What are the signs and symptoms of hemorrhoids?

So, what are haemorrhoids (or piles)? Inside the anus just proximal to the dentate line are three to four cushions of tissue formed by a rich arteriovenous network of blood vessels, the corpora cavernosi recti, covered by the fragile epithelial lining of the anus. The purpose of these cushions is to squash together when the anus closes after opening the bowels, giving the anus its final airtight and watertight seal. They are a normal part of the anatomy and function of the anus. However, when they cause problems, such as bleeding or itching, or even become so large as to protrude from the anus, they are called haemorrhoids. In essence they are just a symptomatic exaggeration of the norm.

Risk factors and pathophysiology

Haemorrhoids are usually caused by a combination of factors (straining, hard stools, poor diet). The most important is excessive straining at stool, and certainly the commonest cause in men. The commonest cause in women is childbirth. Haemorrhoidal problems have a tendency to run in families although this is not an overly helpful feature in the history.
Due to the lack of valves in the pelvic veins, straining puts an enormous pressure on the blood vessels that make up the cushions within the anal canal and as a result over time they will slowly swell and enlarge. In response to the swelling, the arteries which supply the anus increase in calibre and pressure and therefore exacerbate the problem. Similar to a balloon that has been blown up, once the anal cushions swell past their original size, they never return to normal and over time will continue to stretch and enlarge. As they enlarge, the lining over them also stretches and eventually can become very thin and fragile, so thin in some patients that it can rupture during defecation and the haemorrhoids bleed. If the haemorrhoids do not bleed they will continue to enlarge in size until they present as a prolapse.

Clinical features

The classical symptom of haemorrhoids is bright red per-rectal (PR) bleeding associated with defecation. However, the bleeding may be due to other (sometimes sinister) causes.

Symptoms suggestive of serious non-haemorrhoidal causes of PR bleeding include
•    The blood is altered, ie, dark or melaena.
•    PR bleeding is independent of defecation.
•    Blood is seen on or in the stool.
•    Change in bowel habit.
•    Weight loss.
•    Loss of appetite.
•    Abdominal pain or distension.

Most patients under the age of 40 who do not have any symptoms of concern can have treatment focused on the haemorrhoids without the need for a colonoscopy. However, patients of any age who present with PR bleeding and have any of the symptoms in Table 2 should be referred for colonoscopy to exclude a malignant lesion or inflammatory bowel disease as the cause of the bleeding. A family history of bowel cancer should not be ignored and in patients over 30 years with a family history who present with PR bleeding, this could be used as an opportunity for their first screening endoscopy/colonoscopy.

In many patients haemorrhoids will be short-lived and self-limiting, usually resolving spontaneously or with topical over-the-counter remedies within a few days or a week or two at the most. Others, unfortunately, will go on to experience more chronic problems. This can include daily bleeding, itching, throbbing and/or discomfort, which — although varying from day to day — never seem to go away. Alternatively, the problems can be cyclical, with periods of more pronounced bleeding and throbbing and often prolapse requiring haemorrhoids to be pushed back in. Most patients will seek some medical advice when their haemorrhoids cause either significant daily problems or cyclical symptoms.

Frequently the true extent of the haemorrhoidal problem is not apparent on examination either in the general practice surgery or in specialist rooms. Not surprisingly, anxiety at the time of examination will contract the pelvic floor muscles and make the haemorrhoids less obvious. The treatment of haemorrhoids should therefore be based on the grade of the symptoms they cause and not on their size. These grades are defined as follows:

•    Grade 1: Piles that are internal to the anus and never prolapse. These piles often present with recurrent bleeding only, although in some patients this can still be very heavy bleeding. (Symptoms such as itching and throbbing are usually related to prolapse.)

•    Grade 2: Piles that prolapse on straining, but return to their normal internal position spontaneously after evacuation without the need for any manual assistance. The patient will usually be aware of tissue prolapsing through the anus on defecation but deny the need to replace the tissue manually. Bleeding is often present on a regular basis.

•    Grade 3: Piles that prolapse on straining, but need to be manually reduced after evacuation. When reduced back into the anus they remain there.

•    Grade 4: Piles that are permanently outside and cannot be reduced manually or if they do reduce, will prolapse again on walking or mild exercise.

Interestingly, bleeding is less of a symptom in significant haemorrhoidal prolapse, probably due to the fact that the excess pressure goes into producing the prolapse rather than causing bleeding.
It is important to take a full defecatory history, including time spent on the toilet, straining and if there is regular deferment of defecation. Many patients like to ‘go’ before they leave the house in the morning, and will also strain without the urge to defecate. This should be discouraged as it will ultimately lead to either haemorrhoids or a fissure at some point.

