All diseases are pain in the butt, but when ‘pain in the butt’ itself becomes a disease, it makes you sit and think, or rather stand and think about how being able to sit down peacefully is an under-appreciated luxury that life offers. Haemorrhoids, commonly known as piles, refers to one such medical condition that if left unchecked can wreak havoc in one’s life and be psychologically debilitating as well. Simple things like going to the toilet in the morning, choosing what to eat, cycling or riding on a motorcycle become things you dread. Even a speed breaker on the road can become a scary sight! Here’s everything you need to know about haemorrhoids and how to manage it or even better, steer clear of it in life.

What are haemorrhoids?

The interior of the anal cavity contains cushions made of specialized soft tissues and smooth muscles. These anal cushions are highly vascular which means they have a rich supply of veins and arteries, and they support the anal sphincters in maintaining continence (prevention of involuntary expulsion of stool). Prolonged constipation or strain on these cushions causes the veins in them to engorge and the resultant enlarged anal cushions are known as haemorrhoids. When these enlargements remain inside the rectum, they’re called internal haemorrhoids and when they’re visible under the skin around the anus, they’re called external haemorrhoids.

Who is at risk of getting haemorrhoids?

You know now that prolonged constipation and abdominal straining can cause haemorrhoids, hence anyone with a medical condition, lifestyle or food habits that make one susceptible to constipation or abdominal straining is at risk of getting haemorrhoids.

• Haemorrhoids are commonly associated with :-
  People who have a low intake of dietary fiber. Foods that are high in fiber make stools softer and easier to pass. Therefore, people who do not consume enough fiber in their diet through vegetables and roughages are naturally at a higher risk of getting haemorrhoids.

•  Pregnancy. Constipation is common during pregnancy and combining this with the pressure from the uterus and hormonal variations places pregnant women at risk of getting haemorrhoids.

• Obesity. Inadequate fiber intake along with a high consumption of oily and fatty food items leads to stool formations that put undue strain on the anal cushions. Adding to this, their decreased level of physical activity and prolonged sitting time, makes obese people more susceptible to getting haemorrhoids.

• The age group between 45 and 60 - The risk of getting haemorrhoids increases with age because the tissues that support the veins in these anal cushions weaken as you get older and this causes the veins to stretch easily.

• Consistently high intra-abdominal pressure. High intra-abdominal pressure is associated with straining and is commonly found in people who lift heavy objects on a day-to-day basis. This is why a lot of people who do regular heavy-weight training in the gym get haemorrhoids. On one hand, they indulge in a high protein, low fiber diet which leads to hard stool formation. The pressure this causes on the veins of the anus is worsened by regular straining in the gym. People with chronic lung diseases are also at risk of developing haemorrhoids as constant coughing also results in high intra-abdominal pressure.                                               

Symptoms of haemorrhoids

For most people, haemorrhoids initially present as painless, bright red bleeding while passing stool. Other symptoms include soreness, itching or a lumpy feeling in the anus. Depending upon the degree of haemorrhoids, any or all of the symptoms may present or it could remain asymptomatic. Also, haemorrhoids aren’t the only medical condition that presents with bleeding while passing stool. Blood from haemorrhoids can be differentiated as bright red spots in the toilet that do not mix with the stool. It goes without saying that any form of rectal bleeding is a cause for concern hence consult a general surgeon immediately in such an event.

A general surgeon diagnoses the presence of haemorrhoids either through a digital rectal (PR) examination or by proctoscopy. In a proctoscopy, the surgeon visualizes the interior of the rectum by inserting a proctoscope through the anus (which isn’t as painful as it sounds!). The latter is more accurate as some types of internal haemorrhoids are difficult or impossible to detect through palpation (PR exam).

Types of haemorrhoids

Apart from internal and external haemorrhoids, they can be classified based on severity as follows.
1st-degree haemorrhoids with no prolapse (external protrusion)
2nd-degree haemorrhoids that prolapse on straining and return into the anus on relaxing.
3rd-degree haemorrhoids that prolapse on straining and do not return while relaxing but can be pushed back inside.
4th-degree haemorrhoids that are permanently prolapsed and are visible on inspection.

