Health Resources

Haemorrhoids or Piles

What are Hemorrhoids

There are several theories, including inadequate intake of fibre, prolonged sitting on the toilet, and chronic straining during a bowel movement. None of these theories has strong experimental support. Pregnancy is a clear cause of enlarged haemorrhoids though, again, the reason is not clear.

What are the symptoms of hemorrhoids

As the anal cushion of an internal haemorrhoid enlarges, it bulges into the anal canal, loses its normal anchoring, and protrude from the anus as a prolapsing internal haemorrhoid.

The haemorrhoid is exposed to the trauma of passing hard stool, which causes bleeding and sometimes pain. The rectal lining that has been pulled down can secrete mucus.

The presence of stool and constant moisture can lead to anal itchiness (pruritus ani), though itchiness is not a common symptom of haemorrhoids.

First-degree hemorrhoids:
bleed but do not prolapse (do not protrude from the anus).

Second-degree hemorrhoids:
prolapse and retract on their own, with or without bleeding.

Third-degree hemorrhoids:
prolapse but must be pushed back in by a finger.

Fourth-degree hemorrhoids:
prolapse and cannot be pushed back in.

Key Points:

Only when haemorrhoidal cushions enlarge that haemorrhoids can cause problems and be considered abnormal or a disease. Common symptoms include
  • Prolapse
  • Rectal bleeding
  • Pain (less often)
  • Anal itchiness (sometimes)
Internal or External hemorrhoids

In general, the symptoms of external haemorrhoids are different to the symptoms of internal haemorrhoids.

External haemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal haemorrhoids. External haemorrhoids can cause problems, however, when blood clots inside them. This is referred to as a perianal hematoma.

Thrombosis of an external haemorrhoid causes an anal lump that is very painful (because the area is supplied by somatic nerves) and may require incision and drainage. This small procedure can effect immediate symptom relief. The thrombosed haemorrhoid may heal with scarring and leave a tag of skin protruding from the anus.

Occasionally, the tag is large, which can make anal hygiene difficult or irritate the anus. In these cases, surgical excision might be necessary.

Perianal hematoma
Perianal hematoma
Clot evacuated from perianal hematoma
Clot evacuated from perianal hematoma
How are hemorrhoids diagnosed

By the history of symptoms, we can suspect that haemorrhoids are present. The diagnosis of an internal haemorrhoid is easy if the haemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal haemorrhoid high in the anal canal, a more thorough examination for internal haemorrhoids is done visually using an proctoscope. As the proctoscope is withdrawn, the area of the internal haemorrhoids is well seen. Straining by the patient may make the haemorrhoids more prominent.

Rectal mucosal prolapse can also mimic internal haemorrhoids. External haemorrhoids appear as a lump and/or dark area surrounding the anus. If the lump is tender, it suggests that the haemorrhoid is thrombosed. 

Although we should try our best to identify the haemorrhoids, it is perhaps more important to exclude other causes of haemorrhoid-like symptoms that require different treatment. These other causes — anal fissures, fistulae, perianal skin diseases, infections, and tumours — can be diagnosed on the basis of a careful examination of the anus and anal canal.

Any lump needs to be carefully followed, however, and should not be assumed to be a haemorrhoid since there are rare cancers of the perianal area that may masquerade as external haemorrhoids.

Rectal bleeding

Whether or not haemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than haemorrhoids. Other serious causes include colorectal cancer or polyps or inflammatory bowel disease. This examination can be done by either flexible sigmoidoscopy or colonoscopy.


  • Do not assume that the rectal bleeding is secondary to hemorrhoids
  • Exclude other causes of hemorrhoid-like symptoms that require a different treatment
  • Rare cancers of the perianal area may masquerade as external hemorrhoids

General Measures for Hemorrhoid Treatment

It is believed generally that constipation and straining to have bowel movements can promote haemorrhoids and that hard stools can traumatize existing haemorrhoids. It is recommended, therefore, that individuals with haemorrhoids soften their stools by increasing their fluid and fibre intake in their diets. This is recommended for all patients who have haemorrhoidal symptoms and can be the only treatment required for patients with first degree haemorrhoids.

Vasoconstrictors applied to the perianal area may reduce swelling, pain and itching due to their mild anaesthetic effect.

Daflon is micronized purified flavonoid fraction (MPFF) associated with fibre supplement has been superior to fibre supplement alone and equivalent to rubber-band ligation plus fibre supplement in stopping anal bleeding due to haemorrhoids.