Management

Conservative treatments

Many patients will respond to conservative measures including avoidance of straining, increasing fibre intake (methylcellulose from vegetables, as well as from wheat bran or psyllium husk) and adequate daily hydration. For patients with intermittent minor bleeding, an over-the-counter preparation (eg, Scheriproct®, Proctosedyl®, Anusol®) is often the first line treatment. These preparations often consist of a mixture of the following ingredients:

Astringents (eg, cinchocaine). Astringents have a vasoconstrictive effect and may also have a local anaesthetic effect.
Cortisones (eg, hydrocortisone, prednisolone). Topical steroids act to reduce oedema and inflammation as well as having an anti-pruritic effect.
•    Topical antibiotics (eg, framycetin). Topical antibiotics act to reduce any superimposed infection which may increase the oedema, inflammation and pruritis.

For many patients an over-the-counter product will reduce or resolve the symptoms completely. For any patient for whom a single course of topical preparation is ineffective, or who returns for repeat courses in a short period of time, a specialist opinion is required to confirm that haemorrhoids are in fact the cause and to exclude any sinister pathology. Many patients present with ‘haemorrhoids’ and long-term failure of topical preparations to settle their haemorrhoidal symptoms when the true cause is a chronic fissure or fistula or even a squamous carcinoma of the anus.

Surgical treatments:

When conservative measures fail, the following surgical treatments may be recommended. The goal of all treatments is to shrink the piles down and stop them from prolapsing.

Injections:

The simplest and easiest treatment for early piles (grade 1-2) is to inject them with a mixture of phenol and almond oil. This is a sclerosant causing intense irritation to the blood vessels which become inflamed (temporarily) and the blood within them then thromboses, causing further inflammation. This irritation then adheres the lining of the haemorrhoid to the fascia/muscle underneath.

The benefits of this treatment are that it is easy and practically painless and can be done without an anaesthetic. The downside is that the result is unpredictable and often needs to be repeated to get the desired result; also, the recurrence rate over time is high. There have also been occasional reports of injection of the sclerosant into the prostate with a resulting chemical prostatitis, and therefore haemorrhoids in the anterior location should be injected with caution.

Rubber banding:

This treatment involves placing a tiny rubber band, approximately 1mm in diameter, over the haemorrhoids towards their base. This treatment is mainly performed for slightly larger haemorrhoids, with grade 2-3 symptoms. This is done using special banding instruments but can be performed without anaesthetic, although many patients do elect to be sedated in hospital for the treatment (with or without colonoscopy, as appropriate). The aim of the banding is to pinch off a section of the haemorrhoid so that it thromboses and necroses and at the same time causes enough irritation to adhere the remaining tissue to the sub-epithelial tissues.

As for injection, the results are a little unpredictable and the treatment often needs to be repeated. The main risk, however, is significant pain and bleeding after the procedure, and although rare this can sometimes be severe enough to require hospitalisation. For this reason, banding should be avoided within ten days to two weeks of planned foreign travel due to the risk of bleeding.

Haemorrhoidectomy:

For more advanced cases of haemorrhoids (grade 3-4) a haemorrhoidectomy may be recommended. This is a surgical procedure in which the haemorrhoids are fully excised and open wounds are left within the anus which can take up to 8-10 weeks to heal fully.

The post-operative pain and discomfort of haemorrhoidectomy is unbearable for most patients. Daily dressings are required along with salt baths and the need to wear a pad in the underwear until healing is complete. Sexual activity is frequently not possible due to the pain. It is one of the only operations originally described in the 1930s still in common use today. There are many patients suffering from large haemorrhoids who continue to suffer simply because they are (understandably) too frightened to have the surgery.

Stapled Haemorrhoidopexy:

The stapled haemorrhoidopexy was introduced in 1998 and is aimed at avoiding surgery directly to the anus. A cuff of lower rectal mucosa (3-4 cm above the anus, where there are few pain nerves) is incorporated into a stapling device which, when fired, excises the cuff of mucosa with simultaneous anastomosis. The procedure includes the submucosal vascular supply to the haemorrhoids in the cuff of tissue and at the same time reduces the haemorrhoids to their anatomical location. The operation is highly effective and post-operative pain is greatly reduced compared with haemorrhoidectomy, and there is no need for post-operative dressings, salt baths or external wounds.

The HAL-RAR procedure was invented in 1995 and is another modern approach to haemorrhoid surgery. The operation is performed using a Doppler guided ultrasound probe which is inserted into the anus to locate the arteries which feed the haemorrhoids above the anus, where there are fewer pain nerves. Once located the probe allows a stitch to be placed around the artery, cutting off the blood supply to the haemorrhoids. Six or seven arteries feed the haemorrhoids and they are all tied during the procedure. The stitch is also configured such that any prolapse associated with the haemorrhoids is dealt with simultaneously (the anal repair component of the procedure).

As a result of HAL-RAR the haemorrhoids lose their high pressure blood supply and shrivel up and disappear. No cuts or wounds are created, and no salt baths or pads in the underwear are needed. There is discomfort and throbbing after the procedure for about a week to ten days but most patients are back to normal very quickly.