What are haemorrhoids and when do you need surgery?

Haemorrhoids, commonly known as piles, are one of the most frequent conditions I see in my clinic. They are also one of the most misunderstood. Many patients have been quietly managing their symptoms for months or even years before they seek help, often because they feel embarrassed or assume that surgery is inevitable. In most cases, it is not. Here is what you need to know.

What are haemorrhoids?

Haemorrhoids are swollen, enlarged blood vessels that develop in and around the rectum and anus. They are extremely common; estimates suggest that around half of all adults will experience them at some point in their lives. There are two types:

• Internal haemorrhoids develop inside the rectum, above the dentate line. Because there are fewer pain-sensing nerves in this area, they often cause no pain but may bleed.
• External haemorrhoids develop under the skin around the anus and can be painful, particularly if a blood clot forms within them (a thrombosed haemorrhoid).

What causes them?

Haemorrhoids develop when the blood vessels in the anal canal come under increased pressure. Common contributing factors include chronic constipation or straining on the toilet, a low-fibre diet, prolonged sitting, pregnancy, and a family history of the condition. They become more common with age as the supporting tissues in the anal canal naturally weaken.

What are the symptoms?

The most common symptoms include bright red bleeding after opening the bowels (typically noticed on the toilet paper or in the pan), a sensation of fullness or a lump around the anus, itching or soreness, and in more advanced cases, a protrusion or prolapse of tissue through the anus. It is important to note that rectal bleeding should always be assessed by a doctor. Whilst haemorrhoids are the most common cause, bleeding can occasionally indicate a more serious underlying condition.

Do haemorrhoids always need surgery?

No. The majority of haemorrhoids respond well to conservative measures and non-surgical treatment. Simple changes such as increasing dietary fibre, staying well hydrated, avoiding straining, and using topical preparations can significantly improve symptoms. For patients who do not respond to these measures, a number of minimally invasive outpatient procedures are available, including rubber band ligation (banding) and injection sclerotherapy, both of which can be performed quickly and without a general anaesthetic. Surgical intervention is reserved for haemorrhoids that are large, symptomatic, prolapsed, or have failed to respond to less invasive treatment. Options include conventional haemorrhoidectomy and stapled haemorrhoidopexy, and the choice of procedure is tailored to the individual patient.

When should you see a specialist?

You should seek a specialist opinion if you experience rectal bleeding for the first time, if your symptoms are persistent or worsening, if you notice a prolapse that does not reduce on its own, or if conservative measures have not improved your symptoms after a few weeks. A consultant colorectal surgeon can assess your haemorrhoids accurately, rule out other causes of your symptoms, and recommend the most appropriate treatment.