Haemorrhoids (Piles) & Rectal Bleeding

The exact cause of haemorrhoids is unclear, but they're associated with increased pressure in the blood vessels in and around your anus. This pressure can cause the blood vessels in your back passage to become swollen and inflamed.

Many cases are thought to be caused by too much straining on the toilet, due to prolonged constipation – this is often due to a lack of fibre in a person's diet. Chronic (long-term) diarrhoea can also make you more vulnerable to getting haemorrhoids.

Other factors that might increase your risk of developing haemorrhoids include:

• being overweight or obese
• age - as you get older, your body's supporting tissues get weaker, increasing your risk of haemorrhoids
• being pregnant - which can place increased pressure on your pelvic blood vessels, causing them to enlarge
• having a family history of haemorrhoids
• regularly lifting heavy objectss
• a persistent cough or repeated vomiting
• sitting down (especially at the toilet bowl) for long periods of time

After you've had a rectal examination or proctoscopy, Dr Ng will be able to determine what type of haemorrhoids you have.

Haemorrhoids can develop internally or externally. Internal haemorrhoids develop in the upper two-thirds of your anal canal and external haemorrhoids in the lower third (closest to your anus). The nerves in the lower part can transmit pain messages, while the nerves in the upper part can't.

Haemorrhoids can be further classified, depending on their size and severity. They can be:

• first degree - small swellings that develop on the inside lining of the anus and aren't visible from outside the anus
• second degree - larger swellings that may come out of your anus when you go to the toilet, before disappearing inside again
• third degree - one or more small soft lumps that hang down from the anus and can be pushed back inside (prolapsing and reducible)
• fourth degree - larger lumps that hang down from the anus and can't be pushed back inside (irreducible)

It's useful for doctors to know what type and size of haemorrhoid you have, as they can then decide on the best treatment.

Haemorrhoid symptoms often settle down after a few days, without needing treatment. Haemorrhoids that occur during pregnancy often get better after giving birth.

However, making lifestyle changes to reduce the strain on the blood vessels in and around your anus is often recommended. These can include:

• gradually increasing the amount of fibre in your diet - good sources of fibre include fruit, vegetables, wholegrain rice, wholewheat pasta and bread, pulses and beans, seeds, nuts and oats
• drinking plenty of fluid - particularly water, but avoiding or cutting down on caffeine and alcohol
• not delaying going to the toilet - ignoring the urge to empty your bowels can make your stools harder and drier, which can lead to straining when you do go to the toilet
• avoiding medication that causes constipation - such as painkillers that contain codeine
• losing weight (if you're overweight)
• exercising regularly - can help prevent constipation, reduce your blood pressure and help you lose weight

These measures can also reduce the risk of haemorrhoids returning, or even developing in the first place.

Haemorrhoids (piles) often clear up by themselves after a few days. However, there are many treatments that can reduce itching and discomfort.

Making simple dietary changes and not straining on the toilet are often recommended first.

Creams, ointments and suppositories (which you insert into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.

If more intensive treatment is needed, the type will depend on where your haemorrhoids are in your anal canal – external (lower third of anus) or internal (upper two-thirds of anus).

Usually non-surgical treatments can be attempted for internal haemorrhoids, but surgery is usually required to treat external haemorrhoids.

If constipation is thought to be the cause of your haemorrhoids, you need to keep your stools soft and regular, so that you don't strain when passing stools.

You can do this by increasing the amount of fibre in your diet. Good sources of fibre include wholegrain bread, cereal, fruit and vegetables.

You should also drink plenty of water and avoid caffeine (found in tea, coffee and cola).

When going to the toilet, you should:

• avoid straining to pass stools, because it may make your haemorrhoids worse
• use moist toilet paper, rather than dry toilet paper, or baby wipes to clean your bottom after passing a stool
• pat the area around your bottom, rather than rubbing it

Various creams, ointments and suppositories are available. They can be used to relieve any swelling and discomfort.

Usually these medicines should only be used for five to seven days at a time. If you use them for longer, they may irritate the sensitive skin around your anus. Any medication should be combined with the diet and self-care advice discussed above.

If there is have severe inflammation (usually externally) aound the anus, a steroid containing cream can help.

However, you should not use steroid cream for more than a week at a time, because it can make the skin around your anus thinner and the irritation worse.

Common painkilling medication, such as paracetamol, can help relieve the pain of haemorrhoids.

However, if you have excessive bleeding, avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, because it can make rectal bleeding worse. You should also avoid using codeine painkillers, because they can cause constipation.

If you're constipated, a laxative provide good relief. Laxatives are a type of medicine that can help you empty your bowels.

If dietary changes and medication don't improve your symptoms, consider coming for consultation. Dr Ng can confirm whether you have haemorrhoids and recommend appropriate treatment.

If you have internal haemorrhoids (grade 1 and 2) in the upper part of your anal canal, non-surgical procedures such as banding and sclerotherapy may be recommended.

Banding involves placing a very tight elastic band around the base of your haemorrhoids to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment.

Banding is usually a day procedure that doesn't need an anaesthetic, and most people can get back to their normal activities the next day. You may feel some pain or discomfort for a day or so afterwards. Normal painkillers are usually adequate, but something stronger can be prescribed that your haemorrhoids have fallen off, as they should pass out of your body when you go to the toilet. If you notice some mucus discharge within a week of the procedure, it usually means that the haemorrhoids have fallen off.

Directly after the procedure, you may notice blood on the toilet paper after going to the toilet. This is normal, but there shouldn't be a lot of bleeding. If you pass a lot of bright red blood or blood clots (solid lumps of blood), go to your nearest accident and emergency (A&E) department immediately.

Ulcers (open sores) can occur at the site of the banding, although these usually heal without needing further treatment.

Electrotherapy, also known as electrocoagulation, is another alternative to banding for people with smaller haemorrhoids. This is a relatively new treatment that only became available in Singapore from 2016.

During the procedure, a specially designed proctoscope is inserted into the anus to locate the haemorrhoid. An electric current is then passed through the base of the haemorrhoid, heating it up to 55 degrees Celcius.

The aim of electrotherapy is to cause the blood supplying the haemorrhoid to coagulate (thicken), which causes the haemorrhoid to shrink. If necessary, more than one haemorrhoid can be treated during each session.

Electrotherapy is usually carried out as a short day case procedure under gentle sedation.

Usually there is no pain at all after the procedure is completed. You may experience rectal bleeding after the procedure, but this is usually short-lived.

Electrotherapy has been shown to be an effective method of treating smaller haemorrhoids. It can also be used as an alternative to surgery for treating larger haemorrhoids, but there's less evidence of its effectiveness.

For Dr Ng, this procedure has almost completely replaced rubber band treatment as it typically causes no pain or discomfort and more areas can be treated at the same time leading to greater efficacy.

Although most haemorrhoids can be treated using the methods described above, around 1 in every 10 people will eventually need surgery.

There are many different types of surgery that can be used to treat haemorrhoids, but they all usually involve either removing the haemorrhoids or reducing their blood supply, causing them to shrink.

Dr Ng believes in individualising treatment. There is no one best treatment for all cases. Some treatments are better for some types of cases and not suitable for others. The most common haemorrhoid surgeries are introduced below:

"Tried and tested", the conventional haemorrhoidectomy is the traditional option for surgical removal of grade 3 and 4 haemorrhoids. The surgery leaves behind open wounds that are painful and relatively slow to heal. Recovery is expected in 4-6 weeks for most cases.

Dr Ng less commonly performs this now as most newer methods are both efficacious and less painful to recover from.

Open wounds at end of conventional haemorrhoidectomy

Nowadays when Dr Ng decides that conventional haemorrhoidectomy is the best approach, he modifies the technique utilising a “Ligasure” device during the operation. The ligasure device is an advanced cutting and dissection tool that has been shown to improve on the traditional method to reduce pain and recovery time.

Ligasure Device

This method was introduced nearly 20 years ago to provide a much less painful alternative to conventional haemorrhoidectomy for grade 3 and 4 disease. Studies have proven this to be the case. There is no open or visible wound after the procedure and the healing is fast (typically within 1-2 weeks). A side benefit of this procedure is that it usually also gives a dramatically improved cosmetic appearance of the anus.

More recently, some surgeons are avoiding to do this procedure or choosing to perform this procedure much less than previously as there were some reports of rare, but serious complications following this surgery.

Dr Ng still performs this operation frequently as, with careful and meticulous technique, as it is still the best choice for many cases in terms of safety, efficacy, recovery time and cosmetic result.

Dr Ng initially performed the original "Longo" technique for this procedure, first described in 1998. However, after travelling to Korea in 2016 and visiting the Goo Hospital, he is now performing the "Goo" technique for staple haemorrhoidectomy. The "Goo" technique is a modification that brings about much safety and consistency to the procedure.

Dr Ng involved in training junior surgeons and giving a lecture on haemorrhoid treatment to other doctors (2017)