Piles (or hemorrhoids) are actually engorged blood vessels around the anus that occurs due to excessive straining at stools or after pregnancy in women. These engorged vessels can be easily traumatized by passage of stools, leading to bleeding during defecation. Excessive straining at stools also causes these engorged anal cushions to be pushed out during defecation. Over long periods of time, the elasticity of the supporting tissues is weakened and the prolapsed elements become increasingly difficult to return to the anal canal after bowel movements. They become painfully incarcerated outside the anus, leading to formation of painful pile(s) externally.
Piles can be external (outside) or internal (inside the anus). They are divided into 4 grades of severity, based on their sizes and the symptoms that they produced:
- Grade I: Enlarged internal piles that usually presents with bleeding during defecation. These can be easily treated with medications.
- Grade II: These larger piles tend to protrude out during straining at stools but are able to spontaneously return back into the anal canal after bowel movement.
- Grade III: These large piles protrude during defecation causing significant bleeding and remain painfully outside the anus, requiring finger pressure to push it back inside the anus.
- Grade IV: These piles are persistently outside the anus and the blood in the engorged vessels is usually clotted, leading to an extremely painful and swollen lump that requires surgery to achieve relieve.
Piles often present with bleeding during bowel movements. Cancers of the colon or rectum can also present with blood in stools. It is not always easy to differentiate bleeding arising from a benign condition such as piles, from other more sinister conditions like cancer. Therefore, it is important to perform diagnostic evaluations in patients with persistent bleeding to make an accurate diagnosis.
There are many medical and surgical options for managing piles. Please click here to know more about the different treatment options.
Treatment for piles should be tailored to the extent of the problem and the symptoms that the piles produced to ensure that the outcomes are the most optimal without taking unnecessary risks. It is difficult to determine which treatment option is the most suitable without an examination, as small piles (grades I or II) will not require surgery and can be easily treated with simple medications or rubber-band ligation in the clinic on the same day with minimal discomfort and no downtime from work or activities, while larger prolapsing ones (grades III or IV) will usually require surgery in the operating theatre for better symptom control. Surgery is advocated only for the treatment of larger symptomatic piles.
The aim of surgery is to remove the grade III or IV piles to relieve the symptoms of pain, swelling and/or bleeding. These symptomatic piles have progressed to such a stage where treatment with medication alone or with less invasive procedures will not be enough to treat and alleviate the symptoms.
These less invasive procedures which may not work for grade III or IV hemorrhoids include:-
- rubber-band ligation (application of an elastic band on enlarged piles, thereby cutting off the blood flow to the piles, causing them to shrink and then fall off); or
- Injection sclerotherapy (involves injecting a chemical that scars the enlarged piles, reducing the blood-flow and thereby shrinking them and alleviating symptoms)
For Singaporeans, surgery for piles can enjoy payment by Medisave, subjected to the amount claimable imposed by CPF Board (Central Provident Fund Board).
The cost of treatment will depend on what modalities are used for treatment, whether hospitalization is needed and whether any disposable equipment (e.g. stapling device) is used. A consultation and physical examination is required to determine the mode of treatment. Sometimes, simple medications may just be all that is necessary.
Surgery, if needed, can be arranged on the same day or the following day after consultation. Surgery should take less than 30 minutes. You will only need Day Surgery and hospitalization for just a few hours with no need for an overnight stay.
The extent of discomfort and recovery period varies depending on the method used to treat the piles. Newer methods of piles treatment are less painful, with faster recovery time and less time off work. Use of better and more effective painkillers further reduce any discomfort.
In Conventional Hemorrhoidectomy, an instrument delivering a high-energy electrical current that cuts tissues and stops bleeding at the same time is used to cut out the enlarged piles. This is the usual method employed for grade III or IV piles. It is usually performed under general or regional anaesthesia and may require hospitalisation. This procedure can be performed as a day-case and patients can be discharged the same evening.
The wound is usually left open to heal on its own over 4 - 6 weeks. The wound can be also closed with sutures to shorten the healing time.
Ligasure Hemorrhoidectomy is a recent modification of the Conventional Hemorrhoidectomy method in which a special vessel sealing device is used to cut off the piles and seal off the engorged blood vessels, thus achieving the intention of removing redundant tissue while minimizing the chances of bleeding. It is also performed under general or regional anaesthesia as a day-case and patients can be discharged the same evening. The wound can be closed with sutures to shorten the healing time.
Stapled Hemorrhoidectomy is a more advanced procedure usually performed under general or regional anaesthesia. The piles are pushed back into their normal positions within the anal canal. A stitch is then placed around the anal canal, and then used to pull the hemorrhoid tissue into the stapler. The stapler is fired and the piles are removed, while the remaining tissue is simultaneously stapled together. This interrupts the blood supply to the piles, and the loose anal skin is also pulled back up into the anal canal. Because it leaves no open wound on the sensitive skin, Stapled Hemorrhoidectomy is generally less painful and has a shorter recovery time compared to Conventional Hemorrhoidectomy. Most patients will be fairly comfortable within 1 – 2 weeks, as opposed to the 4 – 6 weeks healing time using the Conventional method.
During Trans-anal Hemorrhoidal De-arterialization (THD), a special device is inserted through the anus and the blood vessels supplying the piles are precisely located using Doppler ultrasound, and then tied off using surgical stitches. This will interrupt the blood supply to the engorged piles and is suitable if the piles are not too large or prolapsing, with bleeding as the predominant symptom. Since this does not involve cutting any tissue, there is generally minimal post-operative discomfort and no need to be off work after the day of the procedure.
Ligation of piles is an outpatient treatment that can be performed in the clinic without anaesthesia. In this procedure, a small rubber-band is applied to the base of the piles, stopping the blood supply to the piles. The piles will then shrivel and die within 3-5 days. The shrivelled pile will fall off during normal bowel movement 3 – 5 days later. It is usually not possible for the patient to discern the shedding of the shrivelled piles, although some mild bleeding during defecation in the 1st week is expected and should not be persistent or massive. The scarring that forms will prevent further prolapse and bleeding. Because it is only possible to 'pinch' off a small portion of the pile at any one time, a large prolapsing pile may sometimes require 2 – 3 repeat ligations 6 weeks apart to achieve the desirable effect. Most patients should be able to return to work the day following the ligation procedure.