Preventing haemorrhoids

One glaringly obvious lesson you can take away from haemorrhoids is ‘STOP SITTING DOWN SO MUCH!’. If an idle mind is the devil’s workshop, then an idle bottom is the devil's fertile ground for haemorrhoids! A high-fiber diet, movement and physical activity is the first line of defence against haemorrhoids. If your job involves prolonged periods of sitting, remember to stand up and move around for a while at frequent intervals. Skip the elevator and take the stairs every now and then. Choose to walk distances where automobiles can be avoided. This will benefit both the environment and your rear end!

Conservative management of haemorrhoids

Life with haemorrhoids can be difficult both physically and psychologically. But early detection and commencement of treatment mean most cases rarely progress past grade 1 or 2 and the best way to manage them is by letting them resolve on their own. And IT WILL resolve on its own provided you commit yourself to some lifestyle changes.

Addressing and treating constipation is the first step in defeating haemorrhoids. Make sure to include foods with high fiber content in your diet along with a copious amount of fluid intake to ensure a soft and smooth bowel movement. For people who have had haemorrhoids for a prolonged time, constipation would have become chronic and will require laxatives for a successful resolution. However, laxatives should be used ONLY after your doctor prescribes them for you and strictly in recommended dosages as they can cause dependency issues. Alternatively, natural fiber supplements containing Isabgol (Psyllium husk) are effective stool softeners that are available over the counter, and doctors have been increasingly recommending it over chemical laxatives in recent times due to their lack of side effects. Remember to avoid straining during bowel movements too.

Symptoms of haemorrhoids can be treated with topical medications. Gels and ointments containing astringents (shrinking agents) and local anesthetics can be used for relief from the soreness and itching caused by haemorrhoids. Do not ever try to self-medicate with these creams as many of them contain steroids that are included to reduce inflammation, hence it is prudent to use them only after your doctor prescribes it to you in the appropriate dosage and frequency.

Other nonsurgical approaches to treating haemorrhoids include :
Rubber band ligation involves fitting a tight rubber band at the base of the growth to cut off its blood supply.
Injection sclerotherapy involves injecting phenol oil into the growth to induce sclerosis (hardening) and shrinking.
Using Infrared light to cut off blood supply to the haemorrhoids.
Destroying the haemorrhoidal growths using electric current (bipolar diathermy).

Surgical treatment for haemorrhoids

Due to its highly symptomatic nature, most cases of haemorrhoids are detected and treated early which causes it to resolve on its own. Surgical intervention is done only as a final resort and reserved for the rare cases that have progressed to grades 3 and 4.

Surgeries for haemorrhoids include haemorrhoidal artery ligation (suturing the artery that provided blood supply to the growth), haemorrhoidectomy (removal of the entire haemorrhoidal growth) and stapled haemorrhoidectomy among others.

Stapled haemorrhoidectomy is increasingly preferred over conventional haemorrhoidectomy by surgeons nowadays due to lesser postoperative pain and shorter hospital stay with regards to the former and increased risk of postoperative incontinence in the latter.

Haemorrhoid staplers are dedicated transanal circular staplers which help the surgeons remove an annulus or a ring of haemorrhoidal tissue that is prolapsing while simultaneously stapling the remaining parts of the anal cushions in their former position in a circular manner. The staples remain inside the anus for a considerable period of time anchoring the cushions as the wound heals and then falls off and passes through the stool unnoticed after several weeks.

As impressive as these advances are in the field of surgery in effectively treating 3rd-degree and 4th-degree haemorrhoids with minimal postoperative pain, bleeding, soreness and itching, haemorrhoids still are a dreadful disease to have and something to be avoided at all costs. Remember to be mindful of what you eat and take your poor posterior into consideration before putting anything in your mouth. And remember to not sit idly for prolonged periods of time too. Movement is key in preventing haemorrhoids, be it in your bowels or your body!