Understanding Haemorrhoids
What Are Haemorrhoids?
Haemorrhoids are also commonly known as piles. They’re swollen and inflamed veins in the anus or lower rectum.
Haemorrhoids are fairly common and can affect anyone of any age or gender.
In Singapore, estimates suggest that as many as one in three Singaporeans may suffer from haemorrhoids at some point.
There are two main types of haemorrhoids: internal and external.
Internal Haemorrhoids
Internal haemorrhoids form inside the rectum, above the anal opening. You usually cannot see or feel them because they lie inside the anal canal.
These haemorrhoids typically cause painless bleeding. You might notice bright red blood on toilet paper or in the toilet bowl after a bowel movement but feel no pain. This is because that area lacks pain-sensitive nerves.
Straining during a bowel movement can sometimes push an internal haemorrhoid out through the anus. This leads to a protruding soft lump at the anal opening, known as a prolapsed haemorrhoid. This may cause discomfort, irritation, or aching pain if it becomes trapped outside.
External Haemorrhoids
External haemorrhoids develop under the skin around the anus, in an area with many pain-sensing nerves. As a result, they generally hurt and are noticeable.
These haemorrhoids can cause symptoms like anal itching, aching or sharp pain, and a palpable swelling or lump near the anus. They may even lead to bleeding if a swollen vein ruptures, or if there is friction and irritation.
Blood may pool in an external haemorrhoid to form a clot. This leads to a hard, very painful lump known as a thrombosed haemorrhoid – medical review is advised to assess severity and pain control in these cases.
Causes and Risk Factors of Haemorrhoids
Haemorrhoids develop when the veins in the anal or rectal area are put under increased pressure, causing them to stretch, swell, and bulge.
The pressure that leads to haemorrhoids is often the result of a combination of lifestyle factors and daily habits. For example, straining forcefully during bowel movements and spending prolonged periods sitting on the toilet are both commonly associated with the development of haemorrhoids.
Here are some of the common causes and contributing factors of haemorrhoids:
- Aged 50 and above
- Chronic straining during bowel movements
- Genetics and a family history of haemorrhoids
- Prolonged sitting on the toilet, which can cause blood to pool in the anal veins
- Chronic diarrhoea, irritation of the anal area
- Constipation, which can lead to straining
- Low-fibre diet
- Pregnancy
- Obesity
Signs and Symptoms of Haemorrhoids
Haemorrhoids can produce a variety of symptoms, with their severity and mixture varying from one case to another.
Some common signs and symptoms to watch for include:
- Feeling as though you still need to pass stool right after a bowel movement
- Rectal bleeding after a bowel movement
- Swelling or a lump around the anus
- Pain or aching in the anal area
- Soiling or mucus discharge
- Anal itching and irritation
Get Assessed and Diagnosed for Haemorrhoids
If you think you may have haemorrhoids or are experiencing related symptoms, book an appointment for proper medical assessment and diagnosis.
How Haemorrhoids Are Diagnosed
Our colorectal specialist will begin your clinical evaluation with a request for your medical history and a description of your symptoms. You may also be asked about lifestyle factors like your diet and habits.
This may be followed by a physical examination of the anal area. This will involve visual inspection of the anus and surrounding skin for swollen veins, external piles, or fissures. This is often sufficient to identify external haemorrhoids or prolapsed internal ones.
If needed, further assessment may be carried out to confirm the diagnosis or determine the severity (grade) of internal haemorrhoids.
Grading of Internal Haemorrhoids
Internal haemorrhoids are classified into four grades based on the degree of prolapse (how much they bulge out) during bowel movements:
- Grade I: No prolapse and often come with painless bleeding during bowel movements. These are usually managed with diet, hydration, and bowel habit changes.
- Grade II: Prolapse occurs during bowel movements but reduces on its own. Symptoms may include bleeding, mild discomfort, or occasional fullness. These may need office procedures if persistent.
- Grade III: Require manual reduction and come with more frequent bleeding, discomfort, irritation, mucus, or hygiene issues. These often need procedures and surgery may be considered.
