Management of Haemorrhoids
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.
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.
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.
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.
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.
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.