Haemorrhoids

Perianal Conditions

This area of surgery relates to a number of conditions around the anus which can be embarrassing and may lead to patients not seeking medical advice and treatment. In many cases, failure to get treatment can lead to serious consequences. However, if seen and treated early, complications can be avoided.

Haemorrhoids (piles) are probably the most well-known problem, but there are also other lesser-known conditions which affect patients, including: perianal skin tags, perianal haematoma, anal fissure, fistula-in-ano, anal polyps and tumours.

What are Haemorrhoids?

We all have small haemorrhoids! These are the anal equivalent of lips around your mouth, being designed to prevent leakage outside the bowel. Haemorrhoids become a problem if they become excessively enlarged. This can lead to bleeding and in more severe cases, prolapse.

The exact cause of haemorrhoids is unknown; contributing factors include ageing, diet-related constipation/diarrhoea, faulty bowel function, prolonged straining, and pregnancy.

Haemorrhoids and their symptoms are one of the most common afflictions in the world. They can occur at any age and affect both men and women.

Although rarely fatal, they can be painful, embarrassing and disabling. Haemorrhoids are graded by degree of prolapse; the grading determines the most appropriate treatment method.

First degree – small swellings which develop on the inside of the anal canal.

Second degree – larger swellings which prolapse on going to the toilet but which return spontaneously.

Third degree – those which prolapse but can be returned inside manually.

Fourth degree – those which are larger and which cannot be pushed back inside. This results in marked pain and swelling of the haemorrhoid.

Treatment

Haemorrhoids tend to get worse with time and are best treated as early as possible. Depending on the severity of the haemorrhoids, symptoms such as itching and discomfort may be alleviated by over-the-counter creams and ointments.

The majority of first degree, and some second degree, haemorrhoids can be treated in the surgical outpatient clinic without the need for general anaesthetic. In these cases, it is possible to apply a small rubber band onto the haemorrhoid to cut off its blood supply and thus shrink it back to its normal size (some surgeons prefer to inject the irritant phenol into the haemorrhoid to achieve the same effect). Only the most severe cases require surgery under general anaesthetic.

Large second degree and third degree haemorrhoids do require surgery. This can only be performed in cases where the condition has become chronic. Acute prolapsed/strangulated haemorrhoids should be allowed to settle down before surgery is attempted. A haemorrhoidectomy is the surgical removal of the haemorrhoid.

Conventional treatment methods include:

• Cryotherapy
• Infrared coagulation

Differential Diagnosis

Whilst haemorrhoids are the most common anal condition to cause these symptoms, your doctor should ensure that there is no other cause. Possible rarer causes for the above symptoms include:

Perianal Skin Tags

This is a condition which consists of small areas of loose skin protruding from the anal canal. Normally these are a result of a patient having had haemorrhoids which have “shrunk” leaving behind a small area of loose skin. These can be uncomfortable, irritating and lead to problems with personal hygiene. They can be removed very easily.

Perianal Haematoma

This condition is often misdiagnosed as a “thrombosed pile” but is actually an acute condition resulting from the rupture of a small blood vessel under the skin, adjacent to the anal canal. Typically the patient will give a history of sudden pain and the development of a painful lump whilst they were straining on the toilet.

Anal Fissure

This is a tear in the lining of the anal canal. It can be an acute or chronic condition and is often associated with a history of constipation. Usually the history relating to this problem consists of severe anal pain during defaecation. This can be associated with rectal bleeding, particularly after leaving the bathroom. The condition can lead to major problems if it becomes chronic, and can be difficult to treat.

Anal Polyps or Tumours

Polyps are fleshy growths which develop from the bowel lining. If these are near the anal canal they can prolapse outside the body and may mimic haemorrhoids. Some polyps may be premalignant and therefore need to be removed and tested.

It is also possible to develop tumours of the anus. This is a completely different disease to bowel cancer and can present in a number of different ways. If you have any concerns you should seek medical advice.

Fistula-in-Ano

Sometimes a track (fistula) exists between the inside of the bowel and the skin around the anus; this is called a “fistula-in-ano”. This means that bowel content can be extruded down the track and lead to leakage onto the skin. Patients present with smelly discharge from a small hole somewhere around the anus. If the condition is left untreated, and the track becomes blocked, the bowel content can fester in the tissues around the anus and form an abscess, requiring urgent surgical drainage.