Haemorrhoids (Piles)

What are Hemorrhoids / Piles?

They can be divided into internal or external, depending on the location where they start. External piles develop at the outer part of the anus. It usually manifest itself when it forms a blood clot within, resulting in a painful swelling. The external feels like a hard, sensitive lump. Bleeding occurs only if the overlying skin ruptures. Internal piles starts from the upper part of the anal canal. It is believe that repetitive straining at stools causes a high pressure within and it becomes swollen. The wall of the blood vessel gets stretched and is thinned out and tends to break easily. Once this happens, bleeding occurs. Repetitive straining also causes the supporting ligaments in the blood vessel to become overstretched and loses its elasticity. The blood vessel loses its elastic support and descend further down the anal canal and protrude outside of the anus. Once it is outside, it becomes a prolapsed hemorrhoid, which differs from the external piles.

What are the causes?

It is believed that the upright posture of humans alone raise the pressure in the veins and can predispose humans to hemorrhoids. Other postulated factors include chronic constipation, ageing, pregnancy and childbirth.

What are the symptoms?

  • Bleeding during bowel movements
  • Lump at the anus coming out during bowel movements
  • Persistent lump(s) at the anus
  • Itching in the anal area
  • Pain

There are many people with hemorrhoids without any symptoms and are not even aware that they have hemorrhoids. The symptoms also do not correspond well with the stage of the hemorrhoids. Some of the symptoms such as itching, bleeding or pain may be due to other conditions and not necessarily due to hemorrhoids. For example, bleeding may be due to colon cancer and pain may be due to anal fissure (tear).

How Serious is My Hemorrhoids?

Hemorrhoids are divided into 4 different degrees of severity. First degree is within the anal canal and there is no visible lump on the outside. Second degree occurs when its become bigger and bulge out during bowel movement. However, the bulge disappears once straining stops.

Third degree hemorrhoids bulge out during bowel movement, but it stays out for a longer time before gradually going back into the anus, or the patient may push it back in after bowel movement.

Fourth degree, this is the most advanced stage. The piles are out of the anus all the time and cannot be pushed back in.

What are the Complications?


This commonly occurs for the earlier degree where they become inflamed and swollen. This causes pain that may or may not be associated with bleeding.


This occurs when the blood flow is interrupted. It usually happens when the piles prolapse out of the anus. The blood is unable to return to the body and clots. This results in severe pain and swelling.

How it can be treated?

Piles that do not cause any symptoms do not require any treatment.

For first or second degree, symptoms can be relieved by reducing straining during bowel movement. This could mean taking more fluids or laxatives. Oral medication or suppositories may be given by your doctor to relieve the symptoms.

If this does not help, further treatment may be required. This includes

Ligation - the rubber band treatment

Sclerotherapy - an injection is given to the area around the piles. This method is relatively painless and causes the piles to shrink.

Ultrasound guided hemorrhoidal artery ligation - uses an ultrasound probe to locate the arteries. A stitch is then used to tie off the artery. By interrupting the blood supply, the hemorrhoid shrivels up.

For 3rd and 4th degree, treatment includes

Hemorrhoidectomy - or Piles Surgery is the best method for the permanent removal. It is usually used for 3rd or 4th degree piles or 2nd degree that has failed other treatments such as ligation. There are numerous ways to perform piles surgery:

  • Conventional hemorrhoidectomy - involves cutting the piles from outside into the anal canal.
  • Staple hemorrhoidectomy - The hemorrhoids are pushed back into the anus and cut off on the inside. The cut edges are closed together by titanium staples. There is lesser pain compared with conventional hemorrhoidectomy.

Other piles treatments include cryotherapy, BICAP coagulation and direct current to shrink the hemorrhoids. None of these treatments have gained widespread acceptance.

Anal Fistula

What is an Anal Fistula?

An anal fistula is an abnormal connection or tract between the anal canal (the inside of the anus) to the skin around the anus.

Anal fistula usually occurs as a result of a previous perianal abscess.

An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland from which the abscess arose to the skin of the buttocks outside the anus.

What causes a Fistula?

An anal fistula usually starts because a gland in the anus becomes blocked and infected. Instead of the infection breaking through back into the anus, it breaks through to the skin next to the anus and thus creates a tunnel. As long as the internal opening does not close up, the fistula usually do not heal.

An anal fistula may also follow after an abscess that has been drained. This could be that at the time of the abscess, there was already an opening to the inside of the anal canal from the abscess but was not evident at the time of surgery for the drainage of the abscess. This manifests itself as persistent draining of pus from the wound of the incision and drainage, and that the wound would not close completely.

What are the symptoms of an Anal Fistula?

Some fistulas start as a small pimple around the anus. This bursts and some pus and / or blood is discharged out. It then heals, but after a period of time, the pimple can form and burst again.

Another way that the fistula may manifest would be after an abscess has been drained. The wound heals nicely initially, but even after a long time, does not close completely. In some cases, the skin heals, but soon has a swelling under the scar, and then pus comes out when the point in the scar burst.

Diagnosis of a Fistula

Most of the time, a history of repeated swelling and discharge can point towards the diagnosis of the abscess, and examination of the area may even reveal the presence of the tract that leads from the skin into the anus.

For some complex fistula, additional imaging such as endoanal ultrasound (by putting a small ultrasound probe into the anus) or magnetic resonance imaging (MRI) may be required to see the entire length of the fistula tract.

Treatment for a Fistula

Surgery is almost always necessary to cure an anal fistula.

