Haemorrhoids

Haemorrhoids are small swellings made up of tiny blood vessels just inside the anus. They are also known as piles or, more accurately, internal haemorrhoids. 

Many are surprised to learn that haemorrhoids are a normal part of our anatomy, contributing to anal continence. After passing a bowel motion, our haemorrhoids fill with a small amount of blood and meet in the middle. This helps to close the anus and prevent leakage. 

It is believed haemorrhoids contribute to about 20% of our resting anal continence.

One of the most common symptoms of haemorrhoids is bleeding. This is typically fresh, red blood and it tends to come and go. Normally you’d only see this blood on the toilet paper, or blood may also drip into the toilet. 

Occasionally this bleeding can be very heavy, and if it continues for a long time this might even result in anaemia (a low blood count).  With this type of heavy bleeding, a proper evaluation is needed to ensure there is no other cause. 

We all have haemorrhoids, but they can swell because the tissue inside them is elastic.  It’s this swelling that can lead to the haemorrhoids getting larger, and sometimes even stretching and appearing outside the anus. This is called a prolapse. 

As well as bleeding, there are other symptoms of haemorrhoids. These include itching around the anus, mucus leakage or the anus having a concerning appearance.

Itch is generally a result of mucus being trapped around external haemorrhoids, also known as skin tags, which can lead to excessive wiping. 

Mucus leakage is a result of internal haemorrhoids prolapsing. This can also lead to itch or the feeling of moisture around the anus.

Some patients are concerned about the appearance of their anus. This is especially common in those with large skin tags. This can sometimes be improved with a surgical excision.

A number of symptoms are often confused with haemorrhoids, such as difficulty going to the toilet, feeling blocked or feeling pressure or a bulge around the anus. These symptoms are not typically caused by haemorrhoids, and a formal assessment by one of our surgeons may identify another issue such as a problem with the bowel or pelvic floor.

Some people develop haemorrhoids that enlarge and prolapse after every bowel motion. This can cause discomfort or annoyance, with people often describing how they use their finger to push the haemorrhoid back inside.

Occasionally haemorrhoids can enlarge to the point that they become stuck outside, leading to thrombosis, which is clotting of the blood. This results in severe pain – often leading to a trip to the emergency department. It can take one or two weeks for this pain to subside. 

Swollen internal haemorrhoids can also give you the sensation that you’re not emptying your bowels completely.

Many people believe you must be constipated to get problematic internal haemorrhoids.  This is certainly not the case. Yes, constipation is a major cause, but there are other reasons people get haemorrhoids. 

Having to excessively push to pass a firm bowel motion can cause tearing and swelling. Clearly, this is best avoided. On the other hand, having repeated diarrhoea can also have a similar result.

Another common misunderstanding is that there should be no straining at all when on the toilet. This sees some people sitting for long periods – often on social media! – waiting for stool to pass. This is also a significant cause of haemorrhoids, not to mention a waste of precious time. 

Other common causes of haemorrhoids include the types of activities being done at the gym, also pregnancy and childbirth. 

Ideally you want to have a soft, well-formed poo that is easy to pass.  Increasing your fluid intake and incorporating a daily fibre supplement into your routine, such as Benefiber, Metamucil or psyllium husk, will really help here.  

Occasionally a daily stool softener may be required.  Be assured these interventions are very safe and long-term use poses no risk to your bowel.

It’s also important to intentionally reduce the amount of time you spend on the toilet – so leave your phone outside! You really should be on and off the toilet within a couple of minutes. 

Some people describe spending 30 minutes on the toilet. It’s actually better to have two short trips to the loo, rather than sitting there for a long time waiting for things to move. It’s healthy for you to push for short bursts… just not excessively. 

At Brisbane Colorectal, our approach to patients with haemorrhoids is holistic, symptom-based and caring. 

We will take your history and perform an examination to assess the problem. 

A proctoscopy or rigid sigmoidoscopy is a fairly quick, simple test we can do in the rooms to visualise the anal canal using a light. It helps us assess the extent of the haemorrhoids, and other potential issues as well. 

Haemorrhoids themselves are not life-threatening, and the treatment we offer you will depend on what your concerns are. Some patients simply want an assessment and reassurance nothing more sinister is causing their symptoms. Other patients are quite bothered by their haemorrhoids and in these cases, there are a number of treatment options.

We will discuss with you your dietary intake, focusing on how much fibre is in your diet. Bleeding from haemorrhoids responds very well to fibre supplements and we may recommend one for you. 

A formal consultation with a dietician can be a very beneficial way of reaching your dietary targets with fibre intake and healthy eating.

Having a soft, regular stool is important, and we may prescribe a stool softener for you as well.

Topical creams and suppositories (small tablets inserted into the anus) can be useful to reduce symptoms.  They commonly contain a combination of local anaesthetic and steroid to help reduce pain, swelling and inflammation.  Common brands include Anusol and Proctosedyl.

Sometimes we find people benefit from an improvement in their defecatory (pooing!) technique. 

Defecation is actually a complex, dynamic manoeuvre and sometimes people develop poor habits or muscle incoordination problems. There are tests that can identify these problems, and we tend to involve a pelvic floor physiotherapist in our treatment of these patients.

A small number of patients with haemorrhoids will need surgery to relieve their symptoms. This depends on how bad the symptoms are, and the size and severity of the haemorrhoids. 

Two common solutions for bleeding or prolapsing haemorrhoids are haemorrhoid energy therapy (HET) and rubber band ligation.

Patients with larger haemorrhoids might require what’s called an excisional haemorrhoidectomy. This is especially the case when the skin around the anus is involved. 

An excisional haemorrhoidectomy is a surgical procedure where the haemorrhoids are removed. In comparison to all other haemorrhoid operations, it has been proven to be the most effective path for improvement in haemorrhoids. It also has the lowest haemorrhoid return rate of all treatments. 

Other operations involve surgical removal of extra or floppy mucosa (the internal lining of the bowel). A number of operations can achieve this, including stapled haemorrhoidectomy and haemorrhoidal artery ligation and recto-anal repair (HAL-RAR). 

Given the number of treatment options available, it is best to have your surgeon assess you and provide guidance to determine the best course of treatment for you. Just as all our patients are different, there is no “one size fits all” approach. 

Depending on your situation, surgery might be recommended.

Colorectal surgeons are extensively trained in the specific treatment of anorectal disorders. so you are most likely to achieve a satisfactory outcome from seeking their help. 

HET is a simple, gentle haemorrhoid therapy that can be completed within seconds.  It’s a minimally invasive technique for treating symptomatic internal haemorrhoids, relieving bleeding, minor prolapse, mucus seepage and irritation of the skin around the anus. 

It is not used to treat large, prolapsing internal haemorrhoids.

The HET Bipolar System is inserted into the rectum, and low power energy is delivered to the blood supply that feeds swollen haemorrhoids – it’s not delivering the energy to the actual haemorrhoid. This causes the blood volume to be reduced, shrinking the size of the haemorrhoid. 

Like haemorrhoid banding, this procedure is performed in the endoscopy suite at the Mater Private Hospital, where an anaesthetist provides sedation. There is minimal or no discomfort – you will be asleep, comfortable and unaware of the procedure being performed.  

All medical procedures have some risk, and in this case, there is a small risk of minor post-procedure bleeding. However the vast majority of patients experience a very good outcome.