Piles, also called hemorrhoids, are swellings containing distended blood vessels in and around the anus. Piles are formed due to wear and tear of the inner lining of the anus and rectum that causes defects in the underlying miniscule muscle fibers tethering the lining to the anal sphincter muscle.

Efforts at amelioration of piles are hence directed to lessening the wear and tear that’s the underlying cause, and when they become too large or are complicated in some way, a therapeutic intervention is needed.

You may experience a variety of symptoms of varying intensity due to piles. These include:

1. A mass protruding outside the anus either at the time of defecation or at all times.
2. Bleeding, which may range from minimal to massive.
3. Pain
4. Mucus discharge from the anus
5. Soreness or redness around the anus
6. Anemia causing fatigue due to blood loss in certain cases

If you experience one or more of these symptoms persistently, you should visit your doctor. Bleeding is one symptom that should not be ignored and even a little bleeding should prompt a visit to your doctor.

The causes of hemorrhoids are multifactorial. An old theory tried to correlate the location of the hemorrhoids with the location of arteries supplying blood to the anus. Newer research is focused on wear and tear, especially sheer forces experienced by the inner lining of the anal canal during the act of defecation or straining. Due to this wear and tear, the supporting microscopic fibrils that attach the inner lining to the underlying musculature are torn little by little and the resulting spaces become lined with capillary lining to form blood filled distended spaces. These are then visible as hemorrhoids.

Too much straining on the toilet, as caused by constipation, can cause a high degree of shear stress on the anal lining and in a leading cause of hemorrhoids. Prolonged diarrhea can also make a person vulnerable to developing hemorrhoids. Other risk factors are:

1. Age: children and adolescents usually do not suffer from hemorrhoids.
2. Pregnancy
3. Overweight / Obesity
4. Persistent cough
5. Prolonged seating.

Treatment:

Hemorrhoids with a small size, that are pain-free and do not cause bleeding, can be managed with simple management as outlined below.

1. Do not strain on the toilet.
2. Gradually increase the amount of fiber in your diet in order to keep your stools soft and avoid constipation. Fiber (technically termed non-soluble polysaccharides or NSPs) is the principle agent in our diet that holds water in our stools and keeps them soft. Good sources of fiber are whole grain rice (brown rice), whole grain wheat, fruits, vegetables, oats, and pulses. Increasing fiber can solve mild to moderate degrees of constipation and is a very effective way to treat and prevent recurrence of hemorrhoids after treatment.
3. Drink plenty of fluids.
4. Go to the toilet when you feel the urge. Avoiding going to the toilet when you feel the urge to defecate makes the stools dry and hard, thus increasing damage to the inner anal lining.
5. Certain medications, such as codeine-containing cough syrups, cause constipation and can exacerbate hemorrhoids.
6. Exercise regularly.
7. Lose weight.
8. Try using wet wipes or baby wipes instead of dry toilet paper in case you experience soreness around the anus.

Further treatment of piles is decided to take into account the severity of symptoms, the size and number of the pile mass(es), and its location. Piles located in the inner 2/3rds of the anal canal are called internal hemorrhoids, while those located in the outer 1/3rds of the anal canal or outside the anal verge are called external hemorrhoids. Based on their propensity to protrude outside the anus, hemorrhoids may be graded from grade I to grade IV. Small grade I-II internal hemorrhoids can usually be treated without surgery, while grade III-IV internal hemorrhoids, and almost all external hemorrhoids will often require surgery. Let us review the non-surgical options first:

Medications:

Primarily two types of medications are used to treat piles: creams and suppositories for local application, and laxatives to keep the stools soft. There is no evidence to suggest that one cream is superior to another, but in general, you should avoid using a cream for more than 5-7 days without seeing your doctor. Laxatives are also of various types, and those that do not contain senna or phenolphthalein can be taken for longer durations. However, it is important to know that most laxatives need a day or two to make stools soft, and they will take a minimum of 8-12 hours to travel down the colon to be effective. Soaking in a pail of lukewarm water with salt or antiseptic added to it is a good method of reducing the swelling and discomfort associated with hemorrhoids. Plant fiber such as ispaghula (isabgol) husk is also effective in treating constipation caused primarily by lack of fiber in the diet for young and adolescent persons.

