Haemorrhoids

Haemorrhoids, commonly known as piles, are connective tissue cushions located in the anal canal which are rich in blood vessels. While they generally do not cause people any problems, when they engorge with blood and start to protrude from the anal canal they may cause signs and symptoms for those affected (Thaha and Steele, 2022). Although the term haemorrhoids is used to describe the condition, haemorrhoids are actually part of the normal anorectal anatomy (Pullen, 2022).   

Haemorrhoids present as a problem for people affected when they bleed, which can be seen as rectal bleeding on, rather than mixed into the persons faeces, and/or when the individual suffers pain in the perianal region (Thaha and Steele, 2022). Haemorrhoids are thought to affect as many as one in four of the adult population in the UK at some stage of their life (Brown, 2017). 

About 40% of people with haemorrhoids are asymptomatic (Pullen, 2022). The signs and symptoms of haemorrhoids include:

• blood which is bright red and not mixed with the stool on defaecation i.e. it is in the toilet water and on the toilet tissue)
• haemorrhoidal prolapse
• perianal itching and/or irritation
• feeing of rectal fullness and/or incomplete evacuation of the rectum on defaecation
• soiling
• pain – usually associated with prolapsed internal haemorrhoids or thrombosed external haemorrhoids (National Institute for Health and Care Excellence (NICE), 2021).

Some people will be aware of a prolapse and feel the protrusion of the haemorrhoids from their anus as a localised bump (Sun and Migaly, 2016).

The aetiology of haemorrhoids remains poorly understood (Sun and Migaly, 2016), and haemorrhoids are thought to be caused by conditions and behaviours which increase intraabdominal pressure. These include:

• straining when passing stool
• constipation
• heavy lifting
• chronic cough
• pregnancy
• space–occupying lesions
• increased age (Sun and Migaly, 2016; Margetis, 2019; NICE, 2021).

Some people are more prone to haemorrhoids including:

• people aged 45–65 years
• people with a history of constipation
• women during pregnancy
• people with liver disease (Thaha and Steele, 2022; NICE, 2023).

Diagnosis starts with a thorough history taking, including family history, lifestyle, medications and for the presence of other diseases (Pullen, 2022). A diagnosis of haemorrhoids is confirmed when they can be seen. This may occur as the haemorrhoids protrude through the anus and appear as firm, purple-coloured nodules (Sun and Migaly, 2016), or by the use of endoscopic visualisation or an anoscope (Thaha and Steele, 2022). 

It is usual for people presenting with bleeding haemorrhoids to have a full blood count to exclude the occurrence of anaemia (which is rare), as well as a stool check for faecal occult blood (Thaha and Steele, 2022). Some people with mucus discharge associated with haemorrhoids may have a macerated and sore perineum.

Haemorrhoids

Given their aetiology, some haemorrhoids will self-resolve, e.g. after the birth of a child. In other cases, resolution will rely on the person losing weight and/or increasing their dietary fibre intake (Pullen, 2022). Dietary fibre intake, e.g. whole grains and fruit and vegetable intake should be complimented with adequate hydration to ensure that the resultant stools are soft and well lubricated (NICE, 2021) which in turn prevents straining.

Some people will need help with the management of their constipation with a prescription for bulk-forming laxatives. These also soften their stools and are safe for use in pregnancy, e.g.

• ispaghula husk
• methylcellulose
• sterculia (NICE, 2022)

NICE (2021) also advise that nurses provide lifestyle advice including good anal hygiene and drying by patting rather than rubbing. People should also be advised to use the toilet to defaecate when they feel the need, rather than withholding the stool and should, where possible, avoid

Complications arising from haemorrhoids include strangulated internal haemorrhoids and thrombosed perianal varices which may often be treated conservatively but may require acute surgical intervention to achieve the effective outcomes for patients (Hardy and Cohen, 2014).

References

Brown S, Tiernan J, Biggs K et al. The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Health Technol Assess. 2016; 20:88. https://doi.org/10.3310/hta20880

Brown SR. Haemorrhoids: an update on management. Therapeutic Advances in Chronic Disease. 2017;8(10):141-147. https://doi.org/10.1177/2040622317713957

Delves-Yates C. Introduction to the Global Context of Nursing. In: Delves-Yates (ed.) Essentials of Nursing Practice (3rd edn). London: Sage; 2022 pp.745-754

Hardy A, Cohen CR. The acute management of haemorrhoids. Ann R Coll Surg Engl. 2014;96(7):508-511. https://doi.org/10.1308/003588414X13946184900967

Lee KC, Liu CC, Hu WH et al. Risk of delayed bleeding after hemorrhoidectomy. Int J Colorectal Dis. 2019;34(2):247-253. https://doi.org/10.1007/s00384-018-3176-6

Margetis N. Pathophysiology of internal hemorrhoids. Ann Gastroenterol. 2019;32(3):264–272. https://doi.org/10.20524/aog.2019.0355

National Institute for Health and Care Excellence. Health Topics: Haemorrhoids. 2021. https://cks.nice.org.uk/topics/haemorrhoids/ (accessed 10 October 2022)

National Institute for Health and Care Excellence. Health Topics: Constipation. 2022.