CARET Service Our One-Stop Careful Assessment & Rapid Effective Therapy Service

At our clinic, we offer a special CARET service. This ONE-STOP service enables us to offer your patient a flexible sigmoidoscopy or a colonoscopy (as required) and ligation of haemorrhoids as part of our specialist consultation. This service will provide immediate reassurance of the benign nature of the rectal bleeding with simultaneous haemorrhoid treatment.
Hemorrhoids at a Glance
  • Internal haemorrhoids are clumps of tissue within the anal canal that contain blood vessels, muscle, and elastic fibres. External haemorrhoids are enlarged blood vessels surrounding the anus.
  • Internal haemorrhoids cause problems when they enlarge. The cause of the enlargement is not known.
  • Complications of internal haemorrhoids include bleeding, anal itchiness, prolapse, incarceration and gangrene. Pain is not common.
  • The primary complication of external haemorrhoids is pain due to blood clotting in the haemorrhoidal blood vessels called perianal hematoma.
  • When dealing with haemorrhoids, it is important to exclude other diseases of the anus and rectum that may cause similar symptoms such as polyps, cancer and diseases of the skin.
  • Conservative treatment of haemorrhoids includes fibre supplements and MPFF, topical medications.
  • All patients with rectal bleeding should be assessed to confirm the source of bleeding.
  • Rubber band ligation is a quick clinic procedure that is effective and can be repeated.
  • Surgical haemorrhoidectomy is the treatment option reserved for patients with third or fourth degree haemorrhoids.
  • Stapled haemorrhoidectomy is another treatment option. However, this treatment is not suitable for all patients and the best results are obtained in only a selected group of patients and thus this procedure is not recommended for every patient.
Rubber band ligation

Rubber band ligation
Rubber band ligation

The principle of ligation with rubber bands is to encircle the base of the haemorrhoidal anal cushion with a tight rubber band. The tissue cut off by the rubber band dies and is replaced by an ulcer that heals with scarring. It can be used with first-, second-, and third-degree haemorrhoids. Symptoms can recur several years later but usually can be treated with further ligation. 

The most common complication of ligation is pain, but it tends to be mild. However, if the rubber band is applied too distally, the pain is immediate and severe. Bleeding one or two weeks after ligation occurs occasionally and can be severe. Rarely, cellulitis can begin in the tissues surrounding the anal canal. These rare infectious complications may occur in patients who have defective immune systems, from chemotherapy, diabetes to AIDs.

Diathermy hemorrhoidectomy

Surgical removal of haemorrhoids (haemorrhoidectomy) usually is reserved for patients with third or fourth-degree haemorrhoids.

During haemorrhoidectomy, the internal haemorrhoids and external haemorrhoids are excised using diathermy. The wounds left by the removal are left open. This is performed as a day case procedure.

Post-surgical pain is the major problem with haemorrhoidectomy. The addition of NSAIDs enhances the relief of pain. Delayed haemorrhage 7 to 14 days after surgery occurs in 1-2% of patients. Wound infections are uncommon after haemorrhoid surgery. Abscess occurs in less than 1% of cases. 

However, patients commonly complain of discharge postoperatively and this is expected as the wounds are left open. If the wounds look clean, they do not necessarily need antibiotics. Patients should be advised to keep the area clean and dry and avoid topical applications of ointments or powder.

Stapled hemorrhoidectomy

Stapled haemorrhoidectomy is a technique developed in the early 1990s but is a misnomer since the surgery does not remove the haemorrhoids but, rather, the abnormally lax and expanded haemorrhoidal supporting tissue.

The arterial blood vessels that travel within the expanded haemorrhoidal tissue are cut, thereby reducing the blood flow to the haemorrhoidal vessels and reducing the size of the haemorrhoids. During the healing of the cut tissues around the staples, scar tissue forms, and this scar tissue anchors the haemorrhoidal cushions back to their normal position higher in the anal canal — thus, effectively, an anopexy is performed. 

However, external haemorrhoids are not removed. Hence, this procedure is best suited for circumferential third or fourth haemorrhoids with minimal external components. It is associated with much less pain than traditional haemorrhoidectomy and patients usually return earlier to work.

Stapled hemorrhoidectomy - Fig 1
Fig 1
Stapled hemorrhoidectomy - Fig 2
Fig 2


Although rare, there are risks that accompany this procedure:
  •  If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall.
  • The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.
  • As with other surgical treatments for haemorrhoids, cases of pelvic sepsis have been reported following stapled haemorrhoidectomy.
  • Persistent pain and fecal urgency after stapled haemorrhoidectomy.
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