk of haemorrhoids returning, or even developing in the first place.

Medication that you apply directly to your back passage (topical treatments) or tablets bought from a pharmacy or prescribed by your GP may ease your symptoms and make it easier for you to pass stools.

If your haemorrhoid symptoms are more severe, there are a number of treatment options available. For example, banding is a non-surgical procedure where a very tight elastic band is put around the base of the haemorrhoid to cut off its blood supply. The haemorrhoid should fall off after about a week.

Surgery under general anaesthetic (where you are asleep) is sometimes used to remove or shrink large or external haemorrhoids.


 






 

 

 

 


 



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Symptoms of piles (haemorrhoids) 

Most cases of piles (haemorrhoids) are mild, and the symptoms often disappear on their own after a few days. 

Some people may not even realise they have haemorrhoids, as they do not experience symptoms.

However, when symptoms do occur they may include: 



bleeding after passing a stool (the blood will be bright red)



itchiness around your anus (the opening where stools leave the body)



a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool



a mucus discharge after passing a stool 



soreness, redness and swelling around your anus



Haemorrhoids are not usually painful, unless their blood supply slows down or is interrupted.

When to seek medical advice

If you have persistent or severe symptoms of haemorrhoids, see your GP.

You should always get any rectal bleeding checked out, so your doctor can rule out more potentially serious causes.

Causes of piles (haemorrhoids) 

The exact cause of piles (haemorrhoids) is unclear, but many cases are thought to be linked to increased pressure in blood vessels in and around the anus.

This pressure can cause theblood vessels in your back passage to become swollen and inflamed.

Who's at risk

Factors that increase your chance of getting haemorrhoids include:



being overweight or obese



persistent constipation, often due to a lack of fibre in your diet



prolonged diarrhoea



regularly lifting heavy objects  



a persistent cough or repeated vomiting



prolonged sitting down



being pregnant, which can place increased pressure on your pelvic blood vessels, causing them to enlarge (the haemorrhoids will usually improve after you give birth)



being over 45 years of age – as you get older, your body's supporting tissues get weaker, increasing your risk of haemorrhoids



a family history of haemorrhoids, which could mean you're more likely to get them 



Diagnosing piles (haemorrhoids) 

Piles (haemorrhoids) can be easily diagnosed by your GP. To do so, they will examine your back passage to check for swollen blood vessels.

Some people with haemorrhoids are reluctant to see their GP. However, there’s no need to be embarrassed – all GPs are used to diagnosing and treating piles.

It's important to tell your GP about all your symptoms – for example, tell them if you've recently lost a lot of weight, if your bowel movements have changed or if your stools have become dark or sticky.

Rectal examination

Your GP may examine the outside of your anus to see if you have visible haemorrhoids, and they may also carry out an internal examination called a digital rectal examination (DRE).

During a DRE, your GP will wear gloves and use lubricant. Using their finger, they will feel for any abnormalities in your back passage. A DRE should not be painful, but you may feel some slight discomfort. 

Proctoscopy

In some cases, further internal examination using a proctoscope may be needed. A proctoscope is a thin hollow tube with a light on the end that is inserted into your anus.

This allows your doctor to see your entire anal canal (the last section of the large intestine). During the procedure, your doctor may also take a small tissue sample (biopsy) from inside your rectum so it can be tested in a lab.

A proctoscopy can sometimes be carried out by your GP. However, not all GPs have the correct training or access to the right equipment, so you may need to go to a specialist.

Types of haemorrhoids

After a rectal examination or proctoscopy, your doctor can determine what type of haemorrhoid you have.

The two main types of haemorrhoids are those that develop internally or externally.

Internal haemorrhoids develop above a visible line called the dentate line, and external haemorrhoids are below it. This line marks where the nerves in the anal canal can detect pain. The nerves below the dentate line can detect and transmit pain messages, while the nerves above it can't.

Haemorrhoids can be further classified, depending on their size and severity:



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 (prolapsing and reducible)



fourth degree – larger lumps that hang down from the anus and cannot be pushed back inside (irreducible)



It's useful for doctors to know what type and size of haemorrhoid you have, as they can then decide on the best treatment.

