Piles; what actually is it?
The Malays call it “Buasir”, the Chinese call it “痔疮”, while the British call it “Piles”. It all means the same thing.
Haemorrhoid is like a special anal cushion, a specialized, highly vascular tissue found within the anal canal. It mainly contains blood vessels and connective tissue. The main function of this tissue is for the prevention of leakage of faeces from the anus (continence).
When the tissue become enlarged, thickened, and starts causing problems, then they are labelled as haemorrhoidal disease, or “Penyakit Buasir”.
The symptoms of haemorrhoidal disease includes – bleeding while passing motion, swelling from the anus during passage of stool, itchiness, mucuos discharge from the anus and the most important is the sensation of pain. The one important complaint arising from the patient is the cosmetic deformity at the anus.
There are no exact figures of the incidence and prevalence rate of haemorrhoidal disease in Malaysia, even though it is a fairly common disease. This may be partly due to the “shy” nature of Malaysians that refuse to seek treatment in the nearest clinics or hospitals. They would rather have treatment done by traditional practitioners or some quacks. That is the reason that we are seeing lots of clinic springing up all over smaller towns offering quick fix for the “piles” diseases. The prevalence rate in America is about 4.4%. This mean at a given time, 4 to 5 out of 100 people will have piles disease.
The most common cause of piles is constipation. Constipation causes prolong straining while initiating passage of faeces, which later will result in enlarged piles and its associated symptoms. Increased intra-abdominal pressure due to pregnancy, prolonged coughing, aging process, and internal sphincter abnormalities can also cause piles.
There are some myths surrounding haemorrhoidal diseases. The most common myths is that squatting compared to sitting while defecating increases the incidence of haemorrhoids. This is partly true. Straining or pushing hard, while defecating, increases the incidence of haemorrhoidal disease. People tend to strain more while squatting, hence leads to increase incidence of haemorrhoids. This may be related to the facts that that group of patients are all constipated to start with and as such, constipations are associated with increased incidence of haemorrhoidal disease. The other myth is that toilet paper usage after evacuation compared to washing increases the incidence of bleeding. It is true! Wiping action causes friction and abrasion at the tender mucosa surrounding the haemorrhoids and will lead to bleeding in that area.
There are 2 types of piles /haemorrhoids. The one that we can be seen around the anus and felt like a soft extra flesh is called external haemorrhoids. The one that lies inside the anus which could not been seen or felt is called internal haemorrhoids.
Haemorrhoids can also be graded according to the classification below:
- 1st degree – bulge into the lumen of anal canal +/- bleeding
- 2nd degree – protrusion at the time of bowel movement & reduced spontaneously
- 3rd degree – protrude spontaneously or with bowel movement, require manual replacement
- 4th degree – permanently prolapsed and irreducible
The diagnosis of “penyakit buasir” can be confirmed via good history taking, clinical examinations, digital rectal examinations (the doctor inserts a gloved finger into the anus to feel the piles) and proctoscopy. Proctoscopy is performed via insertion of a proctoscope into the anal canal and directly visualize the degree of haemorrhoids and help in deciding the best methods of treatment for the patient.
The treatment of piles depends on the degree of the piles, the symptoms and the associated diseases.
Non-surgical treatment for piles caters for the 1st degree piles. It includes removing all the contributing factors that cause piles such as constipations, hard stool, or habitual prolong sitting on the throne. Short term stool softeners such as syrup lactulose and senokot granules, may help in reducing hard stool, straining and haemorrhoid size. Tablet daflon® may help in reducing the haemorrhoid and associated symptoms.
For 3rd degree piles and also some of the 2nd degree piles, the non-surgical treatment will mostly not work, as the piles have already grew too large to be reduced by medications. The most common treatment for 2nd and 3rd degree piles in the clinic settings is rubber banding ligation (RBL) of the haemorrhoids. It can be done in out-patient clinic settings, very convenient and most are pain free.
The bigger sized 3rd degree piles need to be operated on. There are many surgical methods and instruments used in the treatment of piles. Each has its own merits and associated complications. The latest treatment is laser haemorrhoidoplasty (LHP), where laser beam is used to shrink the haemorrhoids. It is painless, no scar and patients could have faster recovery periods. Other well proven methods used are Stappler Haemorrhoidopexy (using stapling devices by Ethicon or Covedien company). This method also has the benefits of no scar, minimal pain and early recovery period.
4th degree haemorrhoids are the worst. The piles are prolapsed out, swollen, excruciatingly painful and associated with bleeding and mucous discharge. When this condition occurs, the patient needs to be admitted to the hospital and urgent surgical intervention need to be carried out for acute relieved of pain and swelling.
The last advice for all the readers and patients out there, please get treatment for haemorrhoidal disease at an early stage so that the treatment will have a fast and painless recovery. If you wait till 4th degree haemorrhoids to happen, then the pain and long days of suffering is all but unavoidable.
Dr Lam Yeaw Fah is a Consultant General Surgeon and Colorectal Surgeon in Selangor.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]
Where can i have the treatment or check up?