HAEMORRHOIDS

 

DEFINITION

 

Haemorrhoids (piles) are swollen veins which protrude into the anal canal (internal) and may swell so much that they hang down outside the body (external).  The perianal area has many nerve endings and is sensitive to pain, however there are no sensory nerve ending in the rectum but there are pressure receptors that cause discomfort when there is distension.  They can produce symptoms of burning, pain, discomfort and rectal bleeding.  They are the most common anorectal disease.

 

PHYSIOLOGY OF HAEMORRHOIDS

In addition to the veins, haemorrhoids involve mucosal tissue.  Ordinarily, the blood vessels are attached to the muscle wall.  Under certain conditions, there may be a weakness of the tissues causing the vessels to detach from the muscle wall and bulge or displace into the back passage.   The rectum forms the lower end of the gastrointestinal tract and the anal canal connects the rectum to the outside of the body.  The join between the anal canal and the rectum is called the anorectal line.  The area above this line is considered internal and the area below is external.  This gives the classification of haemorrhoids.

 

They can also be further classified as: -

            - those confined to the anal canal and cannot be seen;

            - those which prolapse below the anorectal line and actually protrude outside the anus; they may retract by themselves or are pushed back by the patient;

            - those which are persistently prolapsed outside the body. 

 

 

SYMPTOMS OF HAEMORRHOIDS

 

The main symptoms are pain, irritation and bleeding.  Other symptoms include itching, swelling and general discomfort.

 

PAIN - The rectum has pressure receptors that note distension (feeling of being full and needing ‘emptying’) but no pain receptors.  The anal canal has pressure receptors and sensory nerve endings that allow detection of pain.  The external area of the anus is also able to detect pain.  The pain of haemorrhoids is increased when the haemorrhoid enlarges or protrudes through the anus.  A prolapsed haemorrhoid may also cause spasm and swelling.  It may become infected, ulcerated or thrombosed (clotted).  A thrombosed haemorrhoid causes sudden moderate to severe throbbing or aching pain.  The pain may often appear at the time of defecation but is not relieved by passing a motion.  External haemorrhoids lie under the skin and become more painful if they become thrombosed.  This causes a tender blue swelling at the anal verge.  This is not necessarily associated with swelling of internal veins.

 

IRRITATION - Because of the inflammation of the skin of surrounding areas, itching and tenderness is usually present.  The haemorrhoids themselves do not cause the itch.  These symptoms are usually worse at night and in hot moist conditions; after exercise, in hot weather and in nylon underwear.

 

BLEEDING - Bright red blood is often noticed on toilet paper or on the surface of the motion.  This is because the blood may have been deposited on the stool as it passed through the anal canal.  If the blood is mixed with the stool, it may have come from higher up the gastrointestinal tract and will be darker in colour.  If the patient notices rectal bleeding, they should be advised to see their doctor to ensure that the bleeding is due just to haemorrhoids and to exclude more serious pathology - colorectal cancer can cause rectal bleeding.

 

FACTORS CAUSING WORSENING OF HAEMORRHOIDS

 

Factors that can worsen haemorrhoids include constipation due to straining at stool, coughing, sneezing and vomiting, heavy lifting, pregnancy and childbirth with straining at delivery.  Factors, which may predispose a patient to haemorrhoids, include standing or sitting for prolonged periods due to increased pressure in the veins, poor dietary habits (low fibre and fluid intake), tight clothing and family history.

 

MANAGING HAEMORRHOIDS

 

Symptomatic treatment of haemorrhoids will provide relief from the discomfort.  It should involve treating or preventing constipation.  Because of the pain associated with defecation and the worsening of the condition from straining, many patients suffering with haemorrhoids are constipated also.  They must be instructed to maintain adequate fibre and fluid in their diet.  This can be achieved by taking a bulk-forming laxative such as Nucolox each morning; this product contains both soluble and insoluble fibre, which maintains regularity and keeps the bowel healthy also.  They must also drink at least eight glasses of water a day.  This will ease the pain on defecation and will normalise their bowel habit.  Stimulant laxatives such as Coloxyl and Senna and Senokot must be avoided because if diarrhoea results from their use, it may increase the haemorrhoidal symptoms. 

