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Pilonidal sinus
PR - Per-rectal examination
Pre-Operative Preparation
Piles (haemorrhoids)
Piles, or haemorrhoids, are areas in the anal canal where the tissue, which contains lots of blood vessels, has become swollen. They can be internal, occurring inside the anus, or external, when they can be seen and felt on the outside of the anus. When visible they look like round pink swellings, the size of a pea or a grape. By the age of 50, up to half the population of the UK will have suffered from piles at some point. Piles are common in pregnant women, but are rare in children.
What causes piles?
The exact way piles form is controversial but it may be linked to excess pressure in the anus and lower rectum.
This pressure can have one or more of several different causes:
Straining to empty the bowels when constipated.
Chronic diarrhoea.
Pregnancy – the weight of the fetus on the abdomen and the increased blood flow, as well as the effect of hormones on the blood vessels.
Childbirth – pushing during childbirth increases the pressure in the veins.
Straining to pass urine, especially in men with prostate problems.
Cancer or growths in the pelvis or bowel, which may exert pressure in a similar way to a pregnancy.
Family history – piles can run in families and are potentially hereditary, perhaps because of weak veins in the anal area.
Obesity.
Varicose veins – many people with these also develop piles, although piles are not varicose veins.
Different types of piles
Piles are classified according to their position. First-degree piles remain inside the rectum or anal canal. Second-degree piles protrude (or prolapse) from the anus when the bowels are opened, but return of their own accord afterwards. Third-degree piles are similar, but only return inside when pushed back. Fourth-degree piles hang permanently outside the anus.
What are the symptoms?
Most people affected have internal piles and may not have any symptoms at all. The earliest symptom is often bleeding of fresh, red blood from the anal passage when the bowels are opened. There may be itchiness around the anal area. Third and fourth degree piles may be more painful and tend to produce a slimy discharge of mucus that leaks from the exposed lining of the pile.
There are conditions other than piles that can cause bleeding from the anus, so anyone who notices bleeding in their stool should visit a doctor for advice.
Possible complications
If there is pain, this usually means that some kind of complication has occurred. These include:
Strangulation
This is when a prolapsed pile swells considerably and the blood flowing into it cannot return to the body. This is very painful and can lead to thrombosis.
Thrombosis
This is when the blood in the swollen pile clots. A thrombosed pile may be less painful than a strangulated pile and looks different, being dark purple or black in colour.
Gangrene
Lack of blood supply to a pile may lead to severe pain and gangrene (tissue death). This is a dangerous – and rare – complication needing immediate surgery.
Infection
This is a rare but serious complication. An abscess may form around the rectum and anus causing pain and swelling. Rarely, the infection may spread, particularly to the liver. This is because the blood draining away from the anal area passes through the liver.
Anaemia
Severe loss of blood from piles. Bleeding over a long period of time can cause anaemia, when there are not enough blood cells to supply the body with oxygen.
Diagnosing piles
The doctor will ask about your health and carry out a physical examination.
If there are external piles, these will be spotted on examination. A rectal examination, where a gloved finger is gently inserted into the anal canal, will be performed. Internal piles cannot normally be felt in this way, but the examination can reveal other problems such as an anal fissure - a painful tear of the lining of the anus. These other conditions need to be excluded before a diagnosis can be made.
One of the main investigations is a proctoscopy, where a small telescope known as a proctoscope is passed into the anal canal. This allows the doctor to see any internal piles. Some GPs may be trained to use a proctoscope, but often at this stage it's necessary to see a hospital specialist (usually a general or colorectal surgeon).
Other tests that may be carried out at the hospital include a sigmoidoscopy, where a thin, telescope is inserted into the anus, allowing the doctor to examine the rectum and the lower part of the large bowel (sigmoid colon). Another test that might be done is a barium enema. A liquid dye that shows up on x-rays is passed into the large bowel. This make the bowel show up on x-ray pictures taken of the lower abdomen.
Relieving symptoms
External piles that are causing irritation may be helped by application of soothing creams, which are available over-the-counter from pharmacies. These creams can lubricate the area and some contain a local anaesthetic to provide short term relief from any discomfort.
Regular warm baths may relieve the irritation, but do not over-use soaps, which can increase the irritation. Ice packs may help reduce swelling, but should not be applied directly to the skin.
Treatments
Piles can usually be treated at home. The most important element in encouraging existing piles to clear up is to avoid constipation. By having regular bowel movements, and avoiding straining, stools pass easily and do not put pressure on the blood vessels in the anal area.
Eating plenty of fibre-rich foods such as fruit, vegetables and wholegrain cereals (eg brown rice, wholemeal bread and wholemeal pasta), and drinking plenty of fluids, especially water, should keep bowel movements soft.
It may help to take a fibre supplement such as ispaghula husk (Fybogel) or mild laxatives such as lactulose solution (Duphalac), which soften bowel motions.
Do not use strong laxatives, such as the stimulant laxative senna, on a routine basis unless on the advice of doctor, because long term use of such laxatives can be harmful.
If these self-help measures do not work, there are treatments that are carried out at hospital. These include:
Sclerotherapy
This is injection of the piles with a chemical known as a sclerosant, which causes the piles to shrink. This is quick and relatively painless, but may have to be repeated once or twice.
Banding
The piles are treated by applying an elastic band above them, so the blood supply to them is reduced. The piles then shrink and fall off and in a few days they are are passed with a stool. Only two piles can be treated during each procedure. The bands fall off with time.
Cryosurgery
Freezing the piles causes them to shrink and drop off.
Light coagulation
Using infrared rays, this is a pain free treatment which can be used for non-prolapsing piles.
Surgery
Known as haemorrhoidectomy - this is usually reserved for third degree piles or if the procedures mentioned above fail. Each pile is tied off with a surgical stitch, or suture, and then the pile is cut away. This leaves sore healing areas, or ulcers, which will heal in about six weeks. There is a separate BUPA factsheet about haemorrhoidectomy.
Anal dilatation
Some cases of piles respond to stretching the anus, under anaesthetic, which is thought to relieve the spasm of the anal sphincter and so reduce pressure in the anus.
Prevention
A good intake of dietary fibre, plenty of fluids, especially water, and regular exercise can keep the bowel movements soft and regular, making piles less likely. This is especially important for pregnant women.