Haemorrhoids

Condition

Common — a complex of dilated arteries and veins, usually caused by chronic constipation related to a lack of dietary fibre. Affects 50% of westerners by age 50; usually develops between ages 20 and 50.

Grading:

• First degree — bulges above the dentate line.
• Second degree — increase in size and slide downwards, so the patient is aware of the bulges when straining.
• Third degree — manual replacement required to alleviate discomfort.
• Fourth degree — unable to be reduced.

History and examination

Bleeding is the most common feature — blood on the stool, blood in the toilet separate from stool, or blood on wiping. Also anal mucoid discharge, irritation and itching, tenesmus (incomplete emptying), and pain. Three classical sites on examination: 3, 7, and 11 o’clock.

Management

Most haemorrhoids are controlled with conservative measures: avoid constipation (adequate fibre intake, increased fluids, avoid caffeine), avoid straining at stool, respond promptly to the urge to defecate, and don’t try to initiate defecation without the urge.

OTC topical treatments (e.g. Proctosedyl) lack evidence and may cause irritation. Persistent bleeding is an indication for rubber band ligation. If a haemorrhoid develops during pregnancy, it’s very likely to resolve after delivery.

Perianal haematoma (thrombosed external haemorrhoid)

Recent thrombosis in a vein, often after straining at stool. Presents as a painful, blue swelling protruding through the anus.

Management: if presenting within 72 hours, excision of the haematoma under local anaesthetic is beneficial. Otherwise, it tends to resolve over 1–2 weeks, leaving behind a skin tag.