Haemorrhoids

Haemorrhoids (also known as piles) is a condition where the blood vessels in and around the anus become swollen and inflamed. The anus is the opening of your back passage where stools are passed when you go to the toilet.

Haemorrhoids are caused by an increase pressure in the blood vessels in the anus and rectum (end part of the large bowel). This is often because of straining when trying to pass a stool.

Anyone at any age can be affected by haemorrhoids. They are very common, with about 50% of people experiencing them at some time in their life. However, it is usually more common in elderly people and during pregnancy.

Symptoms of haemorrhoids often begin with an itchy feeling around the anus, but can become painful and lead to bleeding. The condition is not very serious and can be successfully treated.

Types of haemorrhoids

There are two types of haemorrhoids - internal and external.

Internal haemorrhoids occur inside the anus. The swollen blood vessels remain inside your anus and do not usually cause pain. The size of internal haemorrhoids are classified using a grading system from 1 to 4.

• Grade 1 haemorrhoids are often small swellings inside the lining of your anus. They cannot be seen and are very common. In some cases they will enlarge to grade 2 haemorrhoids.
• Grade 2 haemorrhoids are larger in size but are still within your anus. In some instances they become pushed out when you pass a stool, but will return inside immediately after.
• Grade 3 haemorrhoids appear outside your anus. These are also referred to as prolapsed haemorrhoids. Grade 3 haemorrhoids protrude outside your anus and often decrease in size naturally. In most cases these haemorrhoids can be pushed back inside the anus with your fingers.
• Grade 4 haemorrhoids remain outside your anus permanently. They cannot be pushed back inside and will need to be treated by your GP.

External haemorrhoids occur outside your anus. They are also known as perianal haematoma.

You may feel a small lump outside your anus that becomes increasingly itchy. This type of haemorrhoid is less common and will require immediate treatment.

It is possible to have both internal and external haemorrhoids at the same time, but this is rare.

Haemorrhoids (piles) are not considered dangerous or life threatening. In most cases, symptoms of haemorrhoids will go away naturally within a few days.

The majority of people may not even realise they have haemorrhoids as they don't experience any symptoms.

The symptoms of haemorrhoids include:

• itchiness around your anus,
• discomfort around your anus, such as feeling sore or it being visibly red,
• excessive straining when passing a stool,
• bleeding after you have passed a stool,
• discharge of mucus present after passing a stool,
• pain while passing a stool, and
• feeling like your bowels are still full and need emptying.

You may also get a hard lump around your anus. This lump is made up of blood clots forming in a small area (known as a thrombosed external haemorrhoid) and can become very painful.

Speak with your GP if you experience pain or discomfort as a result of haemorrhoids. It's also best to speak with your GP if you have blood or mucus in your stools as this can be a sign of another health condition.

Haemorrhoids (piles) occur due to an increase pressure in the blood vessels in your anus (opening of your back passage where stools are passed) and rectum (end part of the large bowel).

This is often because of straining when trying to pass a stool. The blood vessels in and around your anus begin to become swollen and inflamed.

Others factors that can increase your chances of having haemorrhoids include:

• being overweight,
• being constipated on a regular basis,
• regularly lifting heavy objects, and
• if you are over the age of 50.

Constipation

Lack of fibre in your diet is a common cause of constipation. This can lead to straining on the toilet.

Haemorrhoids tend to improve once your constipation has passed.

Diarrhoea

Haemorrhoids can also be as a result of prolonged diarrhoea.

Pregnancy

Pregnancy can cause haemorrhoids. This is because during pregnancy you experience increased abdominal pressure on your pelvic blood vessel, due to the developing baby. The result is that your blood vessels enlarge.

After giving birth most women find their haemorrhoids disappear naturally.

Haemorrhoids (piles) are easily diagnosed by your GP. They will examine your anus to check for swollen blood vessels.

It's important to inform your GP of the following information:

• Have you recently lost a lot of weight?
• Have your bowel movements changed?
• What colour are your stools?
• Do your stools contain any blood?
• Is there mucus present in your stools?

If your haemorrhoids are internal your GP may perform a digital rectal examination. They will wear gloves, and using lubricant to feel for any internal abnormalities.

If a closer examination is still necessary your GP may use an anoscope. This is a hollow tube fitted with a light on the end. An anoscope makes it possible for your GP to see your entire anal canal. It also allows your GP to take a small tissue sample from inside your rectum, if laboratory tests need to be carried out.

It is important to see your GP if you experience bleeding from your anus. If you are in doubt call NHS Direct on 0845 46 47 for advice.

The treatment of your haemorrhoids depends on the severity of your symptoms. Treatment for haemorrhoids is not always required. Sometimes, symptoms may disappear within a few days.

Dietary changes

If your haemorrhoids are as a result of constipation you should try to keep your stools soft and regular. By making changes to your diet it's likely you will avoid straining whilst on the toilet.

Firstly, increase the amount of fibre in your diet. This could include more wholemeal foods, such as bran and cereal. Vegetables are also a good source of fibre.

Secondly, try to drink at least 2 litres (8 glasses/12 cups) of water a day. Remember that caffeine and alcoholic drinks will have the reverse effect and actually dehydrate you.

For more detailed information about the benefits of dietary changes see the 'prevention' section.

