Piles

• Bleeding during stool passage (the blood is usually bright red)
• Prolapse (protrusion of skin during stool passage)
• Pain during stool passage
• Itching in the anal area
• Presence of lumps in the anal area, which may require pushing back after stool passage
• Mucus discharge, especially while passing stool, which may be seen in underwear or on toilet paper after wiping
• Redness and swelling around the anus
• Fecal seepage (inability to control bowel movements, causing stool to leak unexpectedly from the rectum)
• Feeling of incomplete defecation even after going to the toilet
• Sitting for long periods to pass stool
• Abdominal pain
• Bloating

Piles, also known as hemorrhoids or hemorrhoidal disease, involve disturbances in the naturally occurring cushion-like structures in the anal canal. These cushions, known as hemorrhoids, are composed of loose connective tissue, smooth muscle, and blood vessels. Their main function is to retain stool.

The primary cause of piles is the exertion of excessive pressure in the lower rectum, which leads to an increase in the size of the anal cushions and degeneration of supportive tissues. Contributing factors may include:

• Chronic obstructive pulmonary disease (COPD)
• Enlarged prostate
• Constipation
• Ovarian tumor

Additionally, the anal cushions can be affected by other conditions such as:

• Low fiber diet
• Pregnancy
• Advancing age

Some studies suggest that abnormalities in the quality and quantity of collagen present in the anal cushions may also contribute to the development of piles.

Risk Factors For Piles

Anything that can increase the pressure in the lower rectum for a long period of time increases the risk of piles. Various risk factors are discussed below:

• Long term constipation: Constipation over time increases the chances of straining, which can cause swelling of the veins in the anus and lower rectum, potentially leading to piles. Watch this video by our expert to know the simple Ayurvedic remedies to relieve constipation.
• Age: As we age, the fibers of the muscles that support existing hemorrhoids become weaker, making them less supportive and potentially leading to prolapse of piles.
• Diet: A low fiber diet leads to hardening of stools and increases the chances of straining. Constant straining can cause piles by injuring local tissues.
• Chronic diarrhea: Chronic diarrhea is associated with an increased risk of piles. In a study, patients suffering from diarrheal conditions such as colitis, malabsorption, intestinal bypass, and chronic pancreatitis were found to be more prone to piles.
• Overweight/obesity: Excess weight, especially in the abdominal region, puts extra pressure on anal veins, which can lead to piles. Obesity is a complex and largely preventable disease affecting around one-third of the world’s population. Here are some common health complications due to obesity in women.
• Pregnancy: This is a common risk factor for piles, as the increased weight of the baby puts pressure on the pelvic blood vessels and anal region. Constipation is also a common symptom during pregnancy, further increasing the chances of piles. Here’s a quick guide with tips to help manage constipation during pregnancy.
• Family history: The likelihood of developing piles increases if someone in the family has had piles in the past.

Other factors that might increase the risk of piles include:

• Lifting heavy objects
• Persistent cough
• Repeated vomiting
• Sitting down for long periods
• Sitting on the toilet for extended durations
• Living in developed countries
• Straining during bowel movements
• Faulty bowel function due to overuse of laxatives or enemas
• Spending long periods of time on the toilet
• Sedentary lifestyle
• Higher socioeconomic status
• Injury to the spinal cord
• Rectal surgery
• Anal sex
• Inflammatory bowel disease

Note: The prevalence of piles is more common in developed countries due to dietary habits that include low fiber intake. Additionally, the posture during defecation, which is opposite to squatting, contributes to the higher incidence of piles in these countries.

Piles is often confused with other anorectal diseases such as fissures, fistulas, and abscesses. A complete diagnosis is important to confirm piles before initiating treatment. External hemorrhoids are usually diagnosed by physically examining the area around the anus, while procedures such as a digital rectal exam are performed to confirm internal hemorrhoids.

1. Medical History

The first step in diagnosing piles includes an inquiry about the symptoms and medical history. The doctor will ask about the patient’s eating habits, toilet habits, laxative use, and current medical conditions.

