Haemorrhoids

Peri-Anal ConditionsPeri-anal problems are delicate and personal conditions which are surprisingly common and affect many people. Embarrassment and fear lead to patients not seeking medical advice and treatment. In many cases, failure to get treatment can lead to serious consequences, however if these conditions are seen and treated early, complications can be avoided. 

This area of surgery is called colo-proctology and deals with a number of conditions around the anus. Haemorrhoids (Piles) are probably the most well known condition, but there are also other lesser known conditions which could be affecting patients and presenting with similar symptoms. These include Peri-anal Skin Tags, Peri-anal Haematoma, Fissure in Ano, Fistula in Ano, Anal Polyps or Tumours.

Haemorrhoids

What are Haemorrhoids?

We all have small haemorrhoids! These are the anal equivalent of lips around your mouth and are designed to keep the contents of the gut inside the bowel!! Essentially haemorrhoids are a variation of normal anatomy however when they become enlarged these cushions of vascular tissue become irritating, may start to hurt or itch and in severe cases can prolapse and bleed. Contributing factors to enlarged troublesome haemorrhoids include ageing, constipation (or diarrhoea influenced by diet), faulty bowel function, prolonged straining bowel movement or pregnancy.

Haemorrhoids and their symptoms are one of the most common afflictions in the world. They can occur at any age and can affect both men and women. Although rarely fatal, they can be painful, embarrassing and disabling. Haemorrhoids are graded by degree of prolapse and this grading determines the most appropriate treatment method.

First degree haemorrhoids are the internal enlargement of the haemorrhoidal cushions and are characterised by dilated vessels on the surface of the haemorrhoidal tissue.

Second degree haemorrhoids are as above but the lesions prolapse with defecation returning spontaneously.

Third degree lesions prolapse and require manual replacement

Fourth degree lesions remain prolapsed in the anal canal despite attempts to reduce them.

Treatment

Haemorrhoids tend to get worse with time and are best treated as early as possible. Depending on the severity of the haemorrhoids, some may be alleviated by over the counter remedies such as suppositories and ointments.

The majority of first degree and some second degree haemorrhoids can be treated in the surgical outpatient clinics without the need for general anaesthetic. In these cases, it is possible to apply a small rubber band onto the haemorrhoid to cut off its blood supply and thus shrink it back to its normal size (some surgeons prefer to inject an irritant called phenol into the haemorrhoid to achieve the same effect).

Only the most severe cases require inpatient surgery. This procedure is called a haemorrhoidectomy. Such cases include large second degree and third degree haemorrhoids. If this treatment is required it is usually because the condition has become chronic.

Acute prolapsed / strangulated haemorrhoids can occur from time to time, and in these cases, surgery should be avoided and the condition allowed to settle down before surgery is attempted.

Differential Diagnosis

Whilst haemorrhoids are the most common anal condition presenting with anal discomfort, bleeding and discomfort, your doctor should ensure that there is not another cause for your symptoms. Possible rarer causes for the above symptoms include:
  • Peri-anal skin tags
  • Peri-anal haematoma
  • Fissure in ano
  • Fistula in ano
  • Anal Polyps or tumour

Peri-anal Skin Tags

This is a condition which consists of small areas of loose skin protruding from around the anal canal. Normally these are a result of a patient having had haemorrhoids which have "shrunk" leaving behind a small area of loose skin. These can be uncomfortable, irritating and lead to problems with personal hygiene. They can be removed very easily.

Peri-anal Haematoma

This condition is often mis-diagnosed as a "thrombosed pile" but is actually an acute condition resulting from the rupture of a small blood vessel under the skin adjacent to the anal canal. Typically the patient will give a history of sudden pain and development of a painful lump whilst they were straining on the toilet. If diagnosed accurately and quickly, these painful lumps can be easily treated by a small operation which is normally performed in the surgeon’s office under local anaesthetic.

Fissure in Ano

This is a painful condition, where the patient develops a tear in the lining of the anal canal. It can be an acute or chronic condition and is often associated with a history of constipation. In this condition the history consists of severe anal pain during daefication. This can be associated with blood particularly after leaving the bathroom. The condition can lead to major problems if it becomes chronic and can be difficult to treat.

Treatment for this condition has evolved significantly and treatment can be as simple as using an appropriate cream or a simple injection. Surgery is reserved for only the most stubborn cases, and is performed as a day case procedure under a light anaesthetic.

Fistula in Ano

Sometimes a track (fistula) exists between the inside of the bowel and the skin around the anus. This is called a "fistula in ano". This means that bowel content can be extruded down the track and lead to leakage onto the skin. Patients present with smelly discharge from a small hole somewhere around the anus. If the condition is left and the track becomes blocked the bowel content can fester in the tissues around the anus and form an abscess which would need urgent surgical drainage.

This condition requires careful investigation and analysis before treatment is undertaken. Most cases require simple surgical treatment however some cases can be more complex.  

Anal Polyps or Tumours

Polyps are fleshy growths which develop from the bowel lining. If these are near the anal canal they can prolapse outside the body and may mimick haemorrhoids. Some polyps may be pre malignant and therefore these need to be removed and tested.

It is also possible to develop tumours of the anus. This is a completely different disease to bowel cancer and can present in a number of different ways.

Summary

If you have a condition which is described above or have any concerns regarding the information above you should seek medical advice.

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