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University Surgical Cluster

Common Conditions:

Benign Prostatic Hyperplasia (BPH)

Irritable Bowel Syndrome

Breast Surgery

Kidney Stones

Colon Cancer


Erectile Dysfunction

Prostate Cancer

Face Lift

Upper Gastrointestinal Surgery


Urinary Incontinence

Haemorrhoids or Piles

Hemorrhoids - The Basics

Hemorrhoids can be described as "cushions" of tissue within the anal canal that contain blood vessels and their surrounding supporting tissue are made up of muscle and elastic fibers. Hemorrhoids are present in everyone. It is only when the hemorrhoidal cushions enlarge that hemorrhoids can cause problems and be considered abnormal or a disease.

What causes hemorrhoids?

There are several theories, including inadequate intake of fiber, 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 hemorrhoids though, again, the reason is not clear.

What are the symptoms of hemorrhoids?

As the anal cushion of an internal hemorrhoid enlarges, it bulges into the anal canal, loses its normal anchoring, and protrude from the anus as a prolapsing internal hemorrhoid. The hemorrhoid is exposed to the trauma of passing hard stool causing 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 hemorrhoids.

First-degree hemorrhoids:

Hemorrhoids that bleed but do not prolapse.

Second-degree hemorrhoids:

Hemorrhoids that prolapse and retract on their own (with or without bleeding).

Third-degree hemorrhoids:

Hemorrhoids that prolapse but must be pushed back in by a finger.

Fourth-degree hemorrhoids:

Hemorrhoids that prolapse and cannot be pushed back in.

Key Points

Only when hemorrhoidal cushions enlarge that hemorrhoids 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 hemorrhoids are different to the symptoms of internal hemorrhoids. External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids. External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as a perianal hematoma. Thrombosis of an external hemorrhoid causes an anal lump that is very painful (because the area is supplied by somatic nerves) and may require


Perianal Hematoma


Clot evacuated from perianal hematoma

incision and drainage. This small procedure can
effect immediate symptom relief. The thrombosed hemorrhoid may heal with scarring and leave a tagof 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.


How are hemorrhoids diagnosed

By the history of symptoms, we can suspect that hemorrhoids are present. The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, a more thorough examination for internal hemorrhoids is done visually using an proctoscope. As the proctoscope is withdrawn, the area of the internal hemorrhoids is well seen. Straining by the patient may make the hemorrhoids more prominent. Rectal mucosal prolapse can also mimic internal hemorrhoids. External hemorrhoids appear as a lump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Although we should try our best to identify the hemorrhoids, it is perhaps more important to exclude other causes of hemorrhoid-like symptoms that require different treatment. These other causes - anal fissures, fistulae, perianal skin diseases, infections, and tumors - 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 hemorrhoid since there are rare cancers of the perianal area that may masquerade as external hemorrhoids.

Rectal bleeding

Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than hemorrhoids. 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 promote hemorrhoids and that hard stools can traumatize existing hemorrhoids. It is recommended, therefore, that individuals with hemorrhoids soften their stools by increasing their fluid and fiber intake in their diets. This is recommended for all patients who have hemorrhoidal symptoms and can be the only treatment required for patients with first degree hemorrhoids.

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

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

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 hemorrhoids as part of our specialist consultation. This service will provide immediate reassurance of the benign nature of the rectal bleeding with simultaneous hemorrhoid treatment.

Hemorrhoids at a Glance

  • Internal hemorrhoids are clumps of tissue within the anal canal that contain blood vessels, muscle, and elastic fibers. External hemorrhoids are enlarged blood vessels surrounding the anus.
  • Internal hemorrhoids cause problems when they enlarge. The cause of the enlargement is not known.
  • Complications of internal hemorrhoids include bleeding, anal itchiness, prolapse, incarceration and gangrene. Pain is not common.
  • The primary complication of external hemorrhoids is pain due to blood clotting in the hemorrhoidal blood vessels called perianal hematoma.
  • When dealing with hemorrhoids, 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 hemorrhoids includes fiber 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 hemorrhoidectomy is the treatment option reserved for patients with third or fourth degree hemorrhoids.
  • Stapled hemorrhoidectomy 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

The principle of ligation with rubber bands is to encircle the base of the hemorrhoidal 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 hemorrhoids. 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 hemorrhoids (hemorrhoidectomy) usually is reserved for patients with third or fourth-degree hemorrhoids. During hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are excised using diathermy. The wounds left by the removal are left open. This is performed as a daycase procedure. Post surgical pain is the major problem with hemorrhoidectomy. The addition of NSAIDs enhances the relief of pain. Delayed hemorrhage 7 to 14 days after surgery occurs in 1-2% of patients. Wound infections are uncommon after hemorrhoid 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 powders

Stapled hemorrhoidectomy

Stapled hemorrhoidectomy is a technique developed in the early 1990s but is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue. The arterial blood vessels that travel within the expanded hemorrhoidal tissue are cut, thereby reducing the blood flow to the hemorrhoidal vessels and reducing the size of the hemorrhoids.During the healing of the cut tissues around the staples, scar tissue forms, and this scar tissue anchors the hemorrhoidal cushions back to their normal position higher in the anal canal thus effectively an anopexy is performed. However,external hemorrhoids are not



removed. Hence, this procedure is best suited
for circumferential third or fourth hemorrhoids with minimal external components. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return earlier to work.


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 hemorrhoids, cases of pelvic sepsis have been reported following stapled hemorrhoidectomy.

Persistent pain and fecal urgency after stapled hemorrhoidectomy.


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