Piles and Fissure

Piles (Haemorroids)

Haemorrhoids, also known as piles, are swellings that contain enlarged blood vessels that are found inside or around the bottom (the rectum and anus).
Most haemorrhoids are mild and sometimes don’t even cause symptoms. When there are symptoms, these usually include:

  •  Bleeding after passing a stool (the blood will be bright red)
  •  Itchy bottom
  • A lump hanging down outside of the anus, which may need to be pushed back in after passing a stool
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What causes piles?
The exact cause of haemorrhoids is unclear, although they are associated with increased pressure in the blood vessels in and around your anus. Most cases are thought to be caused by excessive straining on the toilet, due to prolonged constipation, often resulting from a lack of fibre in your diet. Things that can increase your risk of haemorrhoids include:
• being overweight
• being over the age of 45
• pregnancy
• having a family history of haemorrhoids
Preventing and treating piles Haemorrhoid symptoms often settle down after a few days without treatment. Haemorrhoids that occur due to pregnancy usually get better after you give birth. However, making lifestyle changes to reduce the strain on the blood vessels in and around your anus is often recommended. These can include:
• gradually increasing the amount of fiber in your diet – good sources of fiber include fruit, vegetables, wholegrain rice, whole wheat pasta and bread, seeds, nuts and oats
• drinking plenty of fluid, particularly water, but avoiding or cutting down on caffeine and alcohol
• not delaying going to the toilet – ignoring the urge to empty your bowels can make your stools harder and drier, which can lead to straining when you do go to the toilet
• avoiding medication that causes constipation – such as painkillers that contain codeine
• losing weight if you are overweight
• exercising regularly – this can help prevent constipation, reduce your blood pressure and help you lose weight
These measures can also reduce the risk of haemorrhoids returning, or even developing in the first place.
Medication that you apply directly to your back passage (topical treatments) prescribed by your doctor may ease your symptoms and make it easier for you to pass stools.
If your haemorrhoid symptoms are more severe, there are a number of treatment options available.

Symptoms of piles (haemorrhoids)
Most cases of piles (haemorrhoids) are mild, and the symptoms often disappear on their own after a few days.
Some people may not even realise they have haemorrhoids, as they do not experience symptoms.
However, when symptoms do occur they may include:
• bleeding after passing a stool (the blood will be bright red)
• itchiness around your anus (the opening where stools leave the body)
• a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool
• a mucus discharge after passing a stool
• soreness, redness and swelling around your anus
Haemorrhoids are not usually painful unless their blood supply slows down or is interrupted.

Causes of piles (haemorrhoids)
The exact cause of piles (haemorrhoids) is unclear, but many cases are thought to be linked to increased pressure in blood vessels in and around the anus. This pressure can cause the blood vessels in your back passage to become swollen and inflamed.
Who’s at risk
Factors that increase your chance of getting haemorrhoids include:
• being overweight or obese
• persistent constipation, often due to a lack of fiber in your diet
• prolonged diarrhoea
• regularly lifting heavy objects
• a persistent cough or repeated vomiting
• prolonged sitting down
• being pregnant (the haemorrhoids will usually improve after you give birth)
• being over 45 years of age – as you get older, your body’s supporting tissues get weaker, increasing your risk of haemorrhoids
• a family history of haemorrhoids, which could mean you’re more likely to get them.

Diagnosing piles (haemorrhoids)
Piles (haemorrhoids) can be easily diagnosed by your doctor. To do so, they will examine your back passage to check for swollen blood vessels.
Rectal examination
Your doctor may examine the outside of your anus to see if you have visible haemorrhoids, and they may also carry out an internal examination called a digital rectal examination (DRE).
Proctoscopy
In some cases, further internal examination using a proctoscope may be needed. A proctoscope is a thin hollow tube with a light on the end that is inserted into your anus.

Colonoscopy:
In some cases, doctor may advice you Colonoscopy or endoscopy to rule out any other medical conditions like cancer or inflammatory bowel disease.
Types of haemorrhoids
After a rectal examination or proctoscopy, your doctor can determine what type of haemorrhoid you have.
• first degree – small swellings that develop on the inside lining of the anus and are not visible from outside the anus
• second degree – larger swellings that may come out of your anus when you go to the toilet, before disappearing inside again
• third degree – one or more small soft lumps that hang down from the anus and can be pushed back inside (prolapsing and reducible)
• fourth degree – larger lumps that hang down from the anus and cannot be pushed back inside (irreducible)
It’s useful for doctors to know what type and size of haemorrhoid you have, as they can then decide on the best treatment. Read more about treating haemorrhoids.

Treating piles (haemorrhoids)
Piles (haemorrhoids) often go away by themselves after a few days. However, there are many treatments that can reduce itching and discomfort.
Making simple dietary changes and not straining on the toilet are often recommended first.
Dietary changes and self-care
If constipation is thought to be the cause of your haemorrhoids, you need to keep your stools soft and regular, so that you don’t strain when passing stools.
You can do this by increasing the amount of fibre in your diet. Good sources of fibre include whole grain bread, cereal, fruit and vegetables.
You should also drink plenty of water and avoid caffeine (found in tea, coffee and cola).
Follow the below advice when going to the toilet:
• avoid straining to pass stools, as this may make your haemorrhoids worse
• after passing a stool, use moist toilet paper or baby wipes to clean your bottom, rather than dry toilet paper
• pat the area around your bottom, rather than rubbing it

Medication

Corticosteroid cream
If you have severe inflammation in and around your back passage, your doctor may prescribe corticosteroid cream, which contains steroids.

