Hemorrhoidal Disease (Piles)

What Is Hemorrhoidal Disease?

Hemorrhoids are vascular cushions naturally present in everyone's anal canal. These structures:

• Help the closure of the anal canal
• Play a role in distinguishing between gas, liquid, and solid stool
• Act as a buffer during sudden pressure changes

The disease arises when these vascular cushions enlarge, prolapse, start bleeding, or become inflamed for various reasons.

Types of Hemorrhoids

Hemorrhoids are divided into two main types based on location:

Internal Hemorrhoids

• Located in the inner part of the anus, above the dentate line
• Usually painless (no sensory nerves)
• Classic symptom: Bright red bleeding
• May prolapse out of the anus in advanced stages
• Classified into 4 stages

External Hemorrhoids

• Located on the outer part of the anus, below the dentate line
• Covered with skin
• Can be very painful (skin nerves are present)
• Clotting (thrombosis) may develop
• Noticed as swelling around the anus

Mixed Hemorrhoids

A condition where both internal and external hemorrhoids are present together.

Staging of Internal Hemorrhoids

Internal hemorrhoids are divided into four stages:

Stage 1

• Hemorrhoids are inside the anus
• Do not prolapse outside
• Usually noticed by bleeding during defecation
• Responds well to conservative treatment

Stage 2

• Prolapse out of the anus during defecation
• Return spontaneously
• Bleeding is common
• Conservative or minimally invasive treatment

Stage 3

• Prolapse out of the anus during defecation
• Require manual reduction
• Hygiene issues begin
• Surgical treatment is usually considered

Stage 4

• Hemorrhoids are constantly outside the anus
• Cannot be pushed back
• Complaints intensify
• Surgical treatment is required

Causes of Hemorrhoidal Disease

Increased pressure in the anal canal plays a role in the formation of hemorrhoids.

Main Causes

• Chronic constipation and straining: Most common cause
• Long-term diarrhea
• Pregnancy and childbirth: Increased intra-abdominal pressure
• Prolonged sitting: Drivers, office workers
• Heavy lifting
• Low-fiber diet
• Inadequate fluid intake

Risk Factors

• Age: Most common between 45-65 years
• Family history: Genetic predisposition
• Obesity: Increased intra-abdominal pressure
• Sedentary lifestyle
• Chronic cough
• Liver diseases (cirrhosis, portal hypertension)
• Anal intercourse
• Prolonged sitting on the toilet
• Weakening of connective tissue with aging

Symptoms of Hemorrhoidal Disease

Symptoms of Internal Hemorrhoids

• Bright red bleeding: Most common symptom
• Blood on toilet paper, stool, or in the toilet bowl
• Sensation of fullness in the anal area
• Feeling of incomplete evacuation after defecation
• Mass protruding from the anus (in stages 3-4)
• Mucus discharge
• Itching and irritation

Symptoms of External Hemorrhoids

• Swelling or mass around the anus
• Severe pain (especially in thrombosis)
• Skin irritation
• Discomfort when sitting
• Hygiene difficulty

Thrombosed Hemorrhoid

Clot formation within the vessel of an external hemorrhoid:

• Suddenly starting severe pain
• Hard, purple swelling around the anus
• Pain increased when walking and sitting
• May require urgent intervention
• Surgical evacuation in the first 48-72 hours is beneficial

Conditions Requiring Urgent Evaluation

• Large amount of bleeding
• Severe, persistent pain
• Tenderness with fever
• Irreducible and blackened hemorrhoid
• Weakness and dizziness (due to blood loss)

Diagnostic Methods

Medical History and Examination

The foundation of diagnosis:

• Detailed evaluation of complaints
• Bleeding characteristics (color, amount, frequency)
• Bowel habits
• Dietary history
• Family history

Physical Examination

• Visual examination: Evaluation of the area around the anus
• Digital rectal examination: Detection of internal hemorrhoids and other pathologies
• Evaluation of external hemorrhoids and thrombosis status

Anoscopy

• Direct imaging of the anal canal
• Evaluation of internal hemorrhoids
• Detection of other pathologies (fissure, fistula)
• Fast and safe method

Rectosigmoidoscopy/Colonoscopy

In some cases, a more comprehensive examination of the lower digestive system is required:

• Above 45-50 years of age
• If there is colorectal cancer in family history
• Atypical bleeding characteristics
• Presence of anemia
• Changes in bowel habits
• Weight loss

These may be necessary to rule out colorectal cancer and other serious diseases.

Laboratory Tests

• Complete blood count (anemia investigation)
• Iron level
• Coagulation tests (before surgery)

Treatment of Hemorrhoidal Disease

The treatment approach is determined according to the stage of the hemorrhoid, complaints, and the patient's general condition. A stepwise approach is followed.

Conservative Treatment (First Step)

Applied in Stage 1-2 hemorrhoids and mild complaints.

