If you suffer from haemorrhoids or piles (and we do mean suffer in the highest degree known to humankind), misery loves company because one in three people in Singapore understands your predicament. Painful haemorrhoids are one of the most common issues here, especially in those above 30. According to HealthXchange, about half the people over the age of 50 exhibit symptoms.
Interestingly, everyone is born with haemorrhoids. “They are natural anal cushions that help to fully close the anus to prevent leakage while you’re at rest,” said Professor Emile John Tan, the head and senior consultant of Singapore General Hospital’s Department of Colorectal Surgery.
Most people are only intimately aware of these “cushions” of blood vessels when they become swollen and cause problems, said Adjunct Assistant Professor Lee Kai Yin, a consultant with National University Hospital’s Division of Colorectal Surgery, Department of Surgery.
You may know haemorrhoids as a pain in the butt but “the majority of haemorrhoids are actually painless”, said Adj Asst Prof Lee. You may not even know you have them as they are typically the internal ones inside your rectum.
But “out of sight” shouldn’t be “out of mind” as these internal piles can enlarge to the extent of prolapsing or protruding out of the anus, and cause swelling and bleeding, said Prof Tan. In fact, one of the signs of internal haemorrhoids is painless bleeding during bowel movements (you might spot blood on the toilet paper after wiping). You may also experience a sense of incomplete defecation.
Haemorrhoids are classified into internal and external ones. (Photo: iStock/Aleksandr Kharitonov)
The external haemorrhoids that you feel around your anus can range from small, flesh-coloured nodules to grape-sized growths. And if thrombosed (it means a clot known as a thrombus has formed), an external haemorrhoid can even appear dark blue, purple or black.
Regardless of size and appearance, these protrusions are often the ones that cause itching, pain and discomfort – and extremely so when thrombosed. “When haemorrhoids worsen, they enlarge, get inflamed and infected, or have internal bleeding, which cause a lot of pain at a very sensitive part of your body,” said Dr Quah Hak Mien, a general surgeon from Gleneagles Hospital.
Then, add your valiant effort at passing hard stools and you have a horrifically bad time in the bathroom.
Grade 1: Internal haemorrhoids with no prolapse or protrusion from the anus.
Grade 2: Increased pressure from passing hard stools, for example, pushes the internal haemorrhoid out of the anus. But it retracts on its own afterwards.
Grade 3: Similar to Grade 2 but the haemorrhoid, now an external one, doesn’t retract by itself and needs to be pushed back in.
Grade 4: This refers to external haemorrhoids that cannot be pushed back into their normal positions. They also risk becoming strangulated, an emergency situation where the blood supply to the haemorrhoid is cut off, and can result in sudden and immense pain.
Collapse Expand
Straining is the number one cause that results in the prolapse of internal haemorrhoids and the enlargement of external ones. This very act creates excessive pressure on the veins in the rectum and anus, which then causes the veins to stretch, thin out and eventually bleed or protrude. The damage occurs over time and with repeated bouts of straining or pressure.
In fact, any force that increases pressure in your annal area has the potential to push a vein out of position, including constipation, diarrhoea, prolonged sitting, heavy lifting and sitting on the toilet for far too long (get up if you’re reading this while doing your business for more than 15 minutes).
Sitting on the toilet for far too long can lead to haemorrhoids. (Photo: iStock/Patrick Daxenbichler)
“The common reasons are usually attributed to lifestyle and diet, such as low-fibre intake causing hard stools and straining; sedentary lifestyle; sitting on the toilet bowl for long periods of time; and obesity,” said Adj Asst Prof Lee.
Pregnancy is another common factor. The swollen veins in the rectum or anus are caused by increased pressure from the growing uterus and foetus, high blood volume and progesterone-related constipation. In fact, pregnancy piles are known to affect 25 per cent to 35 per cent of women in the third trimester.
If your parents or a close relative has had piles, you may have an increased hereditary risk. You could share genes that determine the strength of your vascular structures, making them more prone to swelling and inflammation.
Grades 1 and 2 haemorrhoids can usually be treated without the need for surgery, said Dr Quah.
Adj Asst Prof Lee agreed. “The majority of patients are treated conservatively. The first line of treatment is diet and lifestyle modifications. This includes increasing fibre and fluid intake, avoiding hard stools and straining, and avoiding prolonged sitting, especially on the toilet.”
Prolonged sitting can increase pressure on the anal veins. (Photo: iStock/Henadzi Pechan)
Next in line are medications, she continued, including over-the-counter topical and oral options. “Topical creams can help to relieve itch and some discomfort. Oral medications are usually given to help relieve the swelling of the haemorrhoids.”
“When the bleeding is persistent, or the piles are swollen and uncomfortable, a doctor’s opinion should be sought,” advised Prof Tan. “OTC medicines should only be used for the initial symptoms but will not substitute for a medical opinion.”
Surgical procedures include the following:
RUBBER BAND LITIGATION
It basically involves tying a band around the haemorrhoid. This is an effective treatment for early-stage piles, according to Dr Quah. “It does not require anaesthesia, causes minimal discomfort and have good success rate of about 80 per cent.” As simple as it sounds, it should be performed by the doctor – not you with a hair tie and an awkwardly held handheld mirror in your bathroom.