 

Taking bioflavonoids daily help to strengthen the walls of the blood vessels.  In the case of haemorrhoids, the increase strength of the haemorrhoidal vessel will reduce the chance of it becoming detached from the muscle wall and will enhance blood flow back to the heart which may, in turn, reduce the likelihood of thrombosing the haemorrhoid.

 

 

Ingredients in Haemorrhoidal Products

 

Local Anaesthetics – useful in perianal and anal canal, not rectum (no nerve endings).  Can also be absorbed systemically from rectum.  Benzocaine most commonly used.

 

Vasoconstrictors – related to adrenaline and stimulate alpha-adrenergic receptors.  Work quickly and produce a local anaesthetic effect via an unknown mechanism to relieve itching. 

 

Adrenaline, ephedrine and phenylephrine are most commonly used.

 

Protectants – prevent irritation and water loss from anal canal by forming a physical barrier.  The skin is protected from faecal matter and itching and irritation is decreased. Zinc oxide, cocoa butter and lanolin are examples of protectants.

 

Counter Irritants – Distracts the perception of pain or itch by stimulating the nerve endings to provide sensations of warmth, cool, tingling or comfort.  Menthol at 0.5% - 2% used externally is recommended.

 

Astringents – relieves irritation and inflammation by reducing cell volume and lessening mucous secretions.  Calamine and zinc oxide are examples.

 

Antiseptics – Alters flora, which can predispose to overgrowth and infection such as boric acid, phenol and resorcinol.

 

Keratolytics – helps to expose the underlying tissue to the therapeutic agents.  They reduce itching by an unknown mechanism.  Should only be applied externally eg ammonium chlorhydroxy allantoinate 0.2-2.0%.

 

 

 

Topical treatment of haemorrhoids involves the use of two active ingredients:

 

Cinchocaine and Hydrocortisone (Proctosedyl)

- cinchocaine is a local anaesthetic, which can help in temporarily reducing the pain and itching.

- hydrocortisone is a corticosteroid, which reduces inflammation and itch and constricts the blood vessels.

- because of sensitisation arising to local anaesthetics and the possible exacerbation of fungal or other topical infections due to steroid use, it is recommended not to use Proctosedyl products for longer than one week.

- these products are S3R and must be referred to the pharmacist; they are legally required to be recorded and must be dispensed through the computer.

 

Topical haemorrhoidal products are presented as ointments, suppositories and wipes.  Suppositories are used for patients whose haemorrhoid/s are not prolapsed.  Ointments can be used externally and internally if there is an applicator included - this is ideal for patients who have haemorrhoids internally but they also prolapse.  The wipes are for use by all patients suffering with haemorrhoids as they can be used after defecation when the pain may be more acute.  In some cases, using toilet paper can cause further irritation of the haemorrhoid.

 

Patient Advice

- External use products shouldn’t be inserted into the rectum

- If rectal insertion causes pain, discontinue product and see doctor

- Apply external products sparingly

- Applicators may be too long and deliver medication high above haemorrhoids

- If possible, a mild soapy water wash should be used on the anorectal area before and after the product

- Good hygiene should be discussed

- Salt-water bathing can help

- Normal bowel function and a good diet can be helpful

- Avoid excessive laxatives

- Avoid straining

- Surgical treatment is simple and successful

 

 

 

 

SOLUTION KIT

·      Proctosedyl ointment

            Topical corticosteroid and local anaesthetic;

            To be applied at least once daily but for no longer than 7 consecutive days;

            The product is S3R and is legally required to be recorded.

 

·      Blackmores Bioflavonoid Complex

            Contains 1000mg bioflavonoid, which aids in strengthening the walls of the           blood vessels;

            To be taken once daily. 

 

·      Nucolox

            Bulk laxative, which treats and reduces chance of constipation;

            Two level teaspoons are to be mixed in a glass of water or fruit juice and    taken up to three times a day.