- Grade IV: Permanently prolapsed and cannot be reduced, and come with ongoing discomfort, swelling, irritation, and a higher risk of complications. These typically need surgical treatment.
If internal haemorrhoids are suspected, extra diagnostic tests may be required, since they cannot be seen externally. These may include:
- Digital rectal exam: A gloved, lubricated finger is inserted into the rectum to feel for any abnormalities or lumps inside.
- Anoscopy: A short, rigid tube with a light (anoscope) is inserted a few inches into the anal canal to view the lower rectum and anal canal.
- Proctoscopy or sigmoidoscopy: A proctoscope examines the entire rectum, while a flexible sigmoidoscope evaluates the rectum and lower colon to help determine additional symptoms or causes for bleeding.
- Colonoscopy: A flexible camera is inserted to examine the colon & rectum, and even remove small polyps or take tissue samples for biopsy.
Potential Complications of Haemorrhoids
Long-standing and untreated or acutely swollen haemorrhoids may lead to complications.
- Anaemia: Prolonged, untreated blood loss from haemorrhoids, especially internal haemorrhoids, can cause iron-deficiency anaemia leading to fatigue and weakness.
- Thrombosed haemorrhoid: When a blood clot forms inside a haemorrhoid, this may cause sudden and severe pain as well as a hard lump near the anus.
- Strangulated haemorrhoid: When the anal sphincter muscle tightens around a haemorrhoid and cuts off its blood supply, this may cause it to swell or die from blood loss, sometimes requiring urgent intervention.
- Infection and abscess: Although uncommon, tears or sores in a haemorrhoid can occasionally lead to infection or abscess formation.
- Skin irritation: Persistent prolapsed haemorrhoids can lead to continuous leakage of mucus or stool, which irritates the perianal skin and may cause itching or dermatitis.
- Skin tags: After a thrombosed external haemorrhoid heals, the stretched-out skin may remain as a skin tag, which can be bothersome for hygiene.
Treatment of Haemorrhoids
Treatment depends on the haemorrhoid type and severity or intensity of the patient’s symptoms.
Non-Surgical Treatments
For mild to moderate haemorrhoids, non-surgical treatments on reducing symptoms and alleviating the discomfort of the condition include:
- Dietary fibre and hydration: Increasing fibre intake and hydration can help keep stools soft, preventing constipation and straining. Patients may be advised to eat more fruit and vegetables, take fibre supplements, and drink more water.
- Stool softeners or laxatives: These are short-term aids to ensure the patient is able to pass stool without straining.
- Topical treatments: There are various creams, ointments, and suppositories available to help soothe haemorrhoid symptoms.
- Warm sitz baths: Soaking the anal area in warm water helps reduce pain, cleanse the area, and relax the anal sphincter muscle, which can soothe bulging haemorrhoids and provide significant relief.
- Cold packs and hygiene: Applying an ice pack or a cold compress to the anal area in the first day or two of a flare can reduce swelling and numb the pain temporarily.
- Oral pain relievers
Most haemorrhoid flare-ups will settle with just these measures, especially if it’s a first occurrence or a mild case. Patients are also advised to avoid straining or heavy lifting so that their bodies may heal.
However, if symptoms fail to improve within a week, follow-ups with a doctor are advised.
Surgical Treatments
Surgery is reserved for complications that arise from haemorrhoids or cases where non-surgical treatment fails.
There are many surgical approaches, with the choice of procedure depending on the haemorrhoid’s size, location, and degree of prolapse:
- Rubber band ligation: The doctor puts a tiny rubber band around the base of the haemorrhoid to cut off its blood flow until it dies and detaches.
- Sclerotherapy: Sclerosant is injected directly into the haemorrhoid tissue to shrink it. Because it’s often used on internal haemorrhoids that have fewer pain nerves, it’s generally painless or low-discomfort.