Non-Surgical Interventions: Sclerotherapy:

This procedure involves an injection of a medicine into hemorrhoid. The medicine acts by sclerosing and hardening hemorrhoid so that it disappears over about 3-6 weeks. More than one session may be required. It is an office procedure performed under topical anesthesia and is essentially painless. You may feel a little discomfort due to the access into the anal canal during the procedure. You can go back home immediately after the procedure, and you should avoid strenuous activity during the day. It is ideally suited for small internal hemorrhoids that are bleeding from multiple points. Bleeding from the hemorrhoids should stop within 3-4 days following the procedure. You should contact your doctor again if you notice anything unusual. Your doctor may schedule another appointment as all the bleeding points may not be covered in one sitting. Your doctor may prescribe some local application creams and/or suppositories, laxatives and analgesics.

Non-Surgical Interventions: Banding:

This procedure is reserved for slightly larger internal hemorrhoids that are not prolapsed out and do not have a very large mass effect. It is a very effective procedure in which a tight elastic band is applied to the base of hemorrhoid that interrupts its blood supply. Hemorrhoid usually falls off painlessly within about a week following the procedure. Since the band is applied internally and hemorrhoid shrivels after the procedure, you may not notice hemorrhoid falling away and may not be able to feel the band. It is generally painless office procedure, after which you can go home immediately. Your doctor may schedule more than one procedure to take care of all the hemorrhoidal masses, and sometimes may even successfully avoid surgery for larger internal hemorrhoids by reducing the size of hemorrhoid over multiple sessions of banding.

Surgery:

Surgical approaches, such as open/closed hemorrhoidectomy in which the hemorrhoids are excised under anesthesia, or stapler hemorrhoidectomy in which hemorrhoidal tissue is stapled, are effective methods of treating larger internal hemorrhoids. Surgery is often the only effective method for treating external hemorrhoids, as the skin overlying these hemorrhoids has a very rich blood supply precluding banding or sclerotherapy. Open/closed hemorrhoidectomy is one of the most sought-after procedures that has withstood the test of time and results in very good control of both bleeding and mass effect from hemorrhoids. It requires hospitalization for two-three days and rest after discharge for another week or so. You can return to work about 7-10 days after the surgery. The total time taken for the anal lining to heal completely may be up to 4-6 weeks. You should not feel much discomfort during this time, though slight bleeding with defecation may occur. Surgery results in very good short-term control of symptoms with a low long term recurrence that usually occurs if underlying factors such as long term constipation are not effectively taken care of. Stapler hemorrhoidopexy is also used to treat large internal hemorrhoids, though it has a slightly higher risk of complications (including infrequent serious complications) than open hemorrhoidectomy. The advantage of a stapler over the conventional method is shorter recovery period and an essentially pain-free convalescence and a quicker return to work.

Other Treatments: Other treatments include cryotherapy, laser, and electrocoagulation. Cryotherapy involves freezing the pile mass and waiting for it to fall off by itself, leaving a healing wound underneath that closes over a period of time. The advantage of this procedure is that most internal hemorrhoids can be dealt within an office setting without the need for anesthesia. The disadvantages are a requirement of specialized equipment, inability to control the depth of the freeze accurately as it is essentially a blind procedure, and a weeping wound that takes time to heal. Laser therapy too requires specialized equipment that can make it quite costly compared to conventional approaches. Because the laser is essentially a form of energy that coagulates and vaporizes tissue, it essentially acts as a high-powered surgical knife with approximately equivalent issues in convalescence. Electro-coagulation requires specialized equipment to identify the feeding vessels of hemorrhoid and coagulation of these blood vessels using an electric current. The lack of blood supply causes hemorrhoid to shrink in size over time. The advantage is quick convalescence due to the absence of a wound and the disadvantage is inherent in the rich blood supply of the anal canal and the multiplicity of the feeders to pile masses. The procedure requires specialized equipment and probes to identify the blood vessels that are essentially invisible to the naked eye.

Hemorrhoids affect a sizeable number of the general population in the UAE. If you are suffering from hemorrhoids symptoms, do not hesitate to consult a doctor as there is nothing to be ashamed of. Not seeking immediate medical help to avoid the so-called ’embarrassment’ you would face or for the fear of surgery can worsen your condition.