The most straightforward fistula surgery is lay open fistulotomy. This entails cutting a small portion of the anal sphincter muscle to open up the entire tunnel, which will then heal from inwards to outwa

For the deeper tracts, cutting open the muscle is not suitable as this would likely lead to incontinence. Some methods of treatment would include

  1. Ligation of Intersphincteric Fistula Tract (LIFT) - this entails locating the tract between the 2 layer of muscle, and separating and tying off the 2 ends of the tract.
  2. Fistula plug - this uses a prosthetic material that fills up the entire tract and allow new tissues to grow into the tract to replace the material.
  3. Fibrin glue - this uses a "glue" to seal up the tunnel Seton - a seton is a stitch (suture) that is placed around the tract. This allows the pus in the tract to come out along the seton, while at the same time, the seton slowly cuts through the muscle below and allows the muscle above it to heal. A second operation may then be required to cut through the rest of the muscles once it is safe enough to do so without risks of incontinence.
  4. Video Assisted Anal Fistula Treatment (VAAFT) - this is one of the latest techniques available for treatment of complex fistulas. It allows the surgeon to put a video scope through the opening to look at the entire tract and follow it to the opening on the inside. The opening on the inside is then closed, and the tract is cleaned out using the brush and a probe through the video scope. This has an added benefit that there will be no long cut over the skin.

Although fistula surgery is usually relatively straightforward, the potential for complication exists, and is preferably performed by a colorectal surgeon for colon and rectal surgery. This operation needs to be done with care, as cutting too much muscle will lead to loss of control of bowel movement. Most of the time, fistula surgery can be performed on an outpatient basis - or with a short hospital stay.

Post-Op Care

Most patients can be discharged the same or next day after surgery. Discomfort after surgery can be mild to moderate for the first week and can controlled with pain pills.

The follow up care for each type of surgery differs. Lay open fistulotomy requires may require daily wound cleaning at the clinic. After care for VAAFT and LIFT tends to be easier with just daily washing or flushing of the wound with a syringe.

For fibrin glue and fistula plug, minimal wound care is required.

What are the chances of a recurrence of an Abscess or Fistula?

If properly healed, the problem will usually not return. However, it is important to follow the directions of your doctor to prevent recurrence.

Anal Fissure

What causes an anal fissure?

It is usually caused by a hard and dry bowel movement which tears the anal lining. Other causes include diarrhoea and inflammation of the anorectal area.

How can a fissure be treated?

At least 50 percent of fissures heal either by themselves without need for an operation. Application of special medicated cream, use of stool softeners, avoidance of constipation, and the use of sitz baths (soaking the anal area in plain warm water for 20 minutes, several times a day) help to relieve the symptoms and allow healing to occur.

For the more chronic fissure, glyceryl trinitrite ointment may be used to relax the sphincter muscles. This would then improve the blood flow to the lining and allow healing to occur. One of the more common side effects of the ointment is headache.

Why is it some fissures do not heal?

When healing starts after a tear, the area is not as healthy as normal lining. Another episode of hard stools will cause the healing area to tear again. Repeated tearing will results in the tear becoming deeper and deeper. When the muscles of the anus lying below the lining are exposed, the muscles go into spasm. This results in more pain, and as the muscle is tight, stronger force is required to push the stools through and this result in more tearing. In these cases, the relaxation induced by the glyceryl trinitrie ointment is inadequate to allow good blood flow for healing.

What if a fissure does not heal?

A fissure that does not heal should be re-examined to determine if an underlying problem that prevents healing exists. This could be due to scarring or muscle spasm of the internal anal sphincter muscle. Those which continue to cause pain and/or bleeding can be corrected by anal surgery.

How long does the healing process take after anal surgery?

Most patients can go home the same day. Complete healing occurs in a few weeks, although pain often disappears after a few days.

Will the problem return?

Most patients who had anal surgery for anal fissure have no further trouble after surgery.

Can fissures lead to colon cancer?

No! Persistent symptoms need careful evaluation, however, since conditions other than fissure can cause similar symptoms.

Treatment For Pilonidal Disease

Pilonidal disease (also called pilonidal abscess, pilonidal sinus) is an infection of the skin in the region between the 2 buttocks.

What is Pilonidal Disease and what causes it?

Pilonidal disease (also called pilonidal abscess, pilonidal sinus) is an infection of the skin in the region between the 2 buttocks. It occurs when body area in the area breaks off and gets embedded into the skin. It is more common in men and those with a lot of thick, stiff body hair.

What are the symptoms?

A pilonidal abscess may just be like a small pimple near to the buttock cleft. It may also be a large painful area under the skin. This may discharge some clear liquid,blood or pus. When the pus is trapped within, the area becomes swollen, red and painful. There may also be fever.

Most times, the pain and swelling would settle after the pus is discharged. In some, it settles after a course of antibiotics.

However, as there are hairs trapped below the skin, the infection is never fully cleared and it develops into a pilonidal sinus. There may be one or more small little openings on the skin leading into the cavity below that contains the hairs.

Some patients get repeated infections and inflammation of these sinus tracts, resulting in episodes of swelling, pain, and discharge of pus. Some of these tracts may extend deep towards the bone below.

How is Pilonidal Disease Treated?

The treatment depends on the severity of the disease. An acute abscess is treated with a small cut to let out the pus and remove the hair. A chronic sinus may require surgery to remove it completely.

Some patients get recurrent pilonidal disease. Part of the reason is because the shape of the buttocks makes it easy for the hair to get embedded. Complex or recurrent disease is treated by more extensive surgery. This may result in removing a large area of skin and moving different areas of skin in to cover the defect. Larger wounds require longer healing times.

It is most important that after any surgery, the skin around the buttocks be kept free of hair to minimize recurrence.

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Note: ** These are general overviews and information aimed for use by their specific patients and reflects their views, opinions and recommendations. This does not constitute medical advice. The contents are provided for information and education purposes only and not for the purpose of rendering medical advice. Please seek the advice of your specific surgeon for further information. **

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