Haemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. Although haemorrhoids are a common condition diagnosed in clinical practice, many patients are too embarrassed to ever seek treatment. Consequently, the true prevalence of pathologic haemorrhoids is not known. In addition, although haemorrhoids are responsible for a large portion of anorectal complaints, it is important to rule out more serious conditions, such as other causes of gastrointestinal (GI) bleeding, before reflexively attributing symptoms to haemorrhoids.
Many patients and clinicians believe that haemorrhoids are caused by chronic constipation, prolonged sitting, and vigorous straining, little evidence to support a causative link exists. Some of these potential aetiologies are briefly discussed below.
Decreased venous return
Most authors agree that low fibre diets cause small calibre stools, which result in straining during defecation. This increased pressure causes engorgement of the haemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause haemorrhoidal problems, presumably by means of the same mechanism, which is thought to be decreased venous return. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged haemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life.
Straining and constipation
Straining and constipation have long been thought of as culprits in the formation of haemorrhoids. This may or may not be true. Patients who report haemorrhoids have a canal resting tone that is higher than normal. Of interest, the resting tone is lower after haemorrhoidectomy than it is before the procedure. This change in resting tone is the mechanism of action of Lord dilatation, a surgical procedure for anorectal complaints that is most commonly performed in the United Kingdom.
Pregnancy clearly predisposes women to symptoms from haemorrhoids, although the aetiology is unknown. Notably, most patients revert to their previously asymptomatic state after delivery. The relationship between pregnancy and haemorrhoids lends credence to hormonal changes or direct pressure as the culprit.
Portal hypertension and anorectal varices
Portal hypertension has often been mentioned in conjunction with haemorrhoids. However, haemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than in those without it.
Other risk factors
Other risk factors historically associated with the development of hemorrhoids include the following:
- Lack of erect posture
- Familial tendency
- Higher socioeconomic status
- Chronic diarrhea
- Colon malignancy
- Hepatic disease
- Elevated anal resting pressure
- Spinal cord injury
- Loss of rectal muscle tone
- Rectal surgery
- Anal intercourse
Complication of Haemorrhoids
- Pruritis ani
- Minor leakage (incontinence)
- Secondary infection
- The recurrence rate with nonsurgical techniques is 10-50% over a 5-year period, whereas that of surgical haemorrhoidectomy is less than 5%.
Grading or Staging of Haemorrhoids
Most clinicians use the grading system proposed by Banov et al in 1985, which classifies internal haemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches, as follows.
- Grade/Stage I haemorrhoids project into the anal canal and often bleed but do not prolapse
- Grade/Stage II haemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases (ie, return to their resting point by themselves)
- Grade/Stage III haemorrhoids protrude spontaneously or with straining and require manual reduction (ie, require manual effort for replacement into the anal canal)
- Grade/Stage IV haemorrhoids chronically prolapse and cannot be reduced; these lesions usually contain both internal and external components and may present with acute thrombosis or strangulation
What are the treatment options?
Sclerotherapy: a chemical (phenol in almond oil) is injected into the blood vessels that ‘service’ the haemorrhoids causing the vessels to shrink and seal shut.
Rubber band ligation: a tight rubber band is wrapped around the haemorrhoids to cut off their blood supply
Haemorrhoidectomy: often used to treat irreducible or prolapsed haemorrhoids. The patient is placed under general anaesthetic. The surgeon inserts a special device into the anus so that the haemorrhoids can be seen. The haemorrhoids are removed using a diathermy or staple gun. After open haemorrhoidectomy, the patient is left with at least two to three open wound in the area of his anus which heals satisfactorily over the next couple of weeks. However with stapled haemorrhoidectomy there are no external wounds.
What should patients expect immediately after the operation?
- You will be placed onto your back with a support.
- Icepacks are sometimes applied to the anal area for pain relief.
- Mild bleeding may occur.
- Regular checks of the operation site will be carried out by nursing staff.
- Regular sitz (salt water) baths will help to clean the area and provide relief.
- Pain-killers are given to relieve pain.
- Stool softeners may be given to help you achieve a bowel motion two days or so after the operation to re-establish a regular elimination pattern.
- Local anaesthetic ointment is prescribed which should be applied 6 hourly for the next seven days
- Rectogesics (which relaxes the anal sphincter) is prescribed which is also applied every 6 hours for the next seven days
What are the possible complications of surgery?
- Excessive bleeding
- Ongoing pain and discomfort.
Taking care of yourself at home
- Follow the dietary advice.
- Avoid constipation by eating adequate fruit and fibre.
- Use regular laxatives until your bowel pattern is regular.
- Drink 2-3 litres of water each day.
- Take a sitz bath after every bowel motion to keep the area clean.
- Apply local anaesthetic ointment every 6 hours
- Apply rectogesics every 6 hours
- Avoid prolong sitting on the toilet
- Avoid unnecessary straining
You may have discomfort for up to six weeks after the operation. Exercising, walking or sitting can be continued after a few days. Do not do any heavy lifting or strenuous activity for 7-10 days (to help reduce the chance of bleeding and facilitate healing).