What are haemorrhoids?
Haemorrhoids, also known as piles, are a fundamental part of the normal anatomical structure found in us all from birth. Haemorrhoids are found around the anus (external haemorrhoids) and within the anal canal (internal haemorrhoids).
Haemorrhoidal cushions contain a dense network of blood vessels, which when they engorge, form a plug in the anal canal. This then contributes to faecal continence.
Haemorrhoids can be internal or external:
- Internal haemorrhoids
Internal haemorrhoids are the haemorrhoids in the anal canal above the “pectinate line”, also known as the “pain line” because below this area you feel pain. This is why you do not feel these haemorrhoids until they become swollen and drop below the “pectinate line”.
- External haemorrhoids
These are haemorrhoidal cushions located outside the anus below the pain line and covered by anoderm which is a very sensitive layer of skin. Sometimes blood clots known as a thrombus can form inside external haemorrhoids and cause severe pain and swelling.
Haemorrhoidal disease is one of the most widespread anorectal disorders in Western countries.
Haemorrhoidal disease main symptoms are:
- Bleeding: haemorrhoidal cushions become bruised and start to bleed.
- Haemorrhoidal prolapse: haemorrhoidal cushions excessively increase in size and become misaligned.
- Haemorrhoidal thrombosis: painful blood clots form inside haemorrhoidal cushions.
Haemorrhoids have historically been classified as grade I, II, III and IV, depending on the severity of the symptoms, mainly to do with the degree of prolapse.
Grades of haemorrhoids
The classification of haemorrhoids is based on the symptoms observed during clinical examination, the grade will dictate the most suitable treatment.
- GRADE I: haemorrhoids are visible on anoscopy and may bulge out on straining, despite not being prolapsed.
- GRADE II: prolapse is visible at the anal margin when straining and reduces spontaneously afterwards.
- GRADE III: persistent prolapse of the mucous membrane outside of the anal canal, that may be pressed in by hand.
- GRADE IV: permanent prolapse of the external mucous membrane of the anal canal that cannot be pressed in.
Note: In all grades above, arterial bleeding is common.
The most common piles symptoms are bleeding, pain, itching around the anus and prolapse.
In haemorrhoidal disease, haemorrhoidal cushions are more sensitive to trauma and therefore there is a higher risk of haemorrhoidal bleeding. Bleeding haemorrhoids are one of the main symptoms of the disease, together with pain and itching.
Piles bleeding is one of the most worrying symptoms for those suffering with haemorrhoids. In less severe cases, bright red blood can be found on toilet paper or faeces, but this is light. On the other hand, in advanced grade haemorrhoids, bleeding of the prolapsed haemorrhoid tissue may be constant. Blood loss is especially common with internal haemorrhoids.
Rectal bleeding is not only a symptom of haemorrhoids. It can be associated with other diseases, like colorectal and anal cancer: so it is important to see a clinician at an early stage.
If you notice changes in bowel habits and blood in your stools or on the toilet paper, consult a colorectal specialist.
Another common symptom is pain, both in the case of internal and external haemorrhoids. Normally, internal haemorrhoids are associated with pain only when the volume of the cushion increases enough to cause significant bulging out of the anus. In these cases, you may notice pain or increased pain at the time of defecation.
- Anal itching
While rectal pain is a more frequent symptom of external haemorrhoids, the itching sensation and discomfort around the anus is linked with internal haemorrhoids. Internal haemorrhoids tend to secrete mucous that causes irritation and itching around the anus.
Increase in volume of one or more haemorrhoidal cushions causes the haemorrhoids to slide into the anal canal and to bulge out during defecation, this then causes haemorrhoidal prolapse.
The prolapse may shrink back on its own, need manual shrinking or be irreducible, depending on the severity of the disease. The choice of the treatment mainly depends on the extent of the prolapse and on the severity of the other symptoms.
For this reason, the assessment of the prolapse must be precise and carried out both at rest and during straining for defecation. It is important to see a doctor and undergo a colorectal exam, when symptoms first appear.
What causes haemorrhoids
Vascular theory and mechanical theory are amongst the most accredited explanations of the causes of hemorrhoid disease.
- vascular theory
The vascular theory considers haemorrhoids swelling as caused by an alteration in the arteriovenous blood flow. Under the pressure of excessive blood flow, the haemorrhoidal cushions stretch and swell.
The increase in arterial in-flow and the reduction in venous out-flow leads to bulging of haemorrhoids and in severe cases, to haemorrhoidal prolapse outside the anus. Increased pressure in the anorectal area can be due to different factors like straining during defecation, low-fiber diet or sitting too long on the toilet.
- mechanical theory
The mechanical theory attributes the prolapse of haemorrhoids to the progressive weakening of the tissue that surrounds the haemorrhoidal cushions.
One of the causes of the weakening of tissues is age. With age, the tissues supporting the cushions in the anorectal area become more fragile and stretch and the risk of prolapsing haemorrhoids is higher. This can also happen during pregnancy when the baby’s weight increases the pressure on the anorectal region.
- other risk factors
There then are other factors that may contribute to the development of hemorrhoidal disease, in particular:
- family history
- environmental factors (e.g., sedentary lifestyle, wrong diet)
- chronic constipation or diarrhoea