Self care

Pain from haemorrhoids can be eased by sitting in a bath of warm water. This should reduce the itchiness around your anus.

You could also use cold compresses, such as ice packs, to ease pain and reduce swelling. Hold the ice pack against your anus for no more than 30 minutes at a time to relieve pain.

Also, instead of using dry paper toilet roll after passing a stool, try cleaning your anus with moist toilet paper. Using baby wipes can also help ease any discomfort that occurs after passing a stool.

Creams, ointments and suppository

Creams, ointments and suppository can not cure your haemorrhoids, but can help sooth any inflammation around your anus.

There are several brands of creams and ointments that you can buy over-the-counter (OTC), but it's best to speak with your pharmacist (chemist) for advice.

Creams that contain anaesthetic can help to ease your pain, and sooth burning or itchy skin. However, these creams should only be used over a short period of time, for example for no longer than seven days. If anaesthetic creams are used over a longer length of time, they can irritate your skin further.

Your GP can also prescribe you with creams to relieve irritation around your anus. These can include:

• bismuth oxide,
• bismuth subgallate,
• peru balsam,
• zinc oxide, and
• witch-hazel.

Creams containing steroids can also be prescribed to reduce inflammation and swelling around your anus. These should not be used for longer than a week.

Always read the patient information leaflet (PIL) that comes with your medicine before using it. Alternatively ask your pharmacist for further information.

Banding

A treatment involving a special type of rubber band may be carried out to make haemorrhoids smaller. This is known as banding. Your GP will place a rubber band around the base of the haemorrhoid inside your anus, and it will eventually decrease in size.

This is because the band cuts off the circulation of blood within a haemorrhoid, making it shrink away. A scar at the base of the haemorrhoid will heal naturally.

This is a common treatment for grade 2 or 3 internal haemorrhoids. Because internal haemorrhoids are often painless, up to three can be treated at a time.

Sclerotherapy

Your GP may also recommend treating your haemorrhoids using sclerotherapy. This is a procedure that involves a chemical solution being injected around the blood vessels in your anus. This solution shrinks the haemorrhoids, which will eventually drop off.

The chemical solution can also be injected into the haemorrhoids directly to speed up the process.

Sclerotherapy is a common treatment for grade 2 or 3 internal haemorrhoids, and is often used as an alternative to banding.

In the first 48 hours after the treatment you may experience a small amount of bleeding.

Infrared coagulation

Infrared coagulation (also know as infrared light) can be used to treat your haemorrhoids.

A special device is used to burn the tissue of the haemorrhoid. One or two bursts of infrared lights can cut off the circulation to small internal haemorrhoids, such as grade 1 or 2.

Surgery

Surgery is often used to treat internal haemorrhoids that are either very large or are grade 4 (meaning they protrude outside your anus permanently). The haemorrhoids will be cut away during the surgery.

An operation can also be performed if banding on grade 2 or 3 internal haemorrhoids is not successful. However, surgery on small internal haemorrhoids is often only recommended if they are causing you persistent pain.

Large internal or external haemorrhoids can also be removed by performing an operation called a haemorrhoidectomy. You will be under general anaesthetic during the surgery. It involves gently stretching your anus whilst the haemorrhoids are cut away.

Haemorrhoids can not always be prevented. However you can reduce your chances of getting haemorrhoids by maintaining regular bowel movements. Your stools should also be soft and easy to pass.

It's also recommended that you empty your bowels as and when you need to. By delaying when you pass your stool, this could mean the stool becomes harder and drier. As a result this increases the likelihood of pressure building up in your anus and rectum blood vessels.

Fibre

Eating a high fibre diet can help to reduce your chances of having haemorrhoids. This is because fibre encourages regular bowl movements.

Good sources of fibre are fruits, vegetables, and whole grains. In addition, your GP may suggest you take a bulk stool softener or a fibre supplement such as psyllium (brand name Metamucil) or methylcellulose (brand name Citrucel).

Water

Drinking at least 2 litres (8 glasses or 12 cups) of fluid a day can help make your stools softer. This will then make it easier for you to pass a stool, avoiding the need to strain.

Drinking plenty of water is preferable. However you might start by cutting down the amount of caffeine and alcohol you consume. Remember that both caffeine and alcohol drinks will dehydrate you.

Lose weight

Being overweight can be a contributing factor to having haemorrhoids. By losing weight you will reduce your chances of having haemorrhoids.

Exercise

Exercising regularly can prevent constipation. By staying active you will be reducing the amount of pressure in your blood vessels.

Exercise will also help you to lose weight and stay in shape.

Other considerations

Try to avoid medication that can cause constipation. For example, painkillers that contain codeine such as co-codamol.

If banding is used to treat your haemorrhoids you may experience bleeding or urinary problems after the procedure.

Infections or ulcers can also occur where the banding took place. However, these complications are rare and can be easily treated.

CLINICAL KNOWLEDGE SUMMARIES (2007). Hemorrhoids. Clinical Knowledge Summaries. Available from http://www.cks.library.nhs.uk/haemorrhoids [accessed 12 February 2008]

JUSTIN DAVIS, R (2006) Hemorrhoids. American Family Physician. 74 (7), 180-183. Available from http://www.aafp.org/afp/20061001/bmj.html [accessed 12 February]