- Infrared coagulation (IRC) or laser therapy: Focused infrared, laser, or electric energy is aimed at an internal haemorrhoid to burn it and cut off blood flow. This is a fairly fast procedure but may require multiple sessions, with a slightly higher haemorrhoid recurrence rate compared to ligation.
- Haemorrhoidectomy: The haemorrhoid is surgically removed, typically under anesthesia (general or regional).
- Stapled haemorrhoidopexy (PPH): Most often used for prolapsing internal haemorrhoids, especially Grade III ones. It involves removing and stapling a ring of tissue above the haemorrhoids to pull them into place and cut off their blood supply until they shrink.
Other Specialised Treatments
There are other specialised haemorrhoid treatments available at some centres, such as Doppler-guided haemorrhoidal artery ligation (HAL) and haemorrhoidal artery embolisation.
- Haemorrhoidal artery ligation (HAL): Also called transanal haemorrhoidal dearterialisation. This involves tying off arterial blood supply to haemorrhoids using a special ultrasound probe.
- Haemorrhoidal artery embolisation: Uses a radiological procedure to block blood flow to the haemorrhoids. Like HAL, it can result in a shrinking of the haemorrhoids without cutting tissue.
These procedures are reserved for select cases and are less commonly performed than conventional treatments like rubber band logation or IRC.
Choice of Treatment
Our colorectal specialist uses a grading system to determine severity and guide treatment for internal haemorrhoids, but not for external haemorrhoids.
External haemorrhoids are not usually graded in the same way because they sit outside the anal canal. Instead, they are assessed based on symptoms such as pain, swelling, or thrombosis.
Our specialist will discuss the specific procedure you need based on your situation and the expected recovery time after the procedure.
Recovery and Prognosis for Haemorrhoids
Recovery varies based on the type of treatment and the patient’s individual condition.
- For conservative management and minor procedures (e.g. rubber band ligature or injections), recovery can be quick. You may experience mild discomfort or light bleeding for a few days, but can generally continue normal activities with some caution within 1-2 weeks.
- For surgical treatments, it depends on the procedure and severity of the condition. Haemorrhoidectomy patients can resume light activities after a week or so, must avoid heavy exercise or straining for 2-4 weeks, and are often largely pain-free by a month. Stapled haemorrhoidopexy often allows faster recovery, though recurrence rates may be higher compared to conventional haemorrhoidectomy.
Haemorrhoids are generally not life-threatening, even if they can be chronic or recurrent. The prognosis for haemorrhoids is generally good when properly managed.
Overall, most patients can control or eliminate symptoms in a way that improves quality of life significantly with the right treatments.
Prevention and Management Tips
Some healthy lifestyle habits can help reduce the risk of developing haemorrhoids or prevent their recurrence.
- Eat a fibre-rich diet: Fruits, whole grains, and vegetables help form soft and bulky stools that are less likely to lead to straining.
- Stay hydrated: The colon doesn’t have to reclaim as much water from your stool when you’re hydrated, which keeps stool easy to pass. Water intake may need to be higher than the usual 6 to 8 glasses if you sweat a lot.
- Avoid straining on the toilet: Try breathing out as you bear down instead of holding your breath to reduce pressure. Smooth footstools can also elevate your feet and mimic a squatting position to help straighten the rectal angle for stool passage.
- Don’t linger on the toilet: Lingering on the toilet can cause blood to pool in the anal veins due to gravity and posture. Limit yourself to 5 minutes on it.
- Go when you feel the urge: Don’t ignore the urge to pass stool, as it can lead to constipation or harder stool.
- Maintain good anal hygiene: Always gently clean the anal area after bowel movements to prevent irritation and itching.
- Maintain a healthy weight: Extra weight can put continuous pressure on the pelvic veins.
- Avoid prolonged sitting: Sitting for a long time on a hard surface can increase haemorrhoidal pressure.
Conditions
Schedule an Appointment for Haemorrhoids Screening
If you have symptoms or concerns about haemorrhoids, book a consultation with our specialist for an assessment. We can provide an early evaluation and propose a treatment plan if needed.