Ways to Treat Haemorrhoids
What treatment options can you have to help with haemorrhoids?
A number of factors are known to be associated with the development of haemorrhoids, including increasing age, pregnancy and childbirth, chronic constipation, chronic diarrhoea, and family history of haemorrhoids. Estimates of the proportion of the UK population affected range from 4.4% to 24.5%. In 2004–5, approximately 23,000 haemorrhoidal procedures were carried out in England, of which approximately 8000 were excisional interventions. Whilst the above dietary and lifestyle changes may help avoid the development of haemorrhoids, there are a variety of surgical and non-surgical methods of treating haemorrhoids once they become a problem, depending on the grade. Smaller internal haemorrhoids may be treated successfully by rubber band ligation (banding) or injection, whilst the large external haemorrhoids are traditionally dealt with by surgical excision, known as haemorrhoidectomy. Here is a list of treatment options currently available, either privately or on the NHS.
For the smaller grade one and grade two haemorrhoids, without an external element but still symptomatic, there are a number of outpatient treatments available, albeit with limited success and generally a 50% chance of recurrence.
Non-Surgical Ways to Treat Haemorrhoids
Banding is usually carried out under local anaesthetic or sedation. It only takes a few minutes and involves a gun type device which shoots an elastic band around the inflamed cushion, designed to strangulate the haemorrhoid, thereby cutting off its blood supply. The tissue effectively dies and falls away. In practice it is difficult to ensure precise positioning of the band and in some cases, the band snaps or falls off before it has performed its function. This means that the procedure can fail, either immediately or soon afterwards, causing the haemorrhoid to remain. Even if the application is successful, it is said that there is a 30%-50% rate of recurrence, meaning that the process would have to be, and often is, repeated. The procedure itself is not without pain but this settles quite soon afterwards. This is typically the first line treatment offered on the NHS for minor haemorrhoids.
Sclerotherapy – Injections
Injections can be used as an alternative to banding. During the procedure known as sclerotherapy, a chemical solution is injected into the tissue thereby numbing the nerve endings and relieving discomfort. The aim of this procedure is to shrink the haemorrhoid by amaging the blood vessels which feed it, thereby reducing the flow of blood. It usually needs to be carried out several times in order to treat the larger haemorrhoids and are typically given every few weeks. This is not generally as painful as banding, but may need repeated applications. Often the principle of injecting a chemical into the body, makes this a less attractive option.
Surgical Ways to Treat Haemorrhoids
HAL (Haemhorroidal Artery Ligation)
HAL is generally used for grade 2 and 3 haemorrhoids and there is the option for HAL which is performed with a proctoscope modified to incorporate a Doppler transducer. There are two types of equipment in common use, known as HALO and THD. Both enable the detection of the feeder vessel to facilitate a targeted suture ligation of the Haemorrhoidal arteries. This procedure can be combined with a mucopexy suture for prolapsing haemorrhoids. HAL is performed under general anaesthetic as a day case procedure. The recovery can take up to 2 weeks during which the patient is likely to endure some discomfort. Time off work will be required. There is said to be a 30% recurrence rate with this process meaning that the symptoms might well recur with the procedure needing to be repeated. This is commonly offered privately and on the NHS.
Stapled haemorrhoidopexy is a technique that reduces the prolapse of haemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane above the dentate line, using a specific circular stapling device. This interrupts the blood supply to the haemorrhoids