Haemorrhoids

What are haemorrhoids?

Haemorrhoids (also spelt hemorrhoids), or ‘piles’, are lumps that occur inside and around the anus (back passage). They are very common.

Haemorrhoids are sometimes described as ‘varicose veins’ of the anus. They happen when there is a weakness in the side of the anal canal that leads to thickening of the lining and then veins can enlarge to become a haemorrhoid, causing symptoms such as bleeding, pain and discomfort.

Haemorrhoids may be just inside (internal haemorrhoid) or outside (external haemorrhoid) the anus. Large internal haemorrhoids may protrude outside the anus (prolapse).

What are the symptoms of haemorrhoids?

If you have haemorrhoids you may notice bright red blood on the toilet paper or in the toilet when you have a bowel motion (poo). There may be some itchiness, discomfort or pain around the anus. Sometimes there can be a noticeable lump that protrudes out of the anus.

Many people experience no symptoms or very mild symptoms that disappear after a couple of days. For other people, haemorrhoids are more painful.

Internal haemorrhoids are classified into 4 different types based on their degree of prolapse (how much they protrude outside the anus and whether it is temporary or permanent).

• First degree haemorrhoids often bleed a little bit when you pass a bowel motion, but stay inside the anus and are not usually very painful.
• Second degree haemorrhoids bleed and protrude out of the anus when you pass a bowel motion. Once the bowel motion is over, they disappear back inside the anus by themselves.
• Third degree haemorrhoids have to be physically pushed back inside the anus after passing a bowel motion. They may be painful if they are large.
• Fourth degree haemorrhoids are larger lumps that protrude out of the anus permanently, and cannot be placed back inside. The blood inside these haemorrhoids may clot (thrombose) and the lumps can become very painful.

External haemorrhoids occur as a lump outside the anus. A thrombosed haemorrhoid occurs when there is a blood clot in the skin overlying the anus; this can cause severe and constant pain.

What causes haemorrhoids?

Haemorrhoids are usually caused by constipation (having hard bowel motions that are difficult to pass). Constipation causes you to strain when you go to the toilet. This puts pressure on the blood vessels in the anus, making them swell.

Other things can increase the chance you will get haemorrhoids:

• ageing
• being overweight
• having diarrhoea
• spending long periods of time on the toilet
• regularly lifting heavy objects

Haemorrhoids are particularly common during pregnancy. This is because constipation is quite common in pregnancy, but also:

• the growing baby places pressure on the abdomen
• there is more blood flowing through the body
• the hormones produced during pregnancy soften the blood vessels

Haemorrhoids may also be more common in some families than in others.

When should I see my doctor?

Haemorrhoids often go away without any treatment. However, if you notice blood when you have a bowel motion, it is important to get checked out by a doctor, to make sure your symptoms are not a sign of something more serious. The symptoms of haemorrhoids can be very similar to those of bowel cancer.

Tell your doctor if you have noticed:

• blood or mucus in your stools (poo)
• changes in your bowel habits or movements
• changes in the colour of your stools
• recent weight loss

How are haemorrhoids diagnosed?

Diagnosis of haemorrhoids usually involves an examination of the anal passage to look for any swollen blood vessels. Your doctor may conduct one of the following tests.

• Digital rectal examination, where your doctor puts on gloves and places a lubricated finger inside the back passage to gently feel for any abnormalities. This is likely to be uncomfortable but will probably not be painful.
• Proctoscopy, where your doctor examines the inside of the rectum using a proctoscope (a hollow tube with a tiny light at the end) to look for any swelling or other symptoms. Again, this may be uncomfortable but will probably not be painful.

There is no need to feel embarrassed about these tests — haemorrhoids are a common problem and your doctor is used to diagnosing and treating them.

In some cases, your doctor may refer you to a surgeon who can assess your haemorrhoids and recommend a treatment.

How are haemorrhoids treated?

Mild symptoms may go away after a few days without any special treatment. In most cases your doctor will recommend measures to relieve constipation if you have it.

If your haemorrhoids are causing you pain or discomfort, ask your doctor or chemist about medicated creams or ointments that may ease your symptoms.

Medicines

Pain and inflammation can often be relieved using over-the-counter haemorrhoid treatments from the chemist, including medicated creams, ointments and suppositories (solid medicines designed to be inserted into the anus).

If inflammation is severe, your doctor may prescribe a corticosteroid cream.

For more information about haemorrhoid medications visit the NPS MedicineWise website.

Other treatments

In some cases, other treatments may be needed. Common procedures for internal haemorrhoids include:

• Injection (sclerotherapy), where a chemical is injected into the haemorrhoid which numbs the pain, stops any bleeding and causes the haemorrhoid to decrease in size over a period of about 4 to 6 weeks.
• Rubber band ligation, where a very tight elastic band is placed around the haemorrhoid to cut off its blood supply. This causes the haemorrhoid to fall off and be passed out of the body within 7 to 10 days.

Less often, a surgical procedure called haemorrhoidectomy may be needed for third or fourth degree internal haemorrhoids, large external haemorrhoids, thrombosed haemorrhoids, or combined internal and external haemorrhoids. Here, an operation is carried out under general anaesthetic to surgically remove the haemorrhoids.

For more information about surgery for haemorrhoids visit the Colorectal Surgical Society of Australia and New Zealand website.

Can haemorrhoids be prevented?

The best way to prevent haemorrhoids is to eat a healthy, high-fibre diet, drink plenty of water and exercise regularly.

Preventing constipation

To help prevent constipation:

• eat plenty of high-fibre foods
• drink plenty of water every day
• exercise regularly
• empty your bowels when you need to — try not to ‘hang on’ to a bowel movement for too long
• avoid any medicines that can cause constipation (for example, painkillers containing codeine)
• avoid sitting on the toilet for long periods of time. (It’s also best to avoid doing activities such as puzzles, reading or playing electronic games while on the toilet as this tends to increase the amount of time you spend there and places unnecessary pressure on the blood vessels of the anus)

For more information about constipation and how to avoid it visit the Colorectal Surgical Society of Australia and New Zealand website.

Increasing your fibre intake

You can gradually increase the amount of fibre in your diet by eating foods including:

• fresh fruit and vegetables
• wholegrain breads and cereals
• nuts and seeds
• pulses (peas, beans and lentils)

Commercial fibre supplements are also available and can be useful if you think you are not getting enough of the above foods in your diet.

Make sure you increase your fibre gradually so your digestive system has time to adapt.

It’s also important to increase your fluid intake at the same time. This is because fibre in the stools acts like a sponge, absorbing moisture from the body. Try to drink lots of water. Cutting down on sugary drinks will also help you to cut down on calories that cause weight gain.

Maintaining a healthy weight

Being overweight is another factor that may contribute to the development of haemorrhoids. You can lose weight by exercising regularly, eating a low-fat diet and moderating your alcohol intake.

Complications of haemorrhoids

In most cases haemorrhoids are mild and do not cause any serious problems. Haemorrhoids are not associated with an increased risk of bowel cancer.

Sometimes complications can develop as a result of haemorrhoid surgery. These can include:

• excessive bleeding
• infection
• faecal incontinence, where you lose voluntary control over your bowel movements — this is rare, and can sometimes be corrected with another operation
• anal fistula, which is a small channel that develops between the inside of the anus and the surface of the skin near the anus

Before undergoing surgery it’s important to discuss the potential risks and benefits with your surgeon.