Prevention & Treatment of Haemorrhoids (Piles)

What are Haemorrhoids?

Haemorrhoids (Piles) are abnormally enlarged “cushions” in the anus (back passage). Most people have piles to some degree. Often patients think they have piles as they have a tearing pain on opening bowels, but this is usually a “fissure”. Investigations may show the piles but importantly will aim to rule out other causes of bleeding.

Symptoms

  • Bright bleeding from the back passage. Not mixed in with the motion, but often seen on the toilet paper
  • Often accompanied by a feeling of something coming down, or a bulge or lump in the anus which can be uncomfortable or cause itching

What causes Haemorrhoids?

  • Spending a long time on the toilet straining whilst reading books
  • Constipation due to not enough fibre (eg fruit and vegetables) in diet
  • Poor fluid intake
  • During and after pregnancy

What does treatment involve?

Haemorrhoids may resolve themselves, especially if the above causes are avoided. If this is not the case then the treatment options are:

  • Rubber band ligation is used in order to cut off the blood to the haemorrhoid. As a result, the blood flow will slowly diminish and the haemorrhoid will begin to shrink after some weeks.
  • A more effective method of shrinking piles is ligating with a stitch in theatre, though this usually requires anaesthetic.
  • If the piles pop out (prolapse) and are large, bigger procedure may be necessary which can be discussed with your surgeon.

Risks and Complications after banding / ligation

You may expect discomfort or pain for a day or two in the area of treatment, this should be relieved by your usual painkiller, but avoid constipating opioids like codeine.
The rubber bands may take up to a week to ‘drop off’ and you may be aware of some slight bleeding at this time. Bleeding from the back passage, may occur for up to 2 weeks but should not be heavy, although this does vary from person to person. If you are concerned please contact your GP for advice.

Advice

When using toilet paper ‘dab’ gently rather than wipe. You may apply lubricant such as Vaseline to the area; this may help with any discomfort when emptying your bowels.
Do not use steroid containing pile creams for more than 2 weeks as the cream can thin the anal skin and may cause or worsen a skin ulcer called a “fissure”
If you have had treatment for haemorrhoids it is important to think about what you will do to prevent them occurring again. You will need to think about changing your lifestyle;

  • Eat a diet high in fibre (cereal, fruit, vegetables and brown bread/rice)
  • Drink plenty of fluids such as water or squash
  • Avoid becoming overweight by increasing exercise
  • Avoid straining or reading on the toilet

Pilonidal Surgery

Pilonidal means “nest of hairs” and between the buttocks is a site that hairs (usually from the scalp) have burrowed deep to the skin and created a foreign body reaction. Once the hairs are beneath the skin in the midline they cause repeated eruptions of infection. Traditionally the surgery for this condition was to make an incision in the midline between the buttocks to remove the hairs, however this cut was an invitation for further hairs and the recurrence rates were high, in fact the surgery was often worse than the disease!

There are some modern day techniques that reduce the chance of recurrence and it makes sense to perform the smallest of these first but if there is recurrence one of the other techniques can be offered with low recurrence rates.

Bascom's Procedure

Bascom’s procedure (above) which involves an incision away from the midline to burrow down under the midline and remove the hairs and infection. This is one lateralising procedure that keeps the scar away from the natal cleft (which is where the buttocks meet in the midline)

Limberg Flap

This is the result at the end of a procedure that is used to treat resistant pilonidal disease, it is called a Limberg Flap and involves a few days in hospital. It has a very low recurrence rate but is usually offered to patients who have had simpler operations first which have not cured the problem.

BOTOX for Resistant Chronic Anal Fissure

Guy Nash - Colorectal Surgeon - Fissure in Ano

Chronic Fissure

During the past few years there has been renewed interest in the medical management of chronic anal fissure. For those patients who have failed topical GTN and Diltiazem, surgery usually is the next treatment offered. A group of patients who have had previous insults to anal continence, including difficult obstetric deliveries or anal surgery, are most at risk of frank incontinence following fissure surgery. Botox (botulinum neurotoxin) has been recently established as a second or third line treatment, following failed topical treatments in those at highest risk of incontinence. In addition, occasionally patients unable to comply with topical treatment or those unsuitable for a general anaesthetic would be candidates for botox as first line treatment.

Treatment with botulinum neurotoxin is less expensive and easier to perform than surgery and does not require anesthesia. It is also safe (1) and more efficacious (2) than nitrate therapy and is not related to the patient compliance.

Method: The use of botox (8 – 10 units to either side of the anus between the internal and external sphincters) for these patients would reduce the chance of permanent incontinence. This would add a therapeutic option in these patients who are difficult to treat and hopefully reduce the chance of patients becoming incontinent. Each patient should be consented for temporary incontinence is a recognised adverse effect of botox treatment, and using larger doses of Botox has been reported at least once to cause a permanent incontinence.

My experience of administering botox for chronic anal fissure is that it is well tolerated in an outpatient setting and I have had no side effects reported in those patients I have treated at St. Marks and Poole Hospitals. The indication should not normally include first line treatment in my opinion as there are other even cheaper and safer treatment that are well tolerated (topical agents such as  diltiazem 2% which avoids the headache associated with GTN cream). For suitable patients, consented and personally consulted, I believe botox would be a valuable treatment for a persistent and often miserable condition.

 

REFERENCES

1. Madalinski M, Slawek J, Duzynski W, Zbytek B, Jagiello K Adrich Z, et al. Side effects of botulinum toxin injection for benign anal disorders. Eur J Gastroenterol Hepatol 2002; 14: 853-6.
2. Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure. Dis Colon Rectum 1993; 36: 974.