• Haemorrhoidal bleeding and pain is a common disorder in the community.
• It is more common in young men who have higher straining pressures, may be associated with pregnancy and commonly affects older females.

• Haemorrhoids are cushions of submucosal tissues and blood vessels. There is arteriovenous communication, with the main blood supply by an artery.
• Contrary to popular belief, haemorrhoids are NOT the varicose veins of the anus.
• This is why haemorrhoidal bleeding is usually bright red.
• Increased straining pressure thought to cause haemorrhoids - constipation, prolonged labour, explosive diarrhoea.
• When there is chronic engorgement, this may lead to prolapse.
• Haemorrhoids can prolapse, thrombose and become necrotic in extreme cases.

• I – Palpable haemorrhoids, non-prolapsing enlarged venous cushions
• II – Haemorrhoids that prolapse with straining and defecation, SPONTANEOUSLY reduce
• III – Haemorrhoids that protrude spontaneously or with straining, and require MANUAL REDUCTION
• IV - Chronically prolapsed haemorrhoids that CANNOT BE REDUCED

Before surgery, trialling a high fibre diet, stool softeners and drinking lots of fluids to avoid constipation and straining may be useful.
• Avoid sitting in the toilet for prolonged periods.
• Sitz baths (warm salty water to level of the hips) and good hygiene may help with symptoms.
• Stool softeners are useful, but avoid diarrhoea as this aggravates symptoms.
• If you are still getting pain or bleeding despite the abovementioned conservative measures, your doctor may prescribe you medications or try less invasive measures:
Medications which may help with symptoms include:
Proctosedyl cream – local anaesthetic with steroid
Hemocane – local anaesthetic with zinc oxide
Anusol - benzyl benzoate
Rectogesic - glyceryl trinitrate
If you are > 50 years old with bleeding or you have persistent bleeding at a younger age, you may need a colonoscopy to exclude other causes of bleeding (such as cancer).

• If the haemorrhoids are persistent, or symptoms are intractable, less invasive measures may be considered first including:
Rubber Band Ligation – ligating the haemorrhoids with a special device.
Sclerotherapy - Injecting chemical irritant into the haemorrhoids. This includes oily phenol. In males, we avoid anterior injection (due to risk of injecting into prostate).
Haemorrhoidal artery ligation – ligating haemorrhoids instead of excising them, with or without the aid of a doppler ultrasound.
Remember, if you are above the age of 50 or if you have persistent symptoms at a younger age, a colonoscopy is worthwhile to exclude malignancy and other more serious causes or per rectal bleeding.
• Haemorrhoidectomy is usually reserved for most severe cases of haemorrhoids, particularly grade 4 haemorrhoids.

• Excisional procedures are recommended for grade III and IV haemorrhoids.
• Options are for open and closed haemorrhoidal techniques.
Open – Milligan Morgan technique
Closed – Ferguson and Park’s technique
• An energy device or diathermy may be used to excise the haemorrhoids.

• Chronic pain
• Urinary retention
• Faecal incontinence (up to 10%)
• Bleeding (5%)
• Anal canal stenosis (5%)
• Infection (5%)

• A haemorrhoidectomy is associated with post-operative pain for approximately 2 weeks.
• You will need 2-3 weeks off work and you will not be able to drive while on strong pain relief, usually for 2 weeks.
• Unless allergies exist, the usual regimen post haemorrhoidectomy includes:
Metronidazole (an oral antibiotic) for 5 days. The dosage is 400mg three times per day.
Movicol one sachet three times per day.
Targin and endone for pain relief for up to two weeks.
• Paracetamol and NSAIDS may also be used.
You are encouraged to perform sitz baths (warm, salty water in a bath to the level of the hips) 3 times a day for at least 20 mins and to wash after every bowel motion.
• You should be reviewed post-operatively in the rooms in 3-4 weeks.
You should remain on a high fibre diet and avoid straining and constipation to avoid recurrence of haemorrhoids.
Expect to see some blood and clots with bowel motion, but if there is any significant major bleeding please contact the surgeon or go to the emergency department for assessment.
This material is general information only and should not replace medical advice or instructions given by the health professional. No action or inaction should be taken based solely on the contents provided on this information fact sheet.
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