Treating piles (haemorrhoids) 

Piles (haemorrhoids) often go away by themselves after a few days. However, there are many treatments that can reduce itching and discomfort.

Making simple dietary changes and not straining on the toilet are often recommended first.

If more invasive treatment is needed, the type of treatment used will depend on where your haemorrhoids are, particularly if they have developed above, on or below the dentate line. This is a line in the anal canal that separates the areas where the nerves can and can't transmit pain messages.

Non-surgical treatments are likely to be very painful for haemorrhoids that have developed on or below the dentate line, as the nerves in this area can detect pain. In these cases, haemorrhoid surgery will normally be recommended.

Dietary changes and self-care

If constipation is thought to be the cause of your haemorrhoids, you need to keep your stools soft and regular, so that you don't strain when passing stools.

You can do this by increasing the amount of fibre in your diet. Good sources of fibre include wholegrain bread, cereal, fruit and vegetables.

You should also drink plenty of water and avoid caffeine (found in tea, coffee and cola).

Follow the below advice when going to the toilet:



avoid straining to pass stools, as this may make your haemorrhoids worse



after passing a stool, use moist toilet paper or baby wipes to clean your bottom, rather than dry toilet paper



pat the area around your bottom, rather than rubbing it



Medication

Over-the-counter topical treatments

Various creams, ointments and suppositories (which are inserted into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.

These medicines should only be used for five to seven days at a time. If you use them for longer, they may irritate the sensitive skin around your anus. Any medication should be combined with the diet and self-care advice detailed above.

There is no evidence that one method is more effective than another. Ask your pharmacist for advice about which product is most suitable for you. 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.

Corticosteroid cream

If you have severe inflammation in and around your back passage, your GP may prescribe corticosteroid cream, which contains steroids.

You should not use corticosteroid cream for more than a week at a time, as it can make the skin around your anus thinner and the irritation worse.

Painkillers

Common painkilling medication, such as paracetamol, can relieve the pain of haemorrhoids. However, you should avoid codeine painkillers, as they can cause constipation.

Products that contain local anaesthetic (painkilling medication) may also be prescribed by your GP to treat painful haemorrhoids. Like over-the-counter topical treatments, these should only be used for a few days, as they can make the skin around your back passage more sensitive.

Laxatives

If you are constipated, your GP may prescribe a laxative. This is a type of medication that can help you empty your bowels.

Non-surgical treatments

If dietary changes and medication don't help, your GP may refer you to a specialist. They can confirm whether you have haemorrhoids and recommend appropriate treatment.

If your haemorrhoids are found to have developed above the dentate line, non-surgical procedures such as banding and sclerotherapy may be recommended.

Banding

Banding is a procedure that involves placing a very tight elastic band around the base of your haemorrhoids, to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment.

Banding is usually a day procedure, without the need for an anaesthetic, and most people can return to their normal activities the next day. 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 needed.

You may not realise that your haemorrhoids have fallen off, as they should pass out of your body when you go to the toilet. If you notice some mucus discharge within a week of the procedure, it usually means the haemorrhoid has fallen off.

Directly after the procedure, you may notice blood on the toilet paper after going to the toilet. This is normal, but there should not be a lot of bleeding. If you pass a lot of bright red blood or blood clots (solid lumps of blood), go to your nearest accident and emergency (A&E) department immediately.

Ulcers (open sores) can occur at the site of the banding, although these usually heal without needing treatment.

Injections (sclerotherapy)

A treatment called sclerotherapy may be used as an alternative to banding.

During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the 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 may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.

Infrared coagulation

Infrared coagulation is also sometimes used to treat haemorrhoids.

During the procedure, a special device that emits infrared light is used to burn the haemorrhoid tissue and cut off their blood supply.

A similar procedure can also be carried out using an electric current instead of infrared light. This is known as diathermy or electrotherapy.

Surgery

Although most haemorrhoids can be treated using the methods described above, around 1 in every 10 people with the condition will eventually need surgery.

Surgery is particularly useful for haemorrhoids that have developed below the dentate line because, unlike non-surgical treatments, anaesthetic is used to ensure you don’t feel any pain as they are carried out.

There are many different types of surgery that can be used for haemorrhoids, but they usually involve either removing the haemorrhoids or reducing their blood supply, causing them to shrink.

