Hemorrhoids or Piles, as they are commonly known, are one of the most common problems that have afflicted mankind since time immemorial. It is responsible for much discomfort and suffering, though hemorrhoids are seldom life threatening or serious.

Hemorrhoids DO NOT cause nor lead to cancer. What is important, is to establish if the symptoms are caused purely by hemorrhoids, and not some other more serious and sinister condition. Further investigations like a colonoscopy may be necessary in some patients to rule out other causes.

What are Hemorrhoids?

Hemorrhoids are swellings in the anal canal. They have a rich blood supply and often swell, especially in response to a bowel movement and straining. The bleeding is often bright red due to bleeding from these swellings.

The exact cause of hemorrhoids is unknown. However, there are various significant predisposing or contributory factors. The commonest factor seems to be related to straining during bowel movements. Pregnancy and childbearing are commonly cited as an originating event in women with hemorrhoids. Nevertheless, it is also common to see people with no known contributory factors having hemorrhoids.

Two types of hemorrhoids are commonly described – Internal and External Hemorrhoids.

External Hemorrhoids

External hemorrhoids usually present acutely with a painful swelling around the anus. Commonly, there is a history of a strained bowel movement, diarrhea, lifting of heavy weights, long travel journeys or heavy exercise.

These are usually described as a ‘thrombosed external hemorrhoid’ which is essentially a blood clot at the edge of the anus under the skin. Although uncomfortable, no specific treatment is required. Medication for pain and ointments may help symptoms. Thrombosed external hemorrhoids usually resolve without the need for surgery. The pain lasts for a few days, but the swelling may persist for a few weeks before it becomes smaller and resolves completely.

In some instances, where the swelling is large or very uncomfortable, surgery may be considered. In this surgery, the blood clot is evacuated by an incision. This procedure is relatively minor compared to surgery for internal hemorrhoids.

Internal Hemorrhoids

Internal hemorrhoids are much more common and seem to be related to the main arteries supplying the anal region and are commonly at the 4, 7 and 11 o’clock positions. They originate internally, above a line called the “dentate line” and are usually covered by rectal mucosa.

Many people have some degree of hemorrhoids but do not cause them any symptoms or problems. These do not usually require treatment.

The commonest symptom of internal hemorrhoids is bleeding. The bleeding from internal hemorrhoids is typically fresh red in color and usually accompanies a bowel movement or some straining. Another common symptom is prolapse, which is when a person feels a swelling protruding out from the anus. This may or may not reduce in size by itself. It may sometimes be necessary for one to manually push it back after it comes out. Pain is not a usual symptom of internal hemorrhoids. Pain usually occurs only when there is a thrombosis or hardening of the blood vessels. It also occurs when there is a prolapse that cannot be reduced. If pain is the primary symptom, another cause of the pain must be looked for and other conditions like an abscess, anal fissure, fistula, or a thrombosed external hemorrhoid must be considered. Some patients present with itch and a ‘wet’ anus. These problems are more difficult to deal with but usually are related to prolapse.

Treatment of Hemorrhoids

The treatment of hemorrhoids is, essentially, the treatment of the tolerance of symptoms!

Hemorrhoids do not really need to be treated if the patient is able to, and is willing to, tolerate the symptoms. Some patients accept the inconvenience or discomfort and live with the hemorrhoids. However, when there is excessive bleeding, then treatment is important.

The avoidance of constipation and straining on bowel movements is most important in the treatment of hemorrhoids. The ideal is to have bulky soft, well-formed stools without the need to strain to evacuate. Minor degrees of hemorrhoids will respond to increased fluid and fiber intake alone. Laxatives which may cause diarrhea may worsen hemorrhoids.

Medication

There are various sorts of medication available for hemorrhoids. There is a wide array of anal ointments and suppositories that can be obtained. These medications usually help in reducing the inflammation, swelling and discomfort. Some contain a low dose of steroids. Medications containing steroids are recommended only for short periods of use and should not be for prolonged use. Oral medications are also available for hemorrhoids. Studies that are available have shown these oral medications to be helpful in reducing the severity, and symptoms of an acute hemorrhoid attack.

