Haemorrhoids

Haemorrhoids (sometimes called piles) are normal anatomical structures that contribute to continence. They become a clinical problem when they enlarge, bleed, prolapse or cause discomfort. Symptoms are very common, affecting up to half of adults by the age of 50, and are strongly associated with constipation, straining, prolonged sitting, pregnancy and a low-fibre diet.

Haemorrhoids are classified as internal (arising above the dentate line and usually painless) or external (below the dentate line and capable of causing pain). Internal haemorrhoids are further graded from I to IV based on the degree of prolapse, which guides treatment.

Because the symptoms of haemorrhoids overlap with those of more serious conditions, a careful clinical assessment is essential before any treatment is recommended.

The most common symptom is bright red bleeding noticed on the toilet paper, in the bowl or coating the stool. Bleeding is usually painless and intermittent. Other symptoms include a sensation of fullness or prolapse after a bowel motion, itching, mucus discharge and discomfort.

Severe pain is unusual with uncomplicated internal haemorrhoids and should prompt review for other conditions such as an anal fissure or a thrombosed external haemorrhoid, which presents as a tender lump at the anal verge.

• Bright red rectal bleeding, usually painless.
• A lump or prolapse felt after bowel motions.
• Itching, irritation or mucus discharge.
• Discomfort, particularly with prolonged sitting.
• Sudden tender lump at the anus (suggests thrombosis).

Any new rectal bleeding should be reviewed by a doctor. While haemorrhoids are the most common cause, bleeding can also be due to anal fissure, inflammatory bowel disease, polyps or bowel cancer. Symptoms are never normal simply because they are common.

Patients over 45, those with a change in bowel habit, family history of bowel cancer, iron deficiency, weight loss or persistent bleeding are usually advised to have a colonoscopy to exclude other causes before symptoms are attributed to haemorrhoids alone.

Consultation begins with a careful history of symptoms, bowel habit, diet, medications and family history. Examination includes inspection of the anal area, a gentle digital rectal examination and, where appropriate, proctoscopy, a brief examination using a short instrument that allows the lower rectum and anal canal to be inspected directly.

Where there is any concern about a more serious cause of bleeding, or where surveillance is otherwise indicated, colonoscopy is arranged. The aim of assessment is to confirm the diagnosis, grade the haemorrhoids and recommend a treatment plan tailored to the severity of symptoms.

Most patients with mild to moderate symptoms improve substantially with conservative measures. A high-fibre diet, adequate fluid intake, regular physical activity and avoidance of straining are the foundation of long-term management. Stool softeners or fibre supplements such as psyllium are often recommended.

Topical treatments (including barrier creams and short courses of medicated ointments) can reduce inflammation and discomfort. Sitz baths (sitting in shallow warm water for 10 to 15 minutes) provide relief after bowel motions, particularly during flare-ups.

• Increase dietary fibre to 25 to 30 g per day.
• Drink 1.5 to 2 L of water daily.
• Avoid prolonged sitting on the toilet and straining.
• Use stool softeners or fibre supplements as advised.
• Apply topical treatments as recommended.

When conservative measures do not control symptoms, a procedure may be recommended. The choice depends on the grade of the haemorrhoids and your symptoms, and is discussed after examination. Procedures are performed under sedation in an accredited hospital or day procedure unit. Surgery is reserved for more advanced haemorrhoids or symptoms that have not responded to other treatment. The aim is lasting relief with a recovery you are prepared for.

Haemorrhoid procedures are generally safe. Minor bleeding, discomfort and difficulty passing urine in the first 24 hours are not uncommon. More significant complications (including delayed bleeding, infection or, very rarely, effects on continence) are uncommon and discussed in detail during the consent process.

Most patients return to office-based work within one to two weeks after surgery, with more strenuous activity resumed over the following weeks. Long-term outcomes are best when treatment is combined with sustained attention to diet, hydration and bowel habit.