About haemorrhoids
Haemorrhoids, also known as piles, are swellings containing enlarged blood vessels that are found inside or around the bottom (the rectum and anus).
In many cases, haemorrhoids don’t cause symptoms, and some people don’t even realise they have them. However, when symptoms do occur, they may include:
- bleeding after passing a stool (the blood is usually bright red)
- itchy bottom
- 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 aren’t usually painful, unless their blood supply slows down or is interrupted.
Diagnosing haemorrhoids
Your GP can diagnose haemorrhoids (piles) by examining 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 of 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’ll feel for any abnormalities in your back passage. A DRE shouldn’t 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’s inserted into your anus.
This allows your doctor to see your entire anal canal (the last section of the large intestine).
GPs are sometimes able to carry out a proctoscopy. However, not all GPs have the correct training or access to the right equipment, so you may need to go to a hospital clinic to have the procedure.
Types of haemorrhoids
After you’ve had a rectal examination or proctoscopy, your doctor will be able to determine what type of haemorrhoids you have.
Haemorrhoids can develop internally or externally. Internal haemorrhoids develop in the upper two-thirds of your anal canal and external haemorrhoids in the lower third (closest to your anus). The nerves in the lower part can transmit pain messages, while the nerves in the upper part can’t.
Haemorrhoids can be further classified, depending on their size and severity. They can be:
- first degree – small swellings that develop on the inside lining of the anus and aren’t 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 can’t 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 haemorrhoids
Haemorrhoids (piles) often clear up 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.
Creams, ointments and suppositories (which you insert into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.
If more intensive treatment is needed, the type will depend on where your haemorrhoids are in your anal canal – the lower third (closest to your anus) or the upper two-thirds. The lower third contain nerves which can transmit pain, while the upper two-thirds do not.
Non-surgical treatments for haemorrhoids in the lower part of the canal are likely to be very painful, because the nerves in this area can detect pain. In these cases, haemorrhoid surgery will usually be recommended.
The various treatments for haemorrhoids are outlined below.
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).
When going to the toilet, you should:
- avoid straining to pass stools, because it may make your haemorrhoids worse
- use moist toilet paper, rather than dry toilet paper, or baby wipes to clean your bottom after passing a stool
- pat the area around your bottom, rather than rubbing it
Surgery for haemorrhoids
Surgery may be recommended if other treatments for haemorrhoids (piles) haven’t worked, or if you have haemorrhoids that aren’t 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’s usually carried out under general anaesthetic, which means you’ll be unconscious during the procedure and won’t feel any pain while it’s carried out.
A conventional haemorrhoidectomy involves gently opening the anus so the haemorrhoids can be cut out. You’ll need to take a week or so off work to recover.
You’ll 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’s 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.
Haemorrhoidal artery ligation
Haemorrhoidal artery ligation is an operation to reduce the blood flow to your haemorrhoids.
It’s usually carried out under general anaesthetic and involves inserting a small ultrasound probe into your anus. The probe produces high-frequency sound waves that allow the surgeon to locate the vessels supplying blood to the haemorrhoid.
Each blood vessel is stitched closed to block the blood supply to the haemorrhoid, which 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 haemorrhoidal artery ligation as a safe and effective alternative to a haemorrhoidectomy or stapled haemorrhoidopexy (see below). It causes less pain and, in terms of results, a high level of satisfaction has been reported.
The recovery time after having haemorrhoidal artery ligation is also quicker compared with other surgical procedures. There’s 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’s sometimes used to treat prolapsed haemorrhoids and is carried out under general anaesthetic.
The procedure isn’t carried out as often as it used to be, 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 can probably 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).
Other treatments
Other treatment options are available, including freezing and laser treatment. However, the number of NHS or private surgeons who perform these treatments is limited.
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 happen a week or so after the operation
- infection, which may lead to a build-up of pus (known as 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 more 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
