Haemorrhoids

What are haemorrhoids?

The inner surface of the anal canal carries vascular cushions that help it close. Everyone has them and they are a normal structure. They begin to cause complaints when the vessels enlarge and the supporting tissue slackens.

They fall into two groups according to where they sit:

Internal haemorrhoids. These lie in the upper part of the anal canal, where pain sensation is limited. Bleeding is the main sign. As they enlarge they may prolapse outwards.

External haemorrhoids. These sit at the anal margin, close to the skin, where pain sensation is dense. Swelling and discomfort are the leading complaints.

Internal haemorrhoids are graded in four steps according to prolapse:

Grade one. No prolapse. Bleeding only.

Grade two. Prolapses during a bowel movement and returns on its own.

Grade three. Prolapses and has to be pushed back by hand.

Grade four. Permanently prolapsed and cannot be reduced.

This grading is the main heading that determines the treatment option. In the early grades, approaches that do not involve a procedure come first.

Why does an external haemorrhoid hurt suddenly?

When a clot forms in the vessel inside an external haemorrhoid the picture begins abruptly. A firm, purple swelling that is very tender to touch appears at the anal margin. This is called a thrombosed external haemorrhoid. Complaints are at their most intense in the first few days, and presenting early leaves a wider set of options.

Why do they develop?

Factors that raise intra-abdominal pressure and strain the supporting tissue play a part in the development of haemorrhoids. More than one factor is usually present at the same time.

The headings met most often are these:

• Long-standing constipation and straining at stool
• The habit of sitting on the toilet for a long time with a phone
• A low intake of fibre-rich food
• An inadequate daily fluid intake
• Prolonged episodes of diarrhoea
• Pregnancy and childbirth
• Excess weight
• Working for long periods standing or seated
• Work that requires heavy lifting
• A family predisposition
• Slackening of the supporting tissue with advancing age

Most of these factors can be changed. That is why the first step in treatment is always a review of daily habits.

It is common for complaints to increase at certain times of the year. Periods when the diet is disrupted and activity falls contribute to that increase.

What symptoms occur?

Symptoms vary with the type and grade of the haemorrhoid. In a proportion of people there is no complaint at all for a long time.

The findings seen most often:

• Bright red bleeding during a bowel movement
• Blood seen on the toilet paper or in the pan
• A soft fullness that comes out on passing stool
• Itching and moisture around the anus
• Discomfort that increases on sitting
• A feeling of incomplete emptying after the toilet
• A swelling that can be felt at the anal margin
• Staining and discharge on underwear

With internal haemorrhoids pain is usually not to the fore. Where there is marked pain, an anal fissure and inflammatory conditions are also considered.

A thrombosed external haemorrhoid presents differently. There is intense pain of sudden onset, a firm swelling that makes sitting difficult, and discoloration.

Prolonged bleeding may lead to anaemia. Tiredness, fatiguing quickly and pallor may accompany that picture.

When should you see a doctor?

An assessment should be made in the following situations:

• Any new bleeding from the anus
• Complaints lasting longer than a week
• A prolapse that cannot be pushed back by hand
• Pain of sudden onset that keeps increasing
• A marked change in bowel habit
• Dark colour or mucus seen in the stool
• Tiredness and pallor developing alongside
• Bleeding appearing for the first time after the age of fifty

Heavy bleeding, or bleeding accompanied by dizziness or a feeling of faintness, calls for urgent assessment. No time should be lost in that situation.

In people with a family history of bowel cancer, bleeding is investigated in more detail. The threshold for colonoscopy is kept low in this group.

Assessment and treatment options

Assessment begins with a detailed history. Bowel habit, the character of the bleeding, the nature of the pain and eating habits are recorded.

At examination the area around the anus is inspected and a digital rectal examination is carried out. The inner surface of the anal canal is seen with an anoscope. Depending on the findings, examination of the large bowel may be planned.

The approaches are these:

A change in daily habits. Increasing fibre intake, raising daily fluid intake and shortening time spent on the toilet form the first step. This applies at every grade.

Medical treatment. Stool softeners, agents that support the vein wall and topical creams may be used. The duration of use is set by the physician.

Rubber band ligation. An office procedure used for grade one and grade two internal haemorrhoids. A band is placed at the base of the haemorrhoid and the tissue shrinks over the following days.

Laser treatment. This rests on shrinking the haemorrhoidal tissue from the inside with laser energy, without removing the overlying lining.

The stapled technique. This aims to draw the prolapsed tissue back upwards and to interrupt its blood supply.

Conventional surgery. Used in advanced grades and where the external component is prominent. The tissue is excised with the aim of a lasting result.

The outcome varies from person to person and cannot be foreseen without an examination. For that reason no promise of a result is given on this page. You may request an appointment for an assessment through the contact page.

Frequently asked questions