INJECTION SCLEROTHERAPY
A chemical solution is injected into the haemorrhoid (usually an internal one) to harden and shrink it. It is another effective treatment for early-stage piles, said Dr Quah. “It does not require anaesthesia and causes minimal discomfort. It can be done at a specialist clinic.”
Over-the-counter topical and oral medications can help mild haemorrhoids. (Photo: iStock/Ake Ngiamsanguan)
INFRARED PHOTOCOAGULATION
The procedure uses laser to shrink the internal haemorrhoid and cause it to fall off. However, "it is not very effective and not commonly used”, said Dr Quah. Adj Asst Lee also highlighted the issue of increased bleeding risk with this method, especially in patients who are on blood-thinning medications.
HAEMORRHOIDECTOMY
This most-commonly performed form of surgery involves cutting the haemorrhoids away using a hot electrocautery knife. According to Adj Asst Lee, it can be used on both internal and external piles. “It is usually the most painful of all the surgical procedures, with a downtime of three to four weeks.” Post-op care usually includes sitz baths or short soaks in salt water, she explained.
STAPLED HAEMORRHOIDOPEXY
It is also known as stapled haemorrhoidectomy, Longo’s procedure or PPH (Procedure for Prolapse and Haemorrhoids), said Dr Quah. But instead of a knife, it uses a specialised circular stapler. “The device removes the piles and seals the wound with a row of tiny staples,” he explained. “The wounds often heal within two weeks and few patients complain of severe pain.” The staples may fall off on their own and get passed out of the body, or remain without issue in the body.
See a doctor when the bleeding is persistent, or the piles are swollen and uncomfortable, even after using topical or oral medications. (Photo: iStock/sasirin pamai)
LASER HAEMORRHOIDOPLASTY
This procedure involves inserting a laser fibre into the haemorrhoid to concurrently shrink and "lift" it, explained Adj Asst Prof Lee. “Because there is no excision involved, there is much less pain and discomfort after surgery, with faster return to daily activities.”
They most certainly can, said the experts. “The most important treatment is still diet and lifestyle modifications because symptomatic haemorrhoids are usually caused by our lifestyle and diet habits,” said Adj Asst Prof Lee.
The good news is, “only a small proportion of patients require further treatment”, said Dr Quah. “If surgery was not done previously, it may have to be considered now. If surgery was done, we need to evaluate if surgery is suitable again.”
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Interestingly, everyone is born with haemorrhoids. “They are natural anal cushions that help to fully close the anus to prevent leakage while you’re at rest,” said Professor Emile John Tan, the head and senior consultant of Singapore General Hospital’s Department of Colorectal Surgery.
Most people are only intimately aware of these “cushions” of blood vessels when they become swollen and cause problems, said Adjunct Assistant Professor Lee Kai Yin, a consultant with National University Hospital’s Division of Colorectal Surgery, Department of Surgery.
DO DIFFERENT TYPES OF HAEMORRHOIDS HURT DIFFERENTLY?
You may know haemorrhoids as a pain in the butt but “the majority of haemorrhoids are actually painless”, said Adj Asst Prof Lee. You may not even know you have them as they are typically the internal ones inside your rectum.
But “out of sight” shouldn’t be “out of mind” as these internal piles can enlarge to the extent of prolapsing or protruding out of the anus, and cause swelling and bleeding, said Prof Tan. In fact, one of the signs of internal haemorrhoids is painless bleeding during bowel movements (you might spot blood on the toilet paper after wiping). You may also experience a sense of incomplete defecation.
Haemorrhoids are classified into internal and external ones. (Photo: iStock/Aleksandr Kharitonov)
The external haemorrhoids that you feel around your anus can range from small, flesh-coloured nodules to grape-sized growths. And if thrombosed (it means a clot known as a thrombus has formed), an external haemorrhoid can even appear dark blue, purple or black.
Regardless of size and appearance, these protrusions are often the ones that cause itching, pain and discomfort – and extremely so when thrombosed. “When haemorrhoids worsen, they enlarge, get inflamed and infected, or have internal bleeding, which cause a lot of pain at a very sensitive part of your body,” said Dr Quah Hak Mien, a general surgeon from Gleneagles Hospital.
Then, add your valiant effort at passing hard stools and you have a horrifically bad time in the bathroom.
GRADING HAEMORRHOIDS
Grade 1: Internal haemorrhoids with no prolapse or protrusion from the anus.
Grade 2: Increased pressure from passing hard stools, for example, pushes the internal haemorrhoid out of the anus. But it retracts on its own afterwards.
Grade 3: Similar to Grade 2 but the haemorrhoid, now an external one, doesn’t retract by itself and needs to be pushed back in.
Grade 4: This refers to external haemorrhoids that cannot be pushed back into their normal positions. They also risk becoming strangulated, an emergency situation where the blood supply to the haemorrhoid is cut off, and can result in sudden and immense pain.
Collapse Expand
WHAT ARE THE CAUSES?
Straining is the number one cause that results in the prolapse of internal haemorrhoids and the enlargement of external ones. This very act creates excessive pressure on the veins in the rectum and anus, which then causes the veins to stretch, thin out and eventually bleed or protrude. The damage occurs over time and with repeated bouts of straining or pressure.
In fact, any force that increases pressure in your annal area has the potential to push a vein out of position, including constipation, diarrhoea, prolonged sitting, heavy lifting and sitting on the toilet for far too long (get up if you’re reading this while doing your business for more than 15 minutes).
Sitting on the toilet for far too long can lead to haemorrhoids. (Photo: iStock/Patrick Daxenbichler)
“The common reasons are usually attributed to lifestyle and diet, such as low-fibre intake causing hard stools and straining; sedentary lifestyle; sitting on the toilet bowl for long periods of time; and obesity,” said Adj Asst Prof Lee.
Pregnancy is another common factor. The swollen veins in the rectum or anus are caused by increased pressure from the growing uterus and foetus, high blood volume and progesterone-related constipation. In fact, pregnancy piles are known to affect 25 per cent to 35 per cent of women in the third trimester.
If your parents or a close relative has had piles, you may have an increased hereditary risk. You could share genes that determine the strength of your vascular structures, making them more prone to swelling and inflammation.
WHAT TREATMENTS ARE AVAILABLE?
Grades 1 and 2 haemorrhoids can usually be treated without the need for surgery, said Dr Quah.
Adj Asst Prof Lee agreed. “The majority of patients are treated conservatively. The first line of treatment is diet and lifestyle modifications. This includes increasing fibre and fluid intake, avoiding hard stools and straining, and avoiding prolonged sitting, especially on the toilet.”
Prolonged sitting can increase pressure on the anal veins. (Photo: iStock/Henadzi Pechan)
Next in line are medications, she continued, including over-the-counter topical and oral options. “Topical creams can help to relieve itch and some discomfort. Oral medications are usually given to help relieve the swelling of the haemorrhoids.”
WHEN IS SURGERY NEEDED?
“When the bleeding is persistent, or the piles are swollen and uncomfortable, a doctor’s opinion should be sought,” advised Prof Tan. “OTC medicines should only be used for the initial symptoms but will not substitute for a medical opinion.”
Surgical procedures include the following:
RUBBER BAND LITIGATION
It basically involves tying a band around the haemorrhoid. This is an effective treatment for early-stage piles, according to Dr Quah. “It does not require anaesthesia, causes minimal discomfort and have good success rate of about 80 per cent.” As simple as it sounds, it should be performed by the doctor – not you with a hair tie and an awkwardly held handheld mirror in your bathroom.
INJECTION SCLEROTHERAPY
A chemical solution is injected into the haemorrhoid (usually an internal one) to harden and shrink it. It is another effective treatment for early-stage piles, said Dr Quah. “It does not require anaesthesia and causes minimal discomfort. It can be done at a specialist clinic.”
Over-the-counter topical and oral medications can help mild haemorrhoids. (Photo: iStock/Ake Ngiamsanguan)
INFRARED PHOTOCOAGULATION
The procedure uses laser to shrink the internal haemorrhoid and cause it to fall off. However, "it is not very effective and not commonly used”, said Dr Quah. Adj Asst Lee also highlighted the issue of increased bleeding risk with this method, especially in patients who are on blood-thinning medications.
HAEMORRHOIDECTOMY
This most-commonly performed form of surgery involves cutting the haemorrhoids away using a hot electrocautery knife. According to Adj Asst Lee, it can be used on both internal and external piles. “It is usually the most painful of all the surgical procedures, with a downtime of three to four weeks.” Post-op care usually includes sitz baths or short soaks in salt water, she explained.
STAPLED HAEMORRHOIDOPEXY
It is also known as stapled haemorrhoidectomy, Longo’s procedure or PPH (Procedure for Prolapse and Haemorrhoids), said Dr Quah. But instead of a knife, it uses a specialised circular stapler. “The device removes the piles and seals the wound with a row of tiny staples,” he explained. “The wounds often heal within two weeks and few patients complain of severe pain.” The staples may fall off on their own and get passed out of the body, or remain without issue in the body.
See a doctor when the bleeding is persistent, or the piles are swollen and uncomfortable, even after using topical or oral medications. (Photo: iStock/sasirin pamai)
LASER HAEMORRHOIDOPLASTY
This procedure involves inserting a laser fibre into the haemorrhoid to concurrently shrink and "lift" it, explained Adj Asst Prof Lee. “Because there is no excision involved, there is much less pain and discomfort after surgery, with faster return to daily activities.”
CAN HAEMORRHOIDS RECUR?
They most certainly can, said the experts. “The most important treatment is still diet and lifestyle modifications because symptomatic haemorrhoids are usually caused by our lifestyle and diet habits,” said Adj Asst Prof Lee.
The good news is, “only a small proportion of patients require further treatment”, said Dr Quah. “If surgery was not done previously, it may have to be considered now. If surgery was done, we need to evaluate if surgery is suitable again.”
Continue reading...