The best definition of a haemorrhoid is a symptomatic anal cushion. The latter are three normal structures located approximately 4cm in from the anal verge. They are something that everyone is born with. They are simple elevations just underneath the lining (mucosa) of the anal rectal junction, and when they are opposed at rest they help to form a seal (with the help of the sphincter complex), so that nothing leaks out. For reasons that are not clear they swell up and when they swell up they become haemorrhoids.
What causes haemorrhoids?
It is not known what causes haemorrhoids. Things like chronic constipation, straining at stool, a diet that’s low in fibre and pregnancy certainly exacerbate them but do not necessarily cause them per se. Even when you do everything right with regards to diet you can still get haemorrhoids so it’s certainly far from a simple story. There is absolutely no evidence to implicate sitting on cold floors nor reading the newspaper on the toilet.
What are the symptoms of haemorrhoids?
The typical symptoms of haemorrhoids are:
- Bleeding (they are full of dilated blood vessels)
- Discomfort (due to the swelling and a minor degree of inflammation)
- Leakage due to an inadequate and ineffective seal
- Prolapse. The latter is due to the failure of the support of the haemorrhoids in the normal anatomical position allowing them to descend through the sphincter complex. The degree of prolapse is graded as follows (and the grade will inevitably dictate the management):
- Grade 1 – No prolapse
- Grade 2 – Prolapse with spontaneous reduction
- Grade 3 – Prolapse that requires digital reduction
- Grade 4 – Permanently prolapsed
Typically patients will present with a protracted history (many years) of bleeding, discomfort and prolapse. They will often also complain of itching and this is very much a manifestation of faecal soiling, secondary to the failure of the seal, and mucus production by the haemorrhoids themselves which tends to be very irritable to the perianal skin.
The first thing is to establish a proper diagnosis and this will also entail excluding more important causes of haemorrhoidal type symptoms such as rectal cancer (in particular bleeding). As a specialist haemorrhoids surgeon, Dr Renaut will take a careful history and then perform an examination including a Rigid Sigmoidoscopy. If there are any other symptoms to suggest an alternative diagnosis, once again in particular cancer, then he will recommend a colonoscopy.
The definitive treatment of haemorrhoids very much relates to the longevity of symptoms but also to the degree of prolapse.
- Conservative management – This is appropriate for patients that present with a short history and there is nothing to suggest any real prolapse. Management is largely in the form of increasing dietary fibre, including a regular fibre supplement as required, such a Metamucil.
- Prolapsing haemorrhoids require some form of intervention – HAL-RAR (Haemorrhoidal Artery Ligation and Recto-anal Repair). This is the standard treatment for prolapsing haemorrhoids. Dr Renaut no longer performs a haemorrhoidectomy as a first line treatment for prolapsing haemorrhoids. It is an unpleasant experience for both the patient and the surgeon and the recovery time is unacceptably long (several weeks). Importantly it also removes partially or wholly the anal cushions and patients unsurprisingly complain of leakage after the surgery. With a HAL-RAR procedure nothing is excised. The haemorrhoidal arteries are ligated above the haemorrhoid using a Doppler ultrasound probe. The recovery time is very much quicker than the traditional haemorrhoidectomy and the results are generally excellent.
For more information about the HAL-RAR procedure please see the relevant section of the website.