Internal haemorrhoids are varices of the anus. Nearly every patient visiting our clinic with anal problems comes in complaining of “painful haemorrhoids”. They are often assigned blame for anal fissures and itching, perianal dermatitis, anal warts, fistula in ano and incontinence. Not surprisingly, only a minor percentage of these complaints are actually due to haemorrhoids. It is essential, therefore, that treatment options are only undertaken if they are truly symptomatic. The mere presence of haemorrhoids is not an indication for any therapeutic intervention.
Anatomy and Classification
Internal haemorrhoids are found in the right anterior, right posterior and left lateral positions within the anal canal. This was originally thought to be due to the terminal branching of the superior mesenteric artery; however recent studies have refuted this. The position of haemorrhoids within the anal canal however remains remarkably consistent.
Haemorrhoids can be divided into those originating above the dentate line which are termed internal, those originating below the line are termed external. External haemorrhoids or piles are rarely symptomatic unless a thrombus builds up in the plexus.
Haemorrhoids are thought to represent engorgement or enlargement of the normal fibrovascular plexus cushions lining the anal canal. It has been postulated that chronic straining secondary to either constipation, gas passing or diarrhoea results in a pathologic response in haemorrhoids.
Internal haemorrhoids are classified by history and not by physical examination.
Grading of haemorrhoids
- Grade I – bleeding without prolapse.
- Grade II – prolapse with spontaneous reduction
- Grade III – prolapse with manual reduction.
- Grade IV – incarcerated, irreducible prolapse.
This system has been in place for many years and correlates relatively well with treatment algorithms (ie Grade I and II haemorrhoids are often successfully treated by non operative means while Grade III and Grade IV haemorrhoids are more likely to require surgery).
In general, patients with varying rectal complaints seek medical attention complaining of “haemorrhoids”. True haemorrhoidal symptoms, however, are relatively specific.
There are two cardinal symptoms of internal haemorrhoids,
- rectal bleeding
- prolaps with mucosal irritation.
Patients either present with bright red blood per rectum or a prolapsing anal mass. Bleeding associated with haemorrhoids generally occurs with, or following, bowel movements, is almost universally bright red, and very commonly drips into the toilet water. Blood may also be seen while wiping after defecation. Occasionally blood may stain the underclothes if haemorrhoidal prolapse is present. Bleeding associated with haemorrhoids is rarely mixed with the stool, dark, or melanotic in nature. Rarely individuals with large chronic haemorrhoids may present with anaemia secondary to chronic blood loss.
Haemorrhoidal prolapse usually occurs in association with a bowel movement, particularly when straining is present. Haemorrhoids may also prolapse during walking or heavy lifting as a result of increased intra-abdominal pressure. The prolapse is associated with a full, uncomfortable feeling which resolves when the prolapse reduces. If incarcerated prolapse occurs then strangulation may develop. In this circumstance, patients present with extreme pain, bleeding and occasionally signs of systemic illness. These individuals may require urgent haemorrhoidectomy.
Evaluation of rectal bleeding
Anorectal bleeding is commonly associated with haemorrhoids but may certainly be a harbinger of many anorectal abnormalities including colorectal cancer. Any individual with rectal bleeding should undergo an appropriate, thoughtful workup to rule out rectal cancer. In a young individual with bleeding associated with haemorrhoidal disease and no other systemic symptoms, and no family history, perhaps rectoscopy and flexible sigmoidoscopy are all that is warranted. However, in an older individual, with either a family history of colorectal cancer, or change in bowel habits, a complete colonoscopy should be performed to rule out proximal neoplasia.
Your physician felt your haemorrhoids required one of the following treatments:
- Barron ligatures (rubber banding)–A rubber band is put around the haemorrhoid, causing it to wither and fall off over a seven- to ten-day period. Generally it takes two to four treatments three to six weeks apart to get rid of all the prolapsing internal haemorrhoids. Usually only one area, or occasionally two, is treated at a time. Remember that bleeding and prolapse will probably persist until all the haemorrhoids and prolapsing tissue have been treated.
- Laser coagulation–A light source is used to cause a small burn on the surface of the haemorrhoid, causing it to stop bleeding and shrink down to normal size.
- Injection of haemorrhoids–A liquid is injected into the haemorrhoid, stopping the bleeding and preventing it from protruding.
- Haemorrhoidal artery ligation (HAL) –A suture is made over the artery which can be located with a doppler proctoscope, stopping the bleeding and preventing it from protruding.
These treatments are only used for internal haemorrhoids.
Treatment of external haemorrhoids through surgical excision are generally somewhat more painful .
You may feel mild to moderate pain, a dull ache, or essentially nothing for the first 36 to 48 hours. A sense of urgency to have a bowel movement is normal after these treatments. If discomfort is mild, take over-the-counter medications such as Diclofenac or Ibuprofen. Do not take aspirin or products containing aspirin because they promote bleeding and gastric ulcers. If your pain is more severe, you will be given a prescription for pain medicine. Taking warm baths for 15 to 20 minutes will help relieve your discomfort.
After your treatment, it is important to keep your bowel movements soft and regular. Eat foods high in fibre and drink lots of water (6-8 glasses a day). Continue the fibre supplement recommended by your doctor. Caffeine contributes to constipation so limit your consumption of coffee, tea, colas, and chocolate.
You may continue your normal physical activities. You will be able to drive your car immediately, walk up stairs, and do normal exercise.
Causes For Concern
Call the doctor if you have any of the following problems:
- Pain that does not gradually lessen in three days
- Increasing pain several days after treatment
- Tender swelling in the anal area
- Fever or chills
- Difficulty urinating
- Severe constipation (no bowel movement for three days)
- Diarrhoea (more than three watery stools within 24 hours)
- Increased bleeding (more than one cupful)
- Three to four large bloody bowel movements within three hours
- Drainage of pus from the rectum
If your own doctor is unavailable, the doctor on call is available 24 hours a day, every day of the year. After hours, call any of our offices and the answering service will locate one of our doctors on call. In an emergency try to contact us for advice before you go to the hospital. A telephone call may save you a lot of time, discomfort and expense.