Digestion | November 10, 2015 | Author: The Super Pharmacist
Haemorrhoids (also referred to as ‘piles’) are swollen or dilated veins of the rectum or anus that are located either inside the anal canal (internal haemorrhoids) or surrounding the anal opening (external haemorrhoids). Without a clear diagnosis, they can often be differentially diagnosed as an anal fissure – a tear of the sensitive mucosal lining of the anus.
Some of the symptoms of both conditions overlap, which often explains their differential diagnosis without proper examination (1). Internal haemorrhoids can occasionally cause rectal bleeding, with bright red streaks appearing on stools or toilet paper. Bright red blood may also drip into the toilet bowl following a bowel movement. Similarly, an anal fissure is often associated with blood on toilet tissue, in the toilet bowl itself, or on the surface of a stool. Similarly, both conditions can result in a very itchy anus and painful, throbbing symptoms after going to the toilet. It is not usually a serious condition, but they can be sore and distressing.
Although the conditions are very similar, they generally have different causes (aetiologies). Haemorrhoids are caused by repeated pressure in the anal and rectal veins, whereas anal fissures usually occur as a result of trauma to the anal canal (most commonly during a bowel movement). They can also be caused by an infection or inflammatory bowel disease (2), although there are a wide range of contributory factors: prolonged sitting, pregnancy, obesity, rectal surgery or episiotomy, anal infection or intercourse, colon malignancy and alcoholism with cirrhosis are all recognised risk factors of developing the condition (3). Constipation can also contribute towards anal fissure and haemorrhoids, and anal fissures can sometimes develop after prolonged bouts of diarrhoea (4).
The exact prevalence of haemorrhoids and anal fissures is not known, largely because many people experience either condition without informing a medical professional and can self-manage. Additionally, the embarrassment and unwillingness to have the anal area examined may also result in patients not seeking medical advice regarding either condition, instead choosing to use over the counter treatment options to treat the condition. Misdiagnosis is common where anorectal symptoms are displayed, with conditions like anal fissures often being misunderstood for piles – this is reflected in the different prevalence rates recorded in haemorrhoid studies, with over 4-34% of the population estimated as being affected at some point during their lives (5).
A physician is often able to make a diagnosis through taking patient history and an examination of the anal area. For external haemorrhoids and anal fissure this can often be done unobtrusively, although an examination of the anal canal itself may be required to confirm suspicions of haemorrhoids. Other diagnostic procedures that may be required include an anoscopy – this involves a visual examination of the anus using a short tube called an anoscope. Patients may also be referred to a colorectal surgeon/gastroenterologist for an internal examination using a procedure known as a sigmoidoscopy (an examination of the rectum and lower part of the colon using a fibre optical instrument). Patients are often sedated during this procedure and it is relatively painless.
Haemorrhoids are classified according to degree of prolapse: Grade 1 haemorrhoids (do not prolapse), Grade 2 haemorrhoids (prolapsed on straining, reduce spontaneously), Grade 3 haemorrhoids (prolapse on straining, can be reduced manually) and Grade 4 haemorrhoids (permanently prolapsed, cannot be reduced). This grading system is used to indicate level of prolapsed only and does not always accurately reflect the severity of symptoms. There is no formal grading system for anal fissure.
The interventions required to prevent these conditions from developing are lifestyle related. Maintaining a healthy balanced diet, rich in fibre and vegetables, fruits and wholegrain, produced softer stools and reduces the need to strain whilst on the toilet. Maintaining a healthy weight often reduces the chance of developing both conditions, as does keeping the body well hydrated (8-10 glasses of water a day is the recommended amount). Reducing caffeine intake can also help prevent both conditions, and patients suffering from chronic constipation can use bulk-forming laxatives such as ispaghula husk or sterculia (6). Avoiding prolonged sitting on the toilet is also advised, although it’s also advised not to hurry or strain to push bowel movements.
Avoiding vigorous wiping around the anal area will also decrease the risk of irritation.
Although having both conditions can result in bowel movements being painful, it is important not to ignore the urge to go to the toilet as this can result in further constipation and harder stools that aggravate the condition. Withholding the need to go the toilet is particularly common in children due to their painful experience, but it is important that all individuals affected by either condition maintain good toilet habits and good hygiene practice.
Simple analgesic medicines available over the counter can help alleviate the pain associated with haemorrhoids or anal fissure. Paracetamol is acceptable, but codeine based analgesia should be avoided as it has constipating properties (7).
Topical therapies that ease burning sensations, and any associated pain and itching, but they should only be used for several days to avoid inflammation and sensitisation of the skin.
Warm baths can also be soothing – it is important to avoid using soap or other potential irritants around the anal area, and to make sure it is properly dried afterwards.