Haemorrhoids | Mate tero puta

Haemorrhoids can become swollen, painful and inflamed (‘flare up’) and bleed when irritated. They may be itchy or associated with a mucous discharge. At other times, when they are not swollen or irritated, they may cause no symptoms.

Internal haemorrhoids

Internal haemorrhoids come from veins inside the rectum and usually can’t be seen from the outside. However, they can cause a feeling of pressure in the rectum and can bleed, especially when you pass a stool. You might notice streaks of bright blood on the outside of a stool or on the toilet paper when you wipe your bottom, or splashes of blood in the toilet bowl.

Internal haemorrhoids can cause mucus to leak from the rectum onto the anal skin. This moisture encourages secondary skin infections, and results in the itchiness that often accompanies haemorrhoids.

Internal haemorrhoids are not usually painful, but if one becomes very large, it can hang out of the anus (called a ‘prolapsed haemorrhoid’), causing pain and increased swelling.

External haemorrhoids

External haemorrhoids come from veins outside of the anus. They look like one or more firm grape-like swellings on the outside of the anus. External haemorrhoids can become painful and irritated, and can bleed or itch. Blood pooling in an external haemorrhoid can lead to a blood clot forming in the haemorrhoid. This results in a firm, bluish swelling on the edge of the anus that is very painful. This pain usually intensifies over about 3 days then settles as the clot resolves.

When a swollen haemorrhoid subsides, the area of anal skin that overlies it can hang a bit loose, because it was stretched when the haemorrhoid was swollen. This small area of loose skin is called a ‘skin tag’. Several skin tags can give the anus a ruffled rather than a smooth appearance. Skin tags do not usually cause discomfort but they can make cleaning your bottom after passing a motion more difficult. It is best to wash the area or use a moist disposable wipe, rather than dry toilet paper.

Doctors do not always understand exactly what causes haemorrhoids, but increased pressure in the veins of the rectum and anus, and downwards sliding of the tissue containing these veins are thought to be involved.

The increased pressure may be caused by:

• prolonged straining to pass a bowel motion, as can happen when you are constipated
• diarrhoea
• being very overweight
• sitting on the toilet for a long time
• pregnancy and childbirth.

Some people seem to inherit a tendency to develop haemorrhoids - this may be due to weakness of the walls of the veins in the anus and rectum. This weakening can also occur with increasing age.

Failure to pass a stool when needed, eating a diet low in fibre, not exercising regularly, and not drinking enough fluids can lead to constipation, which increases your likelihood of developing haemorrhoids.

• apply a cold compress to the area for relief
• a warm salt bath may help painful haemorrhoids
• use fragrance-free wet wipes instead of toilet paper to clean the anal area
• avoid soap as this may further aggravate the problem
• avoid scratching the area
• wear cotton underwear to minimise discomfort
• treat any constipation or diarrhoea
• eat a high-fibre diet and drink plenty of fluids
• if your diet is not already high in fibre, introduce it gradually
• exercise regularly
• keep stools soft so as to avoid straining when having a bowel motion
• always go to the toilet as soon as you feel the need to go. 'Holding-on' can make haemorrhoids worse.

Tip: If you have blood in your bowel motions, you need to see your doctor to make sure this isn't something else.

First-line treatments

Most haemorrhoids can be treated with some simple changes to the diet and bowel habits.

1. Diet changes to soften stools. The first treatment recommendations will be to make changes to your diet that will make the stool softer and easier to pass. These recommendations include increasing the amount of fibre in the diet through fruits, vegetables and whole grains or taking a fibre supplement. If you can't get enough fibre from your diet and decide to use fibre supplements, it is worth drinking plenty of water each day or the stool could get harder and more difficult to pass. This is because the fibre works to draw more water into the stool, making it bulkier and softer. Without water, the resulting stool is more compact, hard and difficult to pass.
2. Avoid straining. It is also important not to strain while having a bowel movement. If you find yourself holding your breath while pushing, this is known as straining. Straining increases the pressure in the veins in and around the anus, which increases the risk of developing haemorrhoids or making them worse. Instead, avoid straining, keep breathing evenly and focus on changes you can make to soften the stools, which will decrease the work required to have a bowel movement.
3. Exercise regularly. People who exercise consistently have an easier time with their bowel movements because exercise helps the intestinal tract to move more consistently.
4. Topical treatments. There are a number of prescription and over the counter creams and ointments that can help reduce mild discomfort. These products contain ingredients like witch hazel or hydrocortisone that help to reduce pain, swelling and itching. First, check with your doctor/nurse or pharmacist to be sure these are safe for you and to make sure there isn't any other underlying medical condition that needs different treatment. Also check how long to use the creams and to be reviewed if they are not working. 
5. Lose weight if you are overweight. 

Other treatments

If these measures don't work, there are a range of other treatment options.

1. Non-surgical treatments include banding, infrared coagulation and sclerotherapy. These are designed to reduce the blood supply to the haemorrhoid so it shrinks or goes away. Scar tissue will remain that has the function of supporting the surrounding tissue and preventing any further haemorrhoids from developing in the area. 
2. The coagulation procedures - infrared, laser or bipolar - are techniques that cause small, bleeding, internal haemorrhoids to harden and shrivel. While it is quicker and less painful than the rubber band procedure it has a higher incidence of recurrence, or the haemorrhoid coming back.
3. Another procedure which may be considered is sclerotherapy. Sclerotherapy is similar to sclerotherapy that is used for varicose veins or spider veins in other areas of the body. A small amount of an irritant compound is injected. The advantage is it doesn't cause much pain, but is usually less effective than the rubber band ligation.

Surgical treatments include the hemorrhoidectomy and stapling.

In a haemorrhoidectomy the surgeon removes most of the excess tissue that causes the bleeding. There are several variations that can be used based on the particular situation and overall health of the individual. The surgery can be done with a local anaesthesia or combined with sedation and spinal or general anaesthesia. This is the most effective and complete way of removing haemorrhoid tissue. Unfortunately, it also has the highest rate of complications which can include difficulty emptying the bladder or urinary tract infections. Many people also experience pain that can be controlled with medication and warm baths.

Stapling is a procedure that blocks the blood flow to the haemorrhoidal tissue and generally results in less pain than a haemorrhoidectomy. However, stapling tends to have a higher risk of recurrence and rectal prolapse.

Deciding what treatment is best for you

Before deciding on any procedure to treat your haemorrhoids, do your own research and talk with your doctor and surgeon about the side effects, complications and long-term results. You need to understand the pros and cons of each option and balance this with your current health, lifestyle choices and preferences.

To help you decide, you may find this decision aid(external link) from Healthwise useful.

Haemorrhoids(external link) Auckland Gastroenterology Associates, NZ
Piles – an overview(external link) NHS Choices, UK
Haemorrhoids, Patient Plus(external link)  Patient Info
Haemorrhoids(external link) National Digestive Diseases Information Clearinghouse
Chronic constipation [PDF, 470 KB] Harvard Medical Center, US, 2012

Constipation | Mate tūtae kore
Body size and health
Healthy eating basics

A quick guide to managing anal fissures(external link) Best Practice Journal, NZ, 2013
Topical creams and preparations(external link) NZ Formulary
Hydrocortisone + cinchocaine (Proctosedyl)(external link) NZ Formulary
Cinchocaine + fluocortolone hexanoate + fluocortolone pivalate (Ultraproct)(external link) NZ Formulary