Surgery for piles (haemorrhoids) 

Surgery may be recommended if other treatments for piles (haemorrhoids) have not been successful, or if you have haemorrhoids that are not suitable for non-surgical treatment.

There are many different surgical procedures for piles. The main types of operation are described below.

Haemorrhoidectomy

A haemorrhoidectomy is an operation to remove haemorrhoids. It is usually carried out under general anaesthetic, which means you will be asleep during the procedure and won't feel any pain while it is carried out.

A conventional haemorrhoidectomy involves gently opening the anus so the haemorrhoids can be cut out. You will need to take a week or so off work to recover.

You will probably experience significant pain after the operation, but you will be given painkillers. You may still have pain a few weeks after the procedure, which can also be controlled with painkillers. Seek medical advice if you have pain that continues for longer.

After having a haemorrhoidectomy, there is around a 1 in 20 chance of the haemorrhoids returning, which is lower than with non-surgical treatments. Adopting or continuing a high-fibre diet after surgery is recommended to reduce this risk.

Transanal haemorrhoidal dearterialisation (THD) or haemorrhoidal artery ligation (HALO)

Transanal haemorrhoidal dearterialisation (THD) or haemorrhoidal artery ligation (HALO) is an operation to reduce the blood flow to your haemorrhoids.

It's usually carried out under general anaesthetic and involves inserting a small device, which has a Doppler ultrasound probe attached, into your anus. This probe produces high-frequency sound waves that allow the surgeon to locate the blood vessels in and around your anal canal. These blood vessels supply blood to the haemorrhoid.

Each blood vessel is then stitched closed, to block the blood supply to the haemorrhoid. This causes the haemorrhoid to shrink over the following days and weeks. The stitches can also be used to reduce prolapsing haemorrhoids (haemorrhoids that hang down from the anus).

The National Institute for Health and Care Excellence (NICE) recommends this treatment as an effective alternative to a haemorrhoidectomy or stapled haemorrhoidopexy (see below). The procedure causes less pain and, in terms of results, a high level of satisfaction has been reported. Most people are able to return to their normal activities much sooner than with other surgical procedures.

There is a low risk of bleeding, pain when passing stools or the haemorrhoid becoming prolapsed after this procedure, but these usually improve within a few weeks.

Stapling

Stapling, also known as stapled haemorrhoidopexy, is an alternative to a conventional haemorrhoidectomy. It is sometimes used to treat prolapsed haemorrhoids and is carried out under general anaesthetic.

This procedure is not carried out as often as it used to, because it has a slightly higher risk of serious complications than the alternative treatments available.

During the operation, part of the anorectum (the last section of the large intestine), is stapled. This means the haemorrhoids are less likely to prolapse and it reduces the supply of blood to the haemorrhoids, which causes them to gradually shrink.

Stapling has a shorter recovery time than a traditional haemorrhoidectomy, and you will usually be able to return to work about a week afterwards. It also tends to be a less painful procedure.

However, after stapling, more people experience another prolapsed haemorrhoid compared with having a haemorrhoidectomy. There have also been a very small number of serious complications following the stapling procedure, such as fistula to vagina in women (where a small channel develops between the anal canal and the vagina) or rectal perforation (where a hole develops in the rectum).

General risks of haemorrhoid surgery

Although the risk of serious problems is small, complications can occasionally occur after haemorrhoid surgery. These can include:



bleeding or passing blood clots, which may occur a week or so after the operation



infection, which may lead to a build-up of pus (an abscess) – you may be given a short course of antibiotics after surgery to reduce this risk



urinary retention (difficulty emptying your bladder)



faecal incontinence (the involuntarily passing of stools) 



anal fistula (a small channel that develops between the anal canal and surface of the skin, near the anus)



stenosis (narrowing of the anal canal) – this risk is highest if you have treatment on haemorrhoids that have developed in a ring around the lining of the anal canal



These problems can often be treated with medication or further surgery. Ask your surgeon to explain the risks in more detail before deciding to have surgery.

When to seek medical advice

Seek medical advice from the hospital unit where the surgery was carried out, or from your GP, if you experience:



excessive bleeding



a high temperature (fever)



problems urinating



worsening pain or swelling around your anus










Piles (haemorrhoids)