2. Physical Examination

Rectal examination involves inspecting a person's lower rectum, pelvis, and lower abdomen. The test is performed by inserting a gloved finger into the rectum to check for external hemorrhoids, skin tags, prolapsing internal hemorrhoids, fissures, fistulas, and abscesses. The examination also includes pressing on the surface of the rectum to assess for abnormal masses and tenderness. This technique is not usually painful, but slight discomfort may be felt.

3. Anoscopy

Anoscopy involves the examination of the anus and lower rectum using a device called an anoscope. This procedure helps rule out other possible causes of rectal bleeding. It requires the insertion of a tube into the rectum through the anus, and the anal region is inspected using a light. Patients are instructed to sit on a commode and strain during the exam to provide an accurate assessment of the degree of prolapse.

4. Proctoscopy

This test examines the internal organs of the rectum and anus using an instrument known as a protoscope. A protoscope is a straight, hollow metal or plastic tube, sometimes with a light at the end. This instrument is slightly larger than an anoscope and helps in examining the entire anal canal. It is usually performed in cases of red flag symptoms, which include bleeding, weight loss, changes in bowel habits, or anemia.

5. Colonoscopy

Colonoscopy is a procedure in which a doctor uses a colonoscope to look inside the rectum and colon. It is considered for patients with red flag symptoms.

6. Barium Enema

This test involves the injection of barium enema (radio-contrast fluid, barium sulfate) into the rectum from the anus.

7. Other Tests

In some cases, additional tests such as hemoglobin, complete blood count (CBC), blood coagulation studies, and liver function tests (LFT) are also performed.

The proper education about piles, its triggers, and a proper diet is vital for preventing piles. The following measures can aid in preventing piles:

• Maintain a healthy weight
• Eat fiber-rich food
• Keep the bottom clean and dry
• Exercise regularly
• Avoid excessive consumption of tea and coffee
• Avoid long periods of sitting
• Go to the bathroom immediately when there is an urge to defecate
• Avoid taking mobile phones to the bathroom
• Elevate your feet on a support while defecating
• Avoid pushing too hard while passing stool
• Stay physically active

The very first line therapy involves lifestyle modifications and self-care. Patients should adopt dietary modifications with adequate fluid and fiber intake. The treatment regimen is based upon symptoms and grade of piles, which can be grouped as:

A. Non-surgical treatment

It includes medications and office-based treatments. They are initiated if simple home remedies fail to resolve symptoms and include:

1. Medications

• Topical treatments: Creams, ointments, and suppositories are given to relieve discomfort. These medications should be applied only for 5 to 7 days at a stretch, as they may irritate the sensitive skin of the anus. In cases of severe inflammation in the anal region, corticosteroid cream containing steroids may also be prescribed.
• Pain relief medications: Common painkillers such as paracetamol are used to relieve pain associated with piles. However, medications like ibuprofen are avoided in cases of excessive bleeding.
• Laxatives: These medications soften the stools and assist in emptying the bowel. Commonly used laxatives include ispaghula husk and lactulose.
• Phlebotonics: This class of drugs consists of plant extracts and is available as dietary supplements. Examples include diosmin, troxerutin, hydroxyethylrutoside, and calcium dobesilate. They have shown effectiveness in reducing bleeding, itching, and discharge in piles.

2. Hospital-based treatments

These therapies are utilized when home remedies and medications fail to resolve symptoms. The various hospital-based treatments include:

• Rubber band ligation: This popular non-surgical method is favored for its safety and cost-effectiveness. The procedure involves inserting a band at the end of the internal hemorrhoid, restricting blood supply to the hemorrhoid tissue, which helps in reducing and fixing the internal hemorrhoid. This method has a high cure rate with minimal chances of recurrence and is effective for first, second, and third-degree hemorrhoids. Multiple treatments may be necessary for large and bulky hemorrhoids.
• Injection sclerotherapy: This involves injecting sclerosants at the base of hemorrhoids. Sclerosants are chemical agents that incite an inflammatory response, leading to the destruction of hemorrhoid tissue. Commonly used agents include 5% phenol in an oil base, hypertonic saline, 5% quinine, and urea.
• Electrotherapy: This therapy coagulates the blood supply in the hemorrhoids, causing shrinkage of the swollen tissue.
• Cryotherapy: This rarely used technique involves freezing the piles using liquid nitrogen.
• Infrared coagulation (IRC): In this procedure, bursts of infrared light are delivered using a small probe, helping to coagulate the blood supply to the hemorrhoids.

