Avoid constipation and straining at the toilet
Keep the stools (faeces) soft, and don't strain on the toilet. You can do this by:
- Eating plenty of fibre (for example, fruit, vegetables, cereals and wholegrain bread).
- Have lots to drink. Most sorts of drink will do but too much alcohol and caffeine should be avoided.
- Fibre supplements. If a high-fibre diet is not helping, you can take fibre supplements (bulking agents) such as ispaghula, methylcellulose, bran or sterculia.
- Avoid painkillers that contain codeine, such as co-codamol, as they are a common cause of constipation. However, simple painkillers such as paracetamol may help.
- Toileting. Go to the toilet as soon as possible after feeling the need. Do not strain on the toilet.
- Regular exercise helps to reduce constipation.
These measures will often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small and non-prolapsing piles (grade 1). Small grade 1 piles often settle down over time.
Ointments, creams and suppositories
- A bland soothing cream, ointment, or suppository may ease discomfort.
- One that contains an anaesthetic may ease pain better. You should only use one of these for short periods at a time (5-7 days).
- Preparations which contain a corticosteroid for treating piles may be advised by a doctor if there is a lot of inflammation around the piles. This may help to ease itch and pain. You should not normally use a steroid cream or ointment for longer than one week at a time.
What procedures are used to treat piles?
Banding is the most commonly used procedure, especially for grade 2 and 3 piles. It may also be done to treat grade 1 piles which have not settled with the simple advice and treatment outlined above.
This procedure is usually done by a surgeon in an outpatient clinic. A haemorrhoid is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid which then dies and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.
Banding of internal piles is usually painless, as the base of the haemorrhoid originates above the anal opening in the very last part of the gut where the gut lining is not sensitive to pain.
In about 8 in 10 cases, the piles are cured by this technique. In about 2 in 10 cases, the piles come back at some stage. (However, you can have a further banding treatment if this occurs.) Piles are less likely to come back after banding if you do not become constipated and do not strain on the toilet (as described above).
A small number of people have complications following banding, such as bleeding, infection or ulcers forming at the site of a treated haemorrhoid, or urinary problems.
Phenol in oil is injected into the tissues at the base of the piles. This causes a scarring (fibrotic) reaction which obliterates the blood vessels going to the piles. The piles then die and drop off, similar to after banding.
This method uses infrared energy to burn and cut off the circulation to the haemorrhoid, which causes it to shrink in size. It seems to be as effective as banding treatment and injection sclerotherapy for first- and second-degree piles.
Diathermy and electrotherapy
This uses heat energy to destroy the piles. They appear to have similar success rates as infrared coagulation and the risk of any complications is low.
What are the surgical options?
Haemorrhoidectomy (the traditional operation)
An operation to cut away the haemorrhoid(s) is an option to treat grade 3 or 4 piles or for piles not successfully treated by banding or other methods. The operation is done under general anaesthetic and is usually successful. However, it can be quite painful in the days following the operation.
A circular stapling gun is used to cut out a circular section of the lining of the back passage (anal canal) above the piles. This has the effect of pulling the piles back up the back passage. It also has the effect of reducing the blood supply to the piles and so they shrink as a consequence. Because the cutting is actually above the piles, it is usually a less painful procedure than the traditional operation to remove the piles.
Haemorrhoidal artery ligation
The small arteries that supply blood to the piles are tied (ligated). This causes the haemorrhoid(s) to shrink.
What about strangulated or thrombosed piles?
Strangulated or thrombosed piles are uncommon but usually very painful. Treatments usually include bed rest, medication for pain relief, hot baths, ice packs and keeping your stools (faeces) soft (see above). Surgery may, rarely, be needed to remove the haemorrhoid.
Further reading and references
Haemorrhoids; NICE CKS, July 2016 (UK access only)
Haemorrhoidal artery ligation; NICE Interventional Procedure Guidance, May 2010
Stapled haemorrhoidopexy for the treatment of haemorrhoids; NICE Technology Appraisal Guidance, September 2007
Electrotherapy for the treatment of haemorrhoids; NICE Interventional Procedure Guidance, June 2015
Hardy A, Cohen CR; The acute management of haemorrhoids. Ann R Coll Surg Engl. 2014 Oct96(7):508-11. doi: 10.1308/003588414X13946184900967.
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