Hemorrhoids – internal hemorrhoids, piles

“Do I have hemorrhoids?”  We are often asked this question.  The answer is: “Of course you do!”  What most people do not realize is that hemorrhoids are normal.   In fact, if you don’t have them you have a real problem.  Hemorrhoids are lips at the other end.  And just like lips, they are normal structures designed to assist in the closing of a body opening.  Try whistling without lips, and you will see why you don’t want to be without hemorrhoids.  Everyone has them, even infants.  If you didn’t know this, don’t worry, you are in good company – chances are your doctor doesn’t know it either.

So the real question that a patient should be asking is whether or not their hemorrhoids are the cause of their current problem.   The vast majority of time, hemorrhoids do not make any trouble at all.  Sometimes, however, they are guilty.  So what symptoms can they cause?  Well, hemorrhoids can bleed painlessly, they can stick out (prolapse), and occasionally (and quite rarely) the blood inside them can clot, leading to an exquisitely painful condition called thrombosed internal hemorrhoids.  And that, ladies and gentlemen, is about it.

It is important to realize what hemorrhoids do not do:  They do not itch, they do not burn, they do not cause pain during bowel movements, they do not lead to ‘attacks’ for an hour or a day.  If they do clot (thrombose), it is a very painful crisis and that pain will last for 5 to 10 days, the patient will likely not be able to sleep for a few nights, and will have a very large tender mass in the anal area, often protruding like a red or purple cauliflower.  This is a very big deal, and if you get one of these, you will certainly know it.  It’s like nothing else you’ve ever had and you will never want to have it again.  So lets not confuse this with an hour of minor pain or soreness caused by something else.

Given that there are many symptoms in the anal area that hemorrhoids do not cause but for which they are blamed, both by patients and doctors, what does this mean to our health care system?  It means that there are tens of thousands of patients every day in North America that are treated for hemorrhoids, when, in fact, they are suffering from something else.  We see patients all the time who have had surgery for ‘hemorrhoids’ or office treatments of anywhere from 4 to 60 rubber band ligations, when their symptoms were never really from hemorrhoids at all.  Of course, we end up seeing them because the surgery or endless rubber band treatments never fixed their problem, not surprisingly.

So, if your symptoms are from hemorrhoids, there is treatment for that, often either infrared photocoagulation or elastic band ligation in the Clinic, or sometimes surgical excision – either under local anesthetic in the Clinic or under general anesthetic in the hospital.  You can read more about these treatments elsewhere on the site.  If your problem is something else, you should not be treated for hemorrhoids, you should be treated for what the problem actually is.  A full 60 percent of patients referred to us with ‘hemorrhoids’ are actually suffering form something else, either an fissure or anal canal dermatitis or inflammation.

A couple of points of caution: Firstly, if you are getting rubber band treatments for hemorrhoids, you should expect your problem to be largely solved by the first band.  Sometimes a second adds some additional benefit, rarely will a third make any difference at all.  Never accept more than three rubber bands without a second opinion and if you don’t get a good result after the first band you should already be questioning whether this treatment makes sense.  Secondly, keep in mind that if your problem is bleeding and it is thought to be due to hemorrhoids, higher examination with flexible sigmoidoscopy or colonoscopy may be warranted in order to make sure the blood is not coming from a higher source.  Patients should be careful about accepting treatment for bleeding ‘hemorrhoids’ when no assessment of the higher rectum and colon has been carried out or at least carefully considered and discussed.

By the way, no one uses the term ‘piles’ anymore except elderly patients from the old country.

© Pezim Clinic, Vancouver, British Columbia, Canada