B. Surgical treatment

Surgical intervention is required in the following cases:

• Inability to tolerate hospital procedures
• Large external hemorrhoids
• Failure of non-operative procedures
• Mixed hemorrhoids with prolapse
• Grade 3 and 4 hemorrhoids
• Coagulopathic patients requiring management of hemorrhoidal bleeding

Surgery involves either removing the hemorrhoid or restricting their blood supply to cause shrinkage. The various surgical procedures include:

• Hemorrhoidectomy: This procedure involves the removal of excess tissue causing bleeding and protrusion. It is performed for both internal and external hemorrhoids under anesthesia using sutures. Hospitalization and rest are required as part of postoperative care.
• Stapled hemorrhoidectomy: A stapler-like device is used to reposition the hemorrhoids, which eventually cuts off their blood supply.
• Hemorrhoidal artery ligation: In this procedure, the arteries supplying blood to the hemorrhoids are tied and cut off.

1. Follow good toilet practices
   • Limit toilet time to 3 to 5 minutes to prevent protrusion.
   • Avoid excessive wiping.
   • Avoid straining to pass stool to reduce pressure on piles.
   • Use moist toilet paper to clean the area after passing stool.
   • Avoid rubbing the area around the bottom.
2. Do sitz baths

   Sitting in warm water for at least 15 minutes is very helpful for relieving itching, pain, and burning sensations in the anal region. This should be practiced 2-3 times to aid the healing process. Avoid adding salts, lotions, or oils to the water as they can cause inflammation. A warm bath also helps relieve itching and pain.

3. Take high fiber diet/supplements

   It is crucial to keep the stool soft and regular to avoid straining, as excessive straining can worsen the condition. Include foods such as whole grain bread, cereal, fruits, and vegetables to maintain a high fiber diet of 25g/day for women and 38g/day for men. OTC supplements like ispaghula husk can also be taken to soften the stool. Low fiber foods such as white bread, red meat, processed foods, and fried foods should be avoided.

4. Maintain proper hydration

   Patients should consume an adequate amount of water to maintain stool consistency. Watch this video by Dr. Suchin Bajaj addressing the importance of water, the recommended daily intake, and its benefits.

5. Avoid caffeinated beverages

   It is advised to avoid or limit caffeinated beverages (tea and coffee) as they may harden stools and make defecation more painful.

6. Indulge in some physical activity

   Exercise is associated with regular bowel habits. Light physical activity can also help relieve constipation. Patients with piles should allocate time for physical activity.

7. Avoid spicy and processed foods

   Spicy foods can aggravate symptoms of piles such as pain, burning sensation, and discomfort, and should be avoided.

8. Avoid certain medications

   Painkillers such as codeine should be avoided as they can cause constipation. NSAIDs like ibuprofen should also be avoided as they can increase rectal bleeding.

9. Use ice packs

   Ice packs are effective for reducing swelling and pain associated with piles. An ice pack wrapped in a soft towel should be applied for at least 15 minutes on the affected area and can be repeated hourly for immediate relief.

10. Sit right

    Individuals with piles should elevate their feet while passing stool. This changes the position of the rectum, allowing for easier passage of stool.

11. Modify your clothing

    Patients can enhance the healing process of piles by wearing loose-fitting, breathable cotton underwear and pants. This helps prevent irritation from excess sweat and reduces symptoms.

Most hemorrhoids resolve with treatment, but they can rarely lead to the following complications:

• Skin tags: A flap of tissue that hangs off from the skin of the anus. It develops when the clot of a thrombosed hemorrhoid dissolves and often irritates the patient.
• Anemia: The patient's blood count can drop due to bleeding from a chronic hemorrhoid.
• Infection: Untreated external hemorrhoids can become infected due to the presence of sores.
• Strangulated hemorrhoid: Blood flow may be cut off from a prolapsed hemorrhoid, which can be very painful and cause bleeding.
• Blood clots: In some cases, a blood clot forms in the piles, causing extreme pain and sometimes requiring drainage.
• Hemorrhage: The most common complication of piles, where hemorrhoids can rupture and cause serious rectal bleeding, requiring immediate medical attention. Passing very hard stool can aggravate this process.

