HAEMORRHOIDS

What are haemorrhoids?

Haemorrhoids or piles are a common problem. Haemorrhoid forms when the veins in the soft tissue in the anal canal and part of the rectum above it becomes dilated. This causes a swelling that can sometimes bulge out of the back passage(prolapsing haemorrhoids)

Haemorrhoids may cause symptoms such as bleeding, swellling/lumps in anal canal, mucus discharge, itching and pain(especially if thrombosed)

What treatment options are available?

Conservative treatment – high fibre diet, avoiding straining(keeping stools soft). Using haemorrhoid cream/ointment/suppositories(eg Scheriproct, Proctosedyl, Rectinol) – these usually contain a combination of steroids and local anaesthetic.

Injection of haemorrhoids with sclerosant(5% phenol in almond oil) – there are risks of causing severe inflammation outside the rectum(phenol is rather toxic!). Also not that successful for larger haemorrhoids.

Banding of haemorrhoids – there are many ways of doing these. It is important to band above the dentate line of the anal canal to reduce the pain – in fact this is often painless. (The author prefers to band several times in an imaginary vertical line along the branches of the rectal vessels contributing to the haemorrhoids – this is so that the supplying blood vessel is thrombosed and this also helps pull up small prolapsing anal cushions to a degree. This combines the principles of placating the tissue from stapled haemorrhoidectomy and ligation of the vessels without actually needing invasive surgery) Risks – bleeding, recurrence of haemorrhoids in other areas not banded, discomfort/feeling of needing to go to the toilet, pain – if large prolapsing haemorrhoid and some component extends below the dentate line)

Surgery – there are many different techniques available. Haemorrhoidectomy – open or closed technique. Haemorrhoidpexy. Stapled techniques. Coagulation diathermy can be used(as can infrared laser photocoagulation, cryosurgery, harmonic scalpel) Ligation of haemorrhoid artery. Or a combination of the above. (The author prefers surgery only as the last resort - after conservative management or banding has failed. The aim being to excise the haemorrhoids and any associated skin tags with minimal trauma to surrounding tissue to reduce postop pain. Usually with coagulation diathermy, closure of the wound, ligation of the pedicle of the haemorrhoids(to ligate the supplying blood vessel - branches of the superior rectal arteries) and pexy(pulling up) of the mucosal cushions. A Spongostan pack is also usually inserted at the end of the procedure. Generally surgery is indicated for large 4th degree haemorrhoids or in cases where banding has failed. If performed in the Minor Operating theatre with only local anaesthesia - only one haemorrhoid with its associated skin tag is excised at a time and more plication/pexy is performed in that area) Risks of surgery include – pain , urinary retention, bleeding, anal stricture(if too much intervening tissue is taken, anal fissure, abscess, remaining skin/tissue between the areas excised may swell and feel like lumps after the op. Pain postop can be severe in some people. It is important to keep one's stools soft during the healing process.

Post-Operative Instructions after Excision of haemorrhoids / Perianal Skin Tags

The perianal region is highly sensitive and prone to bacterial exposure. Diligent postoperative care is essential to minimize pain, prevent infection, and ensure proper healing of the mucosal and skin margins.

Wound Care & Hygiene

Do Not Scrub: Never rub or scrub the perianal area with toilet paper or a towel. Sitz Baths: Can sit in a tub of plain, warm water for 15–20 minutes 2 to 3 times a day and after every bowel movement. This cleanses the area and relaxes the anal sphincter muscle to reduce pain. Showering/Cleaning: After a bowel movement, use a handheld shower head, a bidet, or water-moistened cotton pads to gently clean the area. Pat dry very gently with a clean towel or use a hairdryer on the cool setting. Dressings: Keep a small, clean piece of gauze tucked over the wound site to absorb any minor ooze. Change this gauze frequently.

Bowel Management (Crucial for Healing)

Prevent Constipation: Straining can disrupt the surgical margins or sutures. Take Movicol to keep stools soft Hydration: Drink at least 8 to 10 large glasses of water daily to keep stools soft. Diet: Eat a high-fibre diet rich in fruits, vegetables, oats, and whole grains. Do Not Delay: Go to the toilet as soon as you feel the urge. Do not sit on the toilet for more than 5 minutes at a time.

Activity Restrictions

Rest: Rest at home for the first 24 to 48 hours. Avoid Straining: Do not lift anything too heavy, or perform strenuous workouts for 1 to 2 weeks eg avoid rowing machine, cycling machine Sitting: Avoid prolonged sitting on hard surfaces. Use a soft cushion if necessary

Pain Management

Medications: Take over the counter Paracematol or Neurofen as needed. Avoid medications containing codeine, as they cause severe constipation. Ice Packs: Apply an ice pack wrapped in a clean cloth to the area for 10–15 minutes at a time during the first 48 hours to reduce swelling.

What to Expect

Minor Bleeding: It is completely normal to see a small amount of bright red blood on the gauze or in the toilet bowl for the first 7 to 10 days, especially during bowel movements. Discharge: A yellowish-pink, watery discharge may persist for a couple of weeks as the mucosal layer heals. Sutures: Dissolvable stitches - will typically fall out or dissolve on their own within 2 to 8 weeks and do not need removal.

Red Flag Symptoms (Contact the Clinic or Hospital Immediately)

Excessive Bleeding: Continuous bleeding that fills a pad or large amounts of blood clots. Severe Pain: Pain that is worsening and not relieved by your prescribed medications. Signs of Infection: Foul-smelling discharge, increasing redness, swelling around the anus, or a fever over 38°C. Urinary Retention: Inability to pass urine, which can sometimes occur as a reflex reaction to perianal surgery. Constipation: No bowel movement for more than 3 days post-surgery.

 

Dr LP Cheah is an expert in treating haemorrhoids. As an endoscopist - he gets referred a lot of patients that are rectal bleeding from haemorrhoids. It is better to have the haemorrhoids banded while it is smaller. Unfortunately a proportion of his patients have already had colonoscopies elsewhere where the haemorrhoids are not banded/treated - please check that your endoscopist will deal with your haemorrhoids if found during the endoscopy.