How are haemorrhoids treated?
Once haemorrhoids have been identified and diagnosed, treatment recommendations may involve lifestyle changes and homecare or medical intervention (or both).
1. Homecare and lifestyle adjustments
A doctor may recommend the following for the relief of mild swelling, inflammation and pain associated with hemorrhoids:
- Adjusting diet: It may be determined that too little fibre in a person’s diet has contributed to the formation of haemorrhoids. A doctor may suggest gradually incorporating more whole grains, fruits and vegetables into a diet going forward (adding too much too quickly can result in gas or flatulence) so as to help soften stools and increase its bulk. In so doing, this will help to reduce bowel movement straining and constipation which can considerably worsen haemorrhoid symptoms. A doctor may also suggest limiting the intake of processed foodstuffs as well, and drinking between 7 and 8 glasses of water every day (those who are fairly active or reside in hot climates may be requested to increase their water intake a little more) as dehydration can contribute to the development of hemorrhoids. A stool softener or fibre supplement may also be recommended.
- Regular soaks in warm baths or a SITZ bath: Plain warm water or a sitz bath (a shallow basin filled with warm water, which fits underneath the toilet seat) can be used to help cleanse the perineum area (i.e. the space between the rectum and scrotum or vulva areas) and relax the clenching sphincter muscle (especially following a bowel movement). Pain, swelling and itching in this area can be alleviated with regular 10 to 15-minute baths (several times a day).
- Hygiene and toilet usage habits: A doctor may suggest bathing daily and gently cleansing the anal area with warm water (no soap). The area can be gently patted dry or dried off with the use of a hairdryer (on a cool setting). A doctor may also advise against the use of perfumed or alcohol-based wipes for cleansing purposes as this will irritate the area and worsen symptoms. He/she may also stress hygiene care when using the toilet and suggest using clean, moist toilettes (or wet toilet paper) to clean the anal area instead of dry toilet paper.
- Cold compresses: For relief from swelling, an ice pack or cold compress may be used.
2. Medical intervention
Medical treatment applies when a patient essentially experiences symptoms associated with haemorrhoids. Asymptomatic formations are typically left alone. In most instances, medical intervention may follow if homecare and lifestyle adjustments have not eased symptoms (namely increased fibre intake and sufficient fluids). Internal haemorrhoids (prolapse degrees 1 to 3), as well as external formations can respond well to such treatment measures (sometimes referred to as ‘conservative therapy’).
If internal hemorrhoids are identified and diagnosed, recommendations may be as follows:
- First-degree: Conservative treatment measures, as well as the avoidance of NSAID medications, fatty and spicy foods will be recommended.
- Second-degree and third-degree: If conservative therapy has not eased symptoms, non-surgical procedures (discussed in detail below) may be recommended. If a third-degree formation presents severe symptoms, surgical treatment can then be considered (i.e. a haemorrhoidectomy).
- Fourth-degree: Formations presenting symptoms, or those which worsen causing complications will require surgical treatment (i.e. removal). A patient is considered a surgical candidate based on symptoms and not on the basis of aesthetic improvement (i.e. the removal of a large, prolapsed haemorrhoid).
For mild symptom relief, a doctor may recommend the following:
- Using topical ointments (external use): Ointments, lotions and creams may be recommended for external hemorrhoids, and are available over-the-counter (OTC) or with a prescription (Rx). Some are available as suppositories and contain hydrocortisone or lidocaine. Alternatives include pads which can be used. These often contain a numbing agent (for symptoms relief) or witch hazel. Over-the-counter steroid creams should only be used for about a week (or as recommended by the treating medical physician).
- Taking oral pain-relievers: Discomfort can be alleviated with the use of pain-relieving medications such as aspirin, ibuprofen or acetaminophen. Symptoms often clear within a week. If not (especially in the case of pain and or / bleeding), a consultation with the treating doctor is advisable for a thorough evaluation.
Some treatment options which are minimally invasive can include:
- Sclerotherapy (injections): This method is generally used to treat relatively small first or second degree internal hemorrhoids. A chemical solution (scelorosants comprising of saline solutions and phenol, an extract of almond oil) is injected into a haemorrhoid in order to shrink the affected tissue, cause it to harden and form a scar that then reinforces the anal wall with the aim of preventing recurrence of the haemorrhoid. The injection causes very little pain (if any at all) and only temporary, mild discomfort (pressure or cramping in the rectum/anus).
- Coagulation or infrared photocoagulation (IRC): Lasers, electric probes or infrared light / heat techniques can be used to treat a haemorrhoid by hardening the tissue (painlessly sealing it), and thus encouraging shrinkage. This procedure is performed with the use of an anoscopy. Temporary discomfort (pressure or cramping in the back passage) may be experienced following the procedure.
