The lining of the anal canal contains three soft, spongy pads of tissue that act as an extra seal to keep the canal closed until you go to the lavatory. The lining of the gut is very slimy (so that faeces can pass along easily); the extra seal stops the slime (mucus) from leaking out. The pads contain a network of tiny blood vessels.
What are piles?
People sometimes think that piles (haemorrhoids) are like varicose veins of the legs (i.e. a single vein that has become swollen). This is not the case. A pile is one of the soft pads that has slipped downwards slightly, because the surrounding tissue is not holding it in place properly (British Medical Journal 2008;336:380–3). When this happens, the small blood vessels within the cushion become engorged with blood, so the cushion swells up. When faeces are passed, the pile may be pushed further down the anal canal to the outside, and this is called a prolapsed pile. Doctors classify piles into three types.
First-degree piles are swollen cushions that always remain within in the anal canal; these are painless.
Second-degree piles are pushed down (prolapsed) when faeces are passed, but return to their starting position afterwards.
Third-degree piles are pushed down (prolapsed) when faeces are passed, or come down at other times. They do not go back by themselves after faeces have been passed.
Who gets piles?
Piles can occur at any age, but are more common in older people. They affect both men and women. In fact, most people suffer from piles at some time, but usually they are nothing more than a temporary problem. Many experts believe that they are caused by continuous high pressure in the veins of the body, which occurs because humans stand upright. They are particularly common in pregnancy because of the additional pressure from the baby, and because of hormonal changes. Sometimes they result from straining hard to pass faeces, which is more likely if you do not eat enough fibre, or lifting heavy weights. They are not caused by sitting on hot radiators or cold, hard surfaces, or by sedentary jobs.
What are the symptoms of piles?
The symptoms of piles can come and go. There are five main symptoms:
bleeding, with bright red blood
itching and irritation
aching pain and discomfort
a lump, which may be tender
soiling of underwear with slime or faeces (‘skid marks’).
Itching and irritation probably occur because the lumpy piles stop acting as soft pads to keep the mucus in; instead, a little mucus leaks out and irritates the area around the anus. Pain and discomfort comes from swelling around the pile, and from scratching of the lining of the anal canal by faeces as they pass over the lumpy area. The scratching also causes bleeding, which is a fresh bright red colour and may be seen on faeces or toilet paper or dripping in the pan. A pile that has been pushed down (a second- or third-degree pile) may be felt as a lump at the anus.
How you can help yourself
Most piles get better in a few days without any treatment, but there are several ways of relieving the discomfort.
Wash the area gently with warm, salty water, to get rid of irritant mucus that has leaked out. Dry carefully with cotton wool and apply petroleum jelly (available from pharmacies) or nappy rash cream to protect your skin if more mucus or moisture leaks out.
Use soft toilet paper, and dab rather than wipe.
Wear loose underwear and clothing (i.e. not tight trousers), so that nothing will rub the pile.
Do not scratch. For more information on dealing with itch, look at the section on anal itching.
Avoid constipation by eating lots of fresh fruit and vegetables and bran cereal. Aim for faeces that are soft enough to change their shape as you push them out.
Drink plenty of fluids.
After you have passed the faeces, do not strain to finish. People with piles often think there is more to come, but this is a false sensation caused by the swollen spongy pads in the piles themselves. Do not read on the toilet and aim to be out of the toilet within a minute.
If you can feel a lump, try pushing it gently upwards; try to relax your anus as you do so.
If you have a lot of discomfort, buy a haemorrhoid cream or gel. A pharmacist will be able to help you choose one that is suitable for you. A haemorrhoid cream or gel does not cure the pile, but will usually relieve the discomfort effectively until the pile goes away of its own accord. Do not use it for longer than a week or two.
To stop piles returning, continue the high-fibre diet to keep your stools soft and do not put off opening your bowels, and avoid straining.
When to see your doctor
See your doctor if the symptoms last longer than a week. You should also see your doctor if you have bleeding, to ensure that there is not some other cause. Your doctor will examine your anus, feel inside the anal canal and may also insert a small metal tube, called a proctoscope, an inch or two into the anal canal to give a better view. For more information, look at the section on seeing your doctor about an anal problem
What your doctor can do
First- and second-degree piles usually go away on their own if constipation is avoided, but your doctor may prescribe a short course of haemorrhoid cream to relieve symptoms. Third-degree piles may also go away on their own, but if they persist, they may need hospital treatment.
Only a few people need an operation; most are treated by banding or phenol injections. There is usually no need for a general anaesthetic or to stay in hospital overnight for these procedures. Stretching (anal dilatation) was a popular treatment in the 1970s, but is seldom used now.
'Venotonic' drugs are popular treatments for piles in Europe (especially France) and in the Far East. The most common are the so-called 'flavonoid' chemicals such as diosmin, hidrosmin, hesperidin and rutosides. Researchers have looked at all the evidence on these drugs, and have concluded that it is not possible to say whether they are effective because most of the research studies have been flawed in one way or another (British Journal of Surgery 2006;93:909–20).
Banding involves placing a small rubber band at the base of the pile, so that it pinches the lining of the anal canal. This ‘strangles’ the pile, so it dies and falls off. It causes some scarring. It is more effective than the other treatments but has some drawbacks, such as severe bleeding in a few cases. There fore you need to tell the surgeon if you are on blood-thinning medication. Some people feel faint and nauseous just after the bands are put on, and they can be quite painful for the following 48 hours. According to an article in the British Medical Journal (2003;327:8847–521), the success rate for banding is:
79% of piles are cured
18% of piles return so that repeat banding is needed
for 2% of piles, it does not work at all.
Injection of phenol in almond oil is a method of causing scarring in the area, but produces a permanent cure in only about 25% of cases. It is less commonly used now, because the results are not as good as with banding.
Cryosurgery freezes the pile to destroy it. It is not used much, because it causes a watery discharge afterwards.
Infrared coagulation uses infrared light to destroy the pile. This method is not commonly used, because it is not as effective as other methods.
Surgery. There are several different operations for piles.
In the usual operation, the swollen spongy pad that forms the pile is cut away. It is painful for 7–10 days afterwards.
A newer operation, called ‘stapling’, involves cutting away a 2 cm strip of the lining of the rectum and joining the cut edges with a special stapler. People seem to recover quicker from ‘stapling’ than from the ordinary operation. It is not yet a common operation in the UK, but it is popular in the rest of Europe. Although it is less painful than the ordinary operation, it seems to be less effective in the long-term and about 12% of people have a recurrence of the piles within 16 months (Surgery 2006;24(4):148–50). However, more research is needed.
Another type of operation uses ultrasound to locate the arteries that feed blood into the pile. These arteries are then closed off using stitches. Bleeding from the pile decreases over the following few weeks. This treatment is becoming more popular, partly because it does not involve any cutting and is almost painless. More research is needed to see if it is effective in the long-term.
Dr Phil Hammond expands on haemorrhoids in his Expert guide to Anal itching video, and for a lighthearted look at piles see his poem, Pile Driver.
Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Friday, March 8th 2013
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