Haemorrhoids

Haemorrhoids are swollen veins in and around the anus and lower rectum. They are sometimes called piles and are very common; about 75% of people will have them at some point in their lives.^[1]

There are two types:

• Internal haemorrhoids: develop inside the lower rectum. Usually painless. May push outward (prolapse) through the anus. Most return on their own; severely prolapsed haemorrhoids may require treatment.
• External haemorrhoids: develop under the skin around the anus. Can be more painful, especially if a blood clot forms (thrombosis), causing a firm, painful lump.

Symptoms

Internal haemorrhoids:

• Bright red blood on stool, toilet paper, or in the toilet bowl after a bowel movement
• Prolapse: a bulge from the anus that may cause discomfort or itching

External (thrombosed) haemorrhoids:

• Pain, swelling, or a hard lump around the anus
• Itching or irritation around the anal area

Causes

Contributing factors include:^[1,2]

• Chronic constipation or diarrhoea
• Straining during bowel movements
• Sitting on the toilet for long periods
• A low-fibre diet
• Pregnancy: increased abdominal pressure can enlarge veins in the lower rectum. Pregnancy-related haemorrhoids usually resolve after birth.
• Ageing: connective tissue in the rectum and anus naturally weakens over time.

Diagnosis

A doctor can usually diagnose haemorrhoids through a physical examination and rectal exam. Haemorrhoid symptoms (particularly bleeding) can overlap with symptoms of other conditions; always see a doctor rather than assuming the cause.^[3,4]

If you are over 40, or if bleeding is significant, your doctor may recommend additional tests to rule out colorectal cancer:^[4]

• Colonoscopy: a flexible camera is passed through the entire colon
• Sigmoidoscopy: examines only the lower section of the bowel

Treatment

At-home treatment

Simple lifestyle changes often relieve symptoms within a few days:^[1,2]

• Increase dietary fibre: aim for 25-38 grams per day. High-fibre foods soften stools and reduce straining.
• Drink 6-8 glasses of water per day.
• Take a fibre supplement such as psyllium husk (Metamucil) if needed.
• Sit in a warm sitz bath for 10 minutes several times a day to reduce swelling and discomfort.
• Exercise regularly to help prevent constipation.
• Do not strain during bowel movements.
• Use over-the-counter haemorrhoid creams or suppositories for short-term relief. Do not use for more than a week without medical advice; prolonged use can damage skin.

Medical procedures

• Rubber band ligation: a small rubber band is placed around the base of the haemorrhoid, cutting off blood supply so it shrinks and falls off within days. The most commonly used and effective procedure for internal haemorrhoids.^[2]
• Sclerotherapy: a chemical solution is injected to shrink the haemorrhoid.
• Infrared coagulation: heat is used to shrink the haemorrhoid tissue.

Surgery

Large external haemorrhoids, or internal haemorrhoids that do not respond to other treatments, may be surgically removed (haemorrhoidectomy) under anaesthesia. This is the most effective long-term treatment.^[2]

Prevention

• Eat a high-fibre diet with plenty of fruit, vegetables, and wholegrains
• Drink plenty of water
• Exercise regularly
• Respond promptly to the urge to have a bowel movement and do not delay
• Avoid sitting on the toilet for extended periods

Resources

• Gastroenterological Society of Australia (GESA): www.gesa.org.au - Find a gastroenterologist and evidence-based management guidelines
• Bowel Cancer Australia: 1800 555 494 | www.bowelcanceraustralia.org - Important information on rectal bleeding and when to seek medical attention
• Continence Foundation of Australia: 1800 330 066 | www.continence.org.au - Resources on bowel health, haemorrhoids, and pelvic floor health
• Dietitians Australia: www.dietitiansaustralia.org.au - Find a dietitian for high-fibre dietary advice

References

1.Mott T, et al. (2018). Hemorrhoids: Diagnosis and Treatment Options. American Family Physician, 97(3), 172-179.

2.Davis BR, Lee-Kong SA, Migaly J, et al. (2018). The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Diseases of the Colon and Rectum, 61(3), 284-292.

3.Gastroenterological Society of Australia (GESA). (2023). Haemorrhoids management.https://www.gesa.org.au

4.Bowel Cancer Australia. (2024). Rectal bleeding - when to seek help.https://www.bowelcanceraustralia.org