Minor Office Procedures which do not require anesthesia or sedation

Many smaller hemorrhoids can be treated by painless, minor procedures. Essentially, these procedures are aimed at causing some shrinkage or fibrosis of the hemorrhoids. These procedures can be performed in the office without the need for any anesthesia and with minimal discomfort or pain.

Injection Sclerotherapy is painless and takes only about 2 – 3 mins to do. A sclerosant (chemical that will harden the pile) is injected into the hemorrhoid. The hemorrhoid will shrink after that.

Rubber Band Ligation is also easily done and is also painless. A rubber band is used to strangulate the hemorrhoid with a device inserted in the anus. After a few days, the rubber band drops off leaving a small wound. This wound eventually heals after a few weeks causing some scarring. These methods can be used with fairly good result for milder degrees of hemorrhoids.

Relatively Minor Procedures that may require some sedation/anesthesia

These procedures require some form of sedation or anesthesia as they are a bit uncomfortable to perform. However, unlike a surgical procedure, there is minimal discomfort after the procedure. These procedures are aimed at hemorrhoids that are moderate-sized for which injection or rubber band ligation may not be effective.

Among the more popular of procedures at present time is HET Bipolar System which stands for “Hemorrhoid Energy Therapy”. This is a simple procedure where a special device is inserted into the anus and the hemorrhoids are ‘heated’ up to 55 degrees C. This serves to reduce the blood supply to the hemorrhoids causing the hemorrhoids to shrink.

As some heat is applied, this procedure is best performed under some sedation. However, after the procedure is performed, there is minimal or almost no pain. There is also hardly any ‘down-time’ after the procedure. Risks are minimal. Because of the requirement for sedation and the use of a disposable device, costs are higher compared to simple injection or rubber band ligation.

Risks of the above minor procedures are of very low frequency and minimal. Some associated risks include post-procedure bleeding that may require surgical intervention, thrombosis, infection, and higher recurrence rate of hemorrhoids. However, because of the usually low risks, minimal discomfort, little or almost no ‘down-time’, these minor procedures can be recommended as an initial procedure.

Surgical Procedures

If hemorrhoids recur after minor procedures, the mainstay of a more permanent solution for larger hemorrhoids is surgery. Surgery for hemorrhoids, however, through the years has earned a bad reputation. Post-operative pain and discomfort is the most common complaint. There have been many modifications of hemorrhoid surgery made over the years to reduce the pain and discomfort that patients face.

Traditional Hemorrhoid surgery involves an Excisional Hemorrhoidectomy. This entails surgically excising (removing) the Hemorrhoids. Countless modifications of this method have been devised. The modifications range from using different cutting devices (from scissors to laser), to suturing the wounds or leaving them open. None of these modifications has stood out from the rest as being much better. However, countless patients have gone through these procedures with excellent results. Excision Hemorrhoidectomy may still be preferred, especially if there is a larger external or skin component of the hemorrhoids.

Presently, the procedure that has shown superior and excellent results, especially with respect to pain and early recovery, is Stapled Hemorrhoidectomy. Stapled Hemorrhoidectomy (Longo Hemorrhoidectomy) is a technique where a Titanium Stapling Gun is used to perform surgery. The hemorrhoids are excised in the upper part and the anal cushions are drawn back into the anal canal. Because there is no skin wound, there is less post-operative pain, and a shorter recovery period with most patients feeling rather well after 2 to 3 weeks. This procedure is mainly for internal hemorrhoids and may not be suitable if there is excess skin.

The treatment of hemorrhoids is individualized to the extent of symptoms, size and type of hemorrhoids, patients’ preferences, and expectations of outcomes. A consultation and discussion with a colorectal surgeon is required to discuss treatment options and determine the most appropriate treatment required, if any.