Painkillers
Common painkilling medication, such as paracetamol, can relieve the pain of haemorrhoids. However, you should avoid codeine painkillers, as they can cause constipation. Products that contain local anaesthetic (painkilling medication) may also be prescribed by your doctor to treat painful haemorrhoids. Laxatives If you are constipated, your doctor may prescribe a laxative. This is a type of medication that can help you empty your bowels.

Non-surgical treatments
If dietary changes and medication don’t help, your doctor may recommend appropriate treatment non-surgical procedures such as banding and sclerotherapy.

Banding
Banding is a procedure that involves placing a very tight elastic band around the base of your haemorrhoids, to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment.

Injections (sclerotherapy) A treatment called sclerotherapy may be used as an alternative to banding. During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so that a scar is formed. After about four to six weeks, the haemorrhoid should decrease in size.

Surgery for piles (haemorrhoids)
Surgery may be recommended if other treatments for piles (haemorrhoids) have not been successful, or if you have haemorrhoids that are not suitable for non-surgical treatment. There are many different surgical procedures for piles. The main types of operation are described below.

Haemorrhoidectomy
A haemorrhoidectomy is an operation to remove haemorrhoids. It is usually carried out under general anaesthetic orspinal anaesthesia. A conventional haemorrhoidectomy involves gently opening the anus so the haemorrhoids can be cut out. You will need to take a week or so off work to recover. After having a haemorrhoidectomy, there is around a 1 in 20 chance of the haemorrhoids returning, which is lower than with non-surgical treatments. Adopting or continuing a high-fibre diet after surgery is recommended to reduce this risk. Transanal haemorrhoidal dearterialisation (THD) or haemorrhoidal artery ligation (HALO) Transanal haemorrhoidal dearterialisation (THD) or haemorrhoidal artery ligation (HALO) is an operation to reduce the blood flow to your haemorrhoids.
It’s usually carried out under general anaesthetic and involves inserting a small device, which has a Doppler ultrasound probe attached, into your anus. This probe produces high-frequency sound waves that allow the surgeon to locate the blood vessels in and around your anal canal. These blood vessels supply blood to the haemorrhoid.

Stapler Heamorroidectomy:
Stapling, also known as stapled haemorrhoidopexy, is an alternative to a conventional haemorrhoidectomy. It is sometimes used to treat prolapsed haemorrhoids and is carried out under general anaesthetic. This procedure is not carried out as often as it used to, because it has a slightly higher risk of serious complications than the alternative treatments available. However, after stapling, more people experience another prolapsed haemorrhoid compared with having a haemorrhoidectomy. There have also been a very small number of serious complications following the stapling procedure, such as fistula to vagina in women (where a small channel develops between the anal canal and the vagina) or rectal perforation (where a hole develops in the rectum). General risks of haemorrhoid surgery
Although the risk of serious problems is small, complications can occasionally occur after haemorrhoid surgery. These can include:
• bleeding or passing blood clots
• infection, which may lead to a build-up of pus (an abscess).
• urinary retention (difficulty emptying your bladder)
• faecal incontinence (the involuntarily passing of stools)
• anal fistula
• stenosis (narrowing of the anal canal)

Cost of Piles (Haemorroids) Surgery:
Cost depends on lots of factors such as
• Bed category
• Type of Surgery (stapled or haemorroidectomy)
• Choice of hospital etc
• Preexisting medical conditions such as diabetes, angina which may prolong your hospital stay or need critical monitoring.
Following your first meeting with the doctor, we would be able to give you an approximate estimate.

Fissure

What is an anal fissure?

An anal fissure is a tear or a small crack in the skin at the lower end of the anus (back passage). The condition is also referred to as Fissure-in-ano. It is probably the result of pressure forced onto the wall of the anal canal either by the passage of hard stool or straining with a loose stool.

What are the symptoms?

Pain: The pain is severe on and following bowel action and it can last a few minutes to several hours. The pain is caused by spasm of the anal sphincter (the inner circle of muscle in the anal canal). Because of the pain, patients with this condition fear bowel movement and often try to avoid it. This leads to further constipation with harder stools, which in turn increases the pain.
Bleeding: The tear may result in bleeding during bowel movement.
Skin tag: Sometimes swelling can occur near or around the fissure. This can cause a skin tag to develop (a piece of skin which hangs from surrounding skin). This can have mucus discharge (oozing) which causes excoriation (rubbing of the area around) and itchiness.

What are the Treatments?

Conservative treatment :
• High fibre diet By eating a high fibre diet you should aim to keep your stools soft but bulky.
• Increase fluids Drinking plenty of water (about 2 to 2.5 litres per day) will also help to keep your stools soft.
• Local anaesthetic ointment Sometimes applying local anaesthetic ointment before and after a bowel movement makes passing stools easier with less pain. Your doctor may prescribe you an ointment to relieve spasm locally and to reduce swelling.

Surgical treatment:
If the above measures have not healed your fissure, surgery might be considered. The operation for anal fissure is called a lateral sphincterotomy and it has a high success rate of curing fissures. 20%) of some change in your ability to control wind from the back passage. You could also experience some soiling (slight incontinence).

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