- Rubber band ligation: This procedure is one of the most common minimally invasive treatment options for first, second and third-degree haemorrhoids. A small, elastic band (sometimes two) is applied to the base of a haemorrhoid. This technique encourages shrinkage of the haemorrhoid by cutting off circulation and causing it to fall off. This generally takes place within a few weeks of the band placement. The procedure carries some degree of bleeding risk, but is very rarely severe. Light bleeding may be experienced around 2 to 4 days after the band/s has been applied.
These procedures can effectively shrink or remove hemorrhoids, but cannot guarantee that they won’t recur at some stage down the line.
The majority of patients with haemorrhoids are not likely to require surgical means to rid themselves of hemorrhoids. It is estimated that less than 10% of patients have large enough internal or external haemorrhoids to require surgical intervention.
If a patient is a candidate for a medical / surgical procedure, a doctor may recommend any of the following options:
- Haemorrhoidectomy: Internal and external haemorrhoids (as well as any excess tissue) can be removed surgically via this method which ensures a very low risk of recurrence. A thrombosed haemorrhoid can also be treated using this procedure. A patient may receive a spinal block (an anaesthetic or narcotic is injected via a needle inserted into the spine), numbing the area, local (with sedation) or general anaesthesia (‘putting a patient to sleep’) ahead of the procedure. Surgical risks which will be carefully assessed and measured against benefits include pain, bladder emptying difficulties (urinary retention) or urinary tract infections / UTIs (as a result of bladder problems). This procedure is thus normally considered for very large and painful hemorrhoids, but is very effective for treating severe or recurring cases. Medication will be prescribed post-op to help relieve pain and tenderness. Warm water or sitz baths may also be recommended as part of post-op homecare. The standard recovery period is normally about two weeks, sometimes a little longer.
- Stapled haemorrhoidopexy (PPH haemorrhoidectomy): While under general anaesthetic, a haemorrhoid (such as a prolapsed haemorrhoid or internal haemorrhoid), may be put back in place / repositioned (to an area with fewer nerve endings) with the use of a stapling instrument. The technique effectively blocks blood flow to the tissue of the haemorrhoid, allowing it to shrink. There is less pain associated with this procedure in comparison to a haemorrhoidectomy, and a patient may resume normal activity a little sooner. Rectal prolapse and haemorrhoid occurrence are some of the main risk factors associated with this procedure, along with complications of urinary retention, pain and bleeding.
- External haemorrhoid thrombectomy: This procedure is performed on a thrombosed haemorrhoid (external haemorrhoid which has formed a blood clot) ideally within 72 hours of the formation of a clot. A surgeon removes the thrombus (blood clot) by making a small incision in the haemorrhoid and draining it. A patient will likely experience rapid relief following this procedure.
- Hemorrhoidal artery ligation (HAL) / transanal hemorrhoidal dearterialisation (THD): A patient will be given an enema before this surgical procedure (normally about an hour beforehand) and then placed under general anaesthetic. Using a Doppler ultrasound (probe or transducer), a surgeon is able to locate the blood vessels connected to the formed haemorrhoid. Using ligates (sutures), blood flow to the haemorrhoid is then cut off. If any prolapsing has occurred, sutures are placed to repair the tissue and hold these up (known as a recto-anal repair / RAR). If a patient has any skin tags, these are generally left untreated as they naturally begin to shrink following this type of surgery. This procedure can take up to 45 minutes and is associated with a fair amount of post-op pain, as well as some light bleeding.
Pain, discomfort and tenderness are the primary side-effects of haemorrhoid surgery. A doctor will advise on specific homecare recommendations to help ease such discomforts. Pain relievers, sound hygiene practices and regular baths are some recommendations which can provide relief in the initial days of recovery. A doctor may also recommend a stool softener to aid in more comfortable bowel movements and consuming a high fibre diet and drinking plenty of water to avoid constipation. Any activities which involve heavy lifting or pulling will be advised against.
Other potential side-effects of surgery include infection, bleeding and adverse reactions to anaesthetic. Swelling and muscle spasms post-op can also cause a little difficulty with emptying the bladder. Some may experience accidental bowel leaks or gas (flatulence) as well.
Should a patient experience significant bleeding, the inability to urinate or have a bowel movement (avoiding bowel movements is discouraged by doctors, even if this is uncomfortable at first) or develop a fever, he or she must consult their treating doctor as soon as possible for a thorough evaluation.
Surgical procedures can be done on an outpatient basis or may require an over-night stay in hospital and have proven to be more effective with a lifelong, proactive change in diet. A healthier diet aids the digestive system and significantly reduces the odds of a recurrence of hemorrhoids later in life.
A full recovery is generally made within a 10 to 14-day period following a procedure.