Piles (or haemorrhoids) are vascular tissue or ‘cushions’ located in the anal canal. They form part of the normal human anatomy, and function to help prevent leakage of stool or gas. Piles become problematic (haemorrhoidal disease) when they swell up and/or bleed during defecation. For some, both internal and external haemorrhoids can occur simultaneously. It is estimated that 35% of the population has a form of haemorrhoid. Generally, most cases of haemorrhoids are mild and people do not experience any symptoms.

Piles can be classified into four grades:

• First degree: Internal piles that bleed, but do not prolapse past the anus (or ‘pop out’).
• Second degree: Piles that prolapse past the anus during bowel movement but reduce spontaneously.
• Third degree: Piles that are prolapsed and must be manually reduced.
• Fourth degree: Piles that are permanently prolapsed and cannot be reduced, or piles with painful blood clots.

Usual symptoms experienced:

• Bleeding before, during or after bowel movement
• Bright red blood from the anus on the toilet paper or in the toilet bowl
• Anal lumps
• Pain or itching in the anal area

It is important to consult your colorectal surgeon if you experience these symptoms, as these symptoms may mimic those of colorectal cancer. A thorough examination and colonoscopy may be required to exclude cancer.

What causes piles?

When the tissue supporting the ’cushion’-like clusters of veins making up haemorrhoids stretch and break, the blood vessels enlarge. This causes the vessel walls to thin out and bleed. With further stretching, the anal cushions may enlarge and prolapse. Some factors that may contribute to the formation of piles include:

• Inadequate fibre in the diet
• Chronic constipation and excessive straining during bowel movements
• Spending long periods of time in the toilet (e.g. reading in the toilet)
• Pregnancy
• Ageing

Piles need only be treated if they cause symptoms. First and second degree piles may be treated without surgery. Third and fourth degree piles almost always require surgery. Mild symptoms can be relieved by improving and regularising bowel habits. Increasing the amount of fibre and fluid intake in the diet usually helps. Eliminating excessive straining reduces the pressure on piles and helps prevent them from protruding. Simple outpatient procedures such as injection treatment or rubber band ligation may be performed for first and second degree piles. Surgical procedures such as conventional haemorrhoidectomy, and stapled haemorrhoidectomy are some treatment options for third and fourth degree piles. Another form of treatment for bleeding piles is available and known as Transanal Haemorrhoidal Dearterialization (THD)

How does injection treatment work?

The surgeon passes a short instrument into the back passage and injects an oily solution into the top of the piles. The oily solution causes mild inflammation at the base of the haemorrhoids, which causes the blood vessels to shrink, thereby reducing the size of the pile.

How does rubber band ligation work?

A rubber band is placed around the base of the haemorrhoid inside the anal canal. The band cuts off blood supply to the haemorrhoid which shrivels and falls off in 3-4 days.

How does transanal haemorrhoidal dearterialization (thd) work?

THD is a form of surgery that does not involve cutting or removal of haemorrhoidal tissue. The surgeon identifies the blood vessels supplying the haemorrhoids with a Doppler Ultrasound, and stitches the appropriate blood vessels. Limitation of blood supply then causes the haemorrhoids to shrink. The prolapsed tissue can then be further reduced by stitching.

How does conventional haemorrhoidectomy work?

A small incision is made to remove the piles. The cut is performed using a sharp instrument, such as a scalpel, scissors, or electrocautery. This may be followed by wound closure.

How does stapled haemorrhoidectomy work?

A circular stapling device is used to remove a circumferential ring of excess haemorrhoidal tissue. This disrupts the blood supply to the piles, and also lifts them back to their normal position within the anal canal.

There are so many options. Which treatment should i pick?

You should consult your doctor to find out which procedure best suits your condition. Each procedure differs in length of recovery process, risks and complications, as well as post-operative discomfort. Make sure you make an informed decision only after a thorough discussion.