Piles - Painful and Embarrassing, but Treatable

NOBODY really likes to discuss their piles, but seeking early treatment is relatively simple and can save you from years of pain and suffering.

ONE in three adults suffer from piles, yet it's not commonly discussed. So what are piles and why do patients prefer to suffer in silence?

What are haemorrhoids?

Piles or haemorrhoids are swellings that appear around the anus. Consultant colorectal surgeon of Hospital Pantai Putri Tambun, Dr M. Sarkunnathas, explains that we all have a circle of stretchable tissue just inside the anus that expands when we pass motion and contracts to keep the anus shut.

"We call them vascular anal cushions because these tissues are rich in blood vessels and line the anus like cushions which play a role in controlling the outflow of faeces," says Dr Sarkunnathas.

He explains that when the tissues become stretched and displaced, or protrude from the anus, we have a condition called haemorrhoids or piles.

Dr Sarkunnathas observes that many patients suffer in silence as they are embarrassed to show their bottom to a doctor.

He explains: "Many people initially panic when they see fresh blood stains on the toilet paper or blood in the toilet bowl. But after a while they learn to live with it. They often self-diagnose and self-medicate and they suffer for many years, until the symptoms become unbearable, before they seek medical treatment."

Myths and facts of piles

TOUCHING on the myths and facts about piles, Dr Sebastian Tong (General and Colorectal Surgeon) agrees that many patients find it embarrassing to talk to their doctor, especially when the doctor has to insert a finger into the anus during the digital rectal examination to diagnose the condition.

"However, the main fear when they bleed is that they have cancer," says Dr Tong, listing the four most common fears bothering these patients:

* Fear of cancer or that their piles will develop into cancer.

"Piles will not turn into cancer even if you have the condition for a long, long time," says Dr Tong. "But you can have piles and anorectal cancer at the same time. As the symptoms are similar, you are likely to believe your piles have become cancerous. If a patient comes in with bleeding, whether fresh or altered blood, swelling of the anus or pain, it is our responsibility to investigate for piles or other causes."

* Recurrence after treatment.

Some patients ask if it is worth treating as they have heard that it will recur again. Treatment is usually aimed at the trouble spots and not the whole ring of tissues. It is to reduce the symptoms, such as bleeding, managing the overstretched parts and occasionally relieving pain.

Dr Tong says: "We do not remove or treat the normal parts of the piles tissue, so there is a risk of recurrence that increases with the severity of the condition and existing risk factors."

* Incontinence after treatment.

Many people are scared of surgery as they fear losing control of their bowel movement after the surgery.

Dr Tong agrees there is some truth to this fear. Piles surgery in earlier years may have contributed to incontinence.

He explains that classical piles surgery required stretching the anus wide, resulting in damage to the muscle that controls the bowel movement, thereby inducing incontinence immediately or later in life.

In 1962, 27 per cent of patients developed incontinence after having open surgery for piles. In 1999 it dropped to seven per cent due to the different surgical techniques currently available for treating piles.

* Pain after surgery.

Piles surgery has gained a fearsome reputation for causing pain. Unfortunately, this is true, as traditional surgery for advanced cases leaves an open wound.

This form of open surgery, called excisional haemomorrhoidectomy, is painful as it removes skin surrounding the lower part of the anus that is covered by a network of nerve fibres.

Dr Tong states: "When you cut these fibres and leave open wounds it can cause severe pain. Every time you pass motion, the movement stretches the wound and the faeces rub against the wound, causing irritation and pain."

Speaking on surgery for Piles, Dr Yunus Gu Alif Gul (Colorectal Surgeon, Prince Court Medical Centre) says that some patients describe the post-operative effects of open piles surgery as passing motion through shards of broken glass.

Fortunately, a new less painful procedure is now available, which significantly reduces the pain and shortens the recovery period for the right candidate.

Stapled haemorrhoidectomy, uses a stapling device to cut a cuff of tissue above the sensitive part of the anus and cut the blood supply to the area without leaving a large, raw wound. Stapled haemorrhoidectomy is currently recommended for third and fourth stage haemorrhoids.

Risk factors

Common risk factors of piles include:

* Chronic constipation or straining.

* Occupations that involve prolonged sitting or standing.

* Obesity.

* Pregnancy and childbirth

The stages of piles

Staging the condition helps in deciding best treatment options.

* Stage 1 - There is bleeding, discomfort, but no external swelling.

* Stage 2 - Patient may complain of bleeding, mucus discharge, and itchiness. The swelling (displaced tissues) is visible during straining, but the tissues will return to the normal position without help.

* Stage 3 - Similar to Stage 2, except that the displaced tissue now protrudes and requires manual replacement.

* Stage 4 - There is bleeding and discharge which continuously soils your undergarments, causing itchiness and discomfort. The swelling is persistently outside and cannot be pushed back into the anus.

Haemorrhoids tend to get worse over time. So the condition should be treated as soon as it occurs, when self-care and lifestyle changes can still be effective.

Treatment options

The best natural treatment for piles starts with lifestyle changes. Eat high- fibre foods like fruit and vegetables. This softens the stool and increases its bulk, which will help improve constipation and reduce excessive straining that can cause haemorrhoids. Drink plenty of liquids. Exercise and lose weight if you are overweight or obese.

Avoid straining during bowel movements, reading in the toilet and minimise use of squatting toilets.

If symptoms persist, doctors may recommend medication or certain procedures. Medication is useful for patients with Stage 1 haemorrhoids. If you have only mild discomfort, your doctor may suggest over-the- counter creams or ointments which usually contain either a mild anaesthetic or soothing agent, or steroids.

This form of medical treatment, in combination with advice on dietary change and on proper bowel opening, complemented with daily warm baths, may relieve the symptoms.

You cannot use these ointments for long periods, however, as these can eventually irritate the skin and make it sensitive.

Daflon, a drug extracted from a rpecific type of orange skin, is frequently used in managing haemorrhoids. This drug helps to compress the blood vessels in the piles tissue and make it shrink.

It is most commonly used on patients with mild or moderate piles, and is not suitable for treating more advanced cases.

Minimally invasive treatments include Rubber Band Ligation. Tiny rubber bands (usually one or two) are tied around the base of a small area of swelling to cut off its blood supply.

Within a week to 10 days, the haemorrhoid painlessly falls off. This simple and practically painless procedure is an outpatient procedure and particularly effective in patients with Stage 2 haemorrhoids.

In Sclerotherapy, a chemical solution is injected around the blood vessels in the pile tissue to shrink it. This procedure is popular in Britain, but is rarely used in North America and Malaysia.

Dr Yunus adds that, unfortunately, when patients delay treatment the condition gets so advanced, the only possible course of treatment is with surgery. For advanced haemorrhoids, the traditional form of excisional open surgery is still recommended.

Patients who suffer from chronic piles may also face the risk of acutely bleeding, or thrombosed, piles.

"When the blood vessels in piles rupture, causing bleeding or clots (thrombosis), it becomes an emergency," says Dr Yunus.