How can hemorrhoids be treated?

Haemorrhoids, also commonly known as piles, can be treated successfully in a variety of different ways.  There is no one ideal treatment and the decision about which option is best will be determined by a number of factors.  We must first understand what haemorrhoids are and what problems they cause.

Haemorrhoids are essentially an enlargement of normal veins.  We all have soft cushions within the anus that help to form a seal to close the anus effectively.  There are usually three of these cushions and they are each made up of a nest of veins.  When these cushions create symptoms they are then called haemorrhoids.  The haemorrhoidal veins will become enlarged when they are placed under high pressure.  This pressure is often generated by straining to go to the toilet which can be the result of constipation or diarrhoea.

As such the first line of treatment is to improve bowel function and reduce the pressure needed to pass a bowel motion.  A fibre supplement, such as psyllium husk, and adequate fluid intake are important in regulating bowel function.  An effort should be made to open the bowels regularly and avoid straining.  These simple measures may stop the bleeding from minor haemorrhoids completely.  Improving bowel function in this way is also important to improve the success of other haemorrhoid treatments and to prevent recurrence of haemorrhoids after treatment

The next step is a simple procedure to destroy the enlarged veins that form the haemorrhoids.  Traditionally this can be done by sclerosant injections into the haemorrhoids or alternatively rubber band ligation (banding) of the haemorrhoids.  The injection, typically phenol in almond oil, causes the blood within the haemorrhoid to clot and with time the tissue essentially shrivels up.  Banding involves placing a small rubber band around the excess veins to strangle them.  The strangled tissue and the rubber band then fall off a few days or so later.  The evidence shows that in general banding is more effective than injection.  Both of these procedures can be performed in the office without sedation.  They involve inserting a proctoscope (a small plastic tube) into the anus so that the haemorrhoids can be seen and then treated.  The procedures are often also performed under sedation at the same time as a colonoscopy.  Following the procedure you can expect some discomfort for 1-2 days and a small amount of bleeding.

Banding and injection therapy are effective for haemorrhoids that bleed without protruding through the anus or if they protrude (prolapse) but then return spontaneously.  This treatment can be successful for haemorrhoids that protrude and need to be pushed back in but for these larger haemorrhoids the procedure may need to be repeated.

For larger haemorrhoids that prolapse more extensive surgery may be required.  Traditionally this has involved cutting out each of the three haemorrhoids from outside the anus and extending up into the rectum.  This operation causes significant pain and the wounds can take several weeks to heal.  As such there is a constant search for less invasive surgery that remains effective.  Common techniques include haemorrhoidal artery ligation and stapled haemorrhoidectomy.  All of these operations are performed in hospital and require some form of anaesthetic.  They also often require at least one night in hospital  after the procedure.  Whilst newer techniques are less painful than traditional haemorrhoidectomy they are not completely painless.  

The choice of treatment depends on the nature and severity of symptoms that the haemorrhoids are causing.

Management of Haemorrhoids
Conservative treatments
Many patients will respond to conservative measures including avoidance of straining, increasing fibre intake (methylcellulose from vegetables, as well as from wheat bran or psyllium husk) and adequate daily hydration. For patients with intermittent minor bleeding, an over-the-counter preparation (eg, Scheriproct®, Proctosedyl®, Anusol ®) is often the first line treatment. These preparations often consist of a mixture of the following ingredients:
 
Astringents (eg, cinchocaine). Astringents have a constrictive effect on the blood vessels and may also have a local anaesthetic effect.
Cortisones (eg, hydrocortisone, prednisolone). Topical steroids act to reduce oedema and inflammation as well as having an anti-pruritic effect.
Topical antibiotics (eg, framycetin). Topical antibiotics act to reduce any superimposed infection which may increase the oedema, inflammation and pruritis.
 
For many patients an over-the-counter product will reduce or resolve the symptoms completely. For any patient for whom a single course of topical preparation is ineffective, or who returns for repeat courses in a short period of time, a specialist opinion is required to confirm that haemorrhoids are in fact the cause and to exclude any sinister pathology. Many patients present with ‘haemorrhoids’ and long-term failure of topical preparations to settle their haemorrhoidal symptoms when the true cause is a chronic fissure or fistula or even a squamous carcinoma of the anus.

Surgical treatments
When conservative measures fail, the following surgical treatments may be recommended. The goal of all treatments is to shrink the piles down and stop them from prolapsing.

Injections:
The simplest and easiest treatment for early piles (grade 1-2) is to inject them with a mixture of phenol and almond oil. This is a sclerosant causing intense irritation to the blood vessels which become inflamed (temporarily) and the blood within them then thromboses, causing further inflammation. This irritation then adheres the lining of the haemorrhoid to the fascia/muscle underneath.

The benefits of this treatment are that it is easy and practically painless and can be done without an anaesthetic. The downside is that the result is unpredictable and often needs to be repeated to get the desired result; also, the recurrence rate over time is high. There have also been occasional reports of injection of the sclerosant into the prostate with a resulting chemical prostatitis, and therefore haemorrhoids in the anterior location should be injected with caution.

Rubber banding:
This treatment involves placing a tiny rubber band, approximately 1mm in diameter, over the haemorrhoids towards their base. This treatment is mainly performed for slightly larger haemorrhoids, with grade 2-3 symptoms. This is done using special banding instruments but can be performed without anaesthetic, although many patients do elect to be sedated in hospital for the treatment (with or without colonoscopy, as appropriate). The aim of the banding is to pinch off a section of the haemorrhoid so that it thromboses and necroses and at the same time causes enough irritation to adhere the remaining tissue to the sub-epithelial tissues.

As for injection, the results are a little unpredictable and the treatment often needs to be repeated. The main risk, however, is significant pain and bleeding after the procedure, and although rare this can sometimes be severe enough to require hospitalisation. For this reason, banding should be avoided within ten days to two weeks of planned foreign travel due to the risk of bleeding.

Haemorrhoidectomy:
For more advanced cases of haemorrhoids (grade 3-4) a haemorrhoidectomy may be recommended. This is a surgical procedure in which the haemorrhoids are fully excised and open wounds are left within the anus which can take up to 8-10 weeks to heal fully.

The post-operative pain and discomfort of haemorrhoidectomy is unbearable for most patients. Daily dressings are required along with salt baths and the need to wear a pad in the underwear until healing is complete. Sexual activity is frequently not possible due to the pain. It is one of the only operations originally described in the 1930s still in common use today. There are many patients suffering from large haemorrhoids who continue to suffer simply because they are (understandably) too frightened to have the surgery.

Stapled Haemorrhoidopexy:
The stapled haemorrhoidopexy was introduced in 1998 and is aimed at avoiding surgery directly to the anus. A cuff of lower rectal mucosa (3-4 cm above the anus, where there are few pain nerves) is incorporated into a stapling device which, when fired, excises the cuff of mucosa with simultaneous anastomosis. The procedure includes the submucosal vascular supply to the haemorrhoids in the cuff of tissue and at the same time reduces the haemorrhoids to their anatomical location. The operation is highly effective and post-operative pain is greatly reduced compared with haemorrhoidectomy, and there is no need for post-operative dressings, salt baths or external wounds.
 
The HAL-RAR procedure was invented in 1995 and is another modern approach to haemorrhoid surgery. The operation is performed using a Doppler guided ultrasound probe which is inserted into the anus to locate the arteries which feed the haemorrhoids above the anus, where there are fewer pain nerves. Once located the probe allows a stitch to be placed around the artery, cutting off the blood supply to the haemorrhoids. Six or seven arteries feed the haemorrhoids and they are all tied during the procedure. The stitch is also configured such that any prolapse associated with the haemorrhoids is dealt with simultaneously (the anal repair component of the procedure).

As a result of HAL-RAR the haemorrhoids lose their high pressure blood supply and shrivel up and disappear. No cuts or wounds are created, and no salt baths or pads in the underwear are needed. There is discomfort and throbbing after the procedure for about a week to ten days but most patients are back to normal very quickly.

I suffered from Hemorrhoids and had several excised at the local GP. One GP when I was 18 and didn't know any better cut into the wall of my bowel to remove it altogether and that was very, very painful and shouldn't of been done in a GP surgery now knowing what I know! I have also had 3 surgeries to band them to no avail, they come back. I was booked in for a Hemorroidectomy and thank god I changed my mind at the last minute and had banding as the pain and recovery from such an operation is gruelling and you can lose your anal seal and leak thereafter. What I did next was to find a surgeon who has performed the HAL/RAR as mentioned above. What a godsend! No more hemmorhoids, very little discomfort and definitely worth looking at above all othe other options.