Lifestyle Changes

• Fiber-rich food consumption: 25-30 g per day
• Plenty of fluid consumption: 2-2.5 liters of water per day
• Regular exercise: Supports bowel movements
• Regulation of toilet habits
• Avoiding excessive straining
• Not sitting on the toilet for long periods
• Healthy weight control

Warm Sitz Baths

• 2-3 times a day, 10-15 minutes
• Warm (not hot) water
• Relaxes the anal sphincter muscle
• Increases blood circulation
• Reduces pain and itching

Medication

• Fiber supplements: Psyllium, methylcellulose
• Stool softeners: Lactulose
• Venotonic drugs: Diosmin, hesperidin (strengthen vascular tone)
• Topical creams and ointments: Local anesthetics, corticosteroids, phenylephrine
• Anal suppositories: Local effect
• Painkillers: When necessary

Office (Minimally Invasive) Treatments

Applied in Stage 1-3 hemorrhoids unresponsive to conservative treatment.

Rubber Band Ligation

The most commonly applied office treatment:

• A special rubber band is placed at the base of the hemorrhoid
• Blood flow is cut, tissue falls off
• Does not require anesthesia
• Takes 5-10 minutes
• Performed in single or divided sessions
• Success rate 70-90%
• Mild pain and bleeding may occur

Sclerotherapy

• Chemical substance injected into the hemorrhoid
• The vascular structure shrinks
• Effective in Stage 1-2
• May be preferred in patients at risk of bleeding
• Repeatable

Infrared Coagulation

• Reduction of hemorrhoid with infrared light
• Effective in small hemorrhoids
• Painless method
• Multiple sessions may be required

Laser Hemorrhoidoplasty (LHP)

A modern, minimally invasive method:

• Laser fiber is placed inside the hemorrhoid
• Vascular structure is controlled from inside
• Skin and mucosa are preserved
• Less pain
• Fast recovery (1 week)
• Low complications
• Effective in Stages 2-3

Hemorrhoidal Artery Ligation (HAL/THD)

Under Doppler ultrasound guidance:

• Arteries feeding the hemorrhoid are tied
• Bleeding control
• Less painful than surgery
• Sphincter-preserving
• Success rate 70-90%

Surgical Treatments

Applied in advanced-stage hemorrhoids (Stage 3-4) or in cases unresponsive to other treatments.

Hemorrhoidectomy (Classical Surgery)

Surgical removal of the hemorrhoid:

Milligan-Morgan Technique (Open Hemorrhoidectomy)

• Hemorrhoid is excised, the wound is left open
• Most commonly applied method
• High success rate
• Low recurrence (2-5%)
• Recovery time: 3-4 weeks
• Significant post-operative pain

Ferguson Technique (Closed Hemorrhoidectomy)

• Hemorrhoid is excised, the wound is sutured
• Less pain
• Fast recovery

Stapler Hemorrhoidopexy (PPH)

• Removal of circulating tissue with a special device (stapler)
• Hemorrhoid is pulled upward
• Less post-operative pain
• Fast recovery
• Effective in Stages 3-4
• Recurrence risk may be higher in certain cases

Laser Hemorrhoidoplasty (Surgical LHP)

• In large and vascular hemorrhoids
• Less pain, fast recovery
• Sphincter-preserving

Thrombosed External Hemorrhoid Treatment

Acute thrombosed external hemorrhoid is very painful. Treatment approach:

Within the First 48-72 Hours

• Surgical evacuation (incision and drainage): Most effective approach
• Under local anesthesia
• Clot is removed
• Provides quick relief

After 72 Hours

• Conservative treatment is sufficient
• Warm sitz baths
• Painkillers
• Topical ointments
• Tissue heals on its own (1-2 weeks)

Post-Operative Process

First Days

• Pain control is important (the most difficult period)
• Warm sitz baths (3-4 times a day)
• Attention to wound cleanliness
• Plenty of fluids and fiber-rich diet
• Use of stool softener
• First defecation may be feared, but soft stool is important

First Week

• Return to light activities
• Avoiding prolonged sitting
• A soft cushion can be used

First Month

• Sports after 3-4 weeks
• Sexual life after 2-3 weeks
• Heavy lifting prohibited for 4-6 weeks
• Full recovery 4-6 weeks

Possible Complications

Early Complications

• Bleeding
• Urinary retention
• Wound infection
• Severe pain
• Anal sphincter spasm

Late Complications

• Anal stenosis (narrowing)
• Gas or stool incontinence (rare)
• Anal fissure
• Hemorrhoid recurrence (5-10%)
• Skin tags

Prevention of Hemorrhoidal Disease

The vast majority of hemorrhoids can be prevented with lifestyle changes.

Nutrition

• Increasing fiber intake: Whole grains, vegetables, fruits, legumes
• Plenty of fluid consumption: 2-2.5 liters per day
• Reducing spicy and hot foods
• Regular and balanced meals
• Limiting alcohol consumption
• Adjusting coffee consumption

Toilet Habits

• Not delaying toilet needs
• Not sitting too long on the toilet (3-5 minutes)
• Avoiding excessive straining
• Not getting distracted with phone or newspaper
• Gentle cleaning after toilet
• Avoiding hard toilet paper

Lifestyle

• Regular exercise (walking, swimming)
• Healthy weight control
• Avoiding prolonged sitting
• Smoking cessation
• Stress management

Hygiene

• Gentle cleaning of the anal area
• Use of soft wet wipes
• Warm sitz baths (if there are complaints)
• Cotton underwear

Special Precautions During Pregnancy

• Adequate fiber and fluid intake
• Light exercise (walking)
• Lying on the left side
• Prevention of constipation
• Topical treatments with physician's recommendation