Patients may also encounter various complications due to procedures performed to treat piles.

Complications of Hemorrhoidectomy

Patients who have undergone surgery usually experience pain and fullness within the first week following hemorrhoidectomy. Other complications include:

Early complications:

• Bleeding
• Urinary retention
• Thrombosed external hemorrhoids

Late complications:

• Anal stenosis (narrowing of the anal canal that makes it difficult to pass stools)
• Skin tags
• Recurrent hemorrhoids
• Delayed hemorrhage
• Fecal or bowel incontinence

Rare complications:

• Sepsis
• Abscess formation
• Excessive bleeding
• Peritonitis (inflammation of the inside of the abdomen)

Complications of Rubber Band Ligation

This procedure can be associated with delayed hemorrhage. Immunocompromised patients may develop sepsis, characterized by fever, perineal edema, and pain.

1. Nutrition and Dietary Supplements

• Psyllium: A well-known fiber that softens stool, reducing pain associated with piles and facilitating smoother bowel movements. It can be consumed with water or milk. Patients with inflammatory bowel disease should consult their doctor before use. The dosage should be gradually increased to avoid bloating.
• Probiotics: Beneficial bacteria that help maintain gut health. Regular consumption of probiotic-rich foods like curd and buttermilk can alleviate symptoms of piles, speed up healing, and prevent recurrence.

2. Herbs

The use of herbs for treatment is a well-established practice. It is advisable to start taking herbs under the supervision of a doctor. Some herbs used to manage piles include:

• Witch hazel (Hamamelis virginiana): Applied topically or used in sitz baths, it can reduce pain by temporarily shrinking piles. Various pads available in the market for piles contain witch hazel.
• Goldenrod (Solidago virgaurea): Reduces inflammation of hemorrhoids through topical application.
• Gotu kola (Centella asiatica): Used for venous insufficiency or varicose veins.
• Yarrow (Achillea millefolium): Treats bleeding associated with hemorrhoids.

3. Other Home Remedies

• Castor oil: Reduces the size of piles and eases pain. It can be consumed with milk or applied topically to the affected area.
• Tea tree oil: Possesses antimicrobial properties, keeping the inflamed area free from germs. It is applied topically.
• Coconut oil: Acts as a moisturizer, relieving symptoms of swelling and inflammation, and reduces itching.
• Myrtle essential oil: Improves bleeding, pain, irritation, and itching for low-grade piles.
• Aloe vera: May provide relief from burning, itching, and swelling when applied to the anal area.

4. Homeopathy

The following homeopathic preparations are used for piles:

• Aesculus: Used to manage piles with a burning sensation.
• Collinsonia: Used for chronic, itchy hemorrhoids accompanied by constipation.

The treatment of piles is not always satisfactory despite its easy diagnosis. It is best managed by a team of professionals dedicated to anorectal conditions. Piles are not life-threatening but can seriously affect quality of life.

Managing Postoperative Pain

The overall result of surgery varies from good to poor. Patients should expect pain and anal fullness in the first week after hemorrhoidectomy. Adequate pain control can be achieved through:

• Oral narcotics
• NSAIDs
• Muscle relaxants
• Sitz baths

The use of stool softeners is also advised to avoid straining that may aggravate pain. Patients who have undergone surgery should reconsult their doctor if their pain worsens, as this may indicate a soft tissue infection.

Educating Patients

Patient education plays a vital role in postoperative care and preventing recurrence. The nurse, dietitian, and pharmacist should encourage patients to:

• Avoid constipation
• Drink sufficient water
• Take stool softeners
• Reduce body weight
• Avoid prolonged sitting
• Eat a high-fiber diet
• Avoid excessive pain medication

These simple measures not only reduce the risk of hemorrhoids but also decrease healthcare expenses.

Managing Relapse

Surgery for piles, especially for those who do not change their lifestyle, is not always satisfactory. Pain, urinary retention, and recurrence are commonly seen postoperatively. Individuals experiencing recurrence, prolapse, and bleeding of internal piles should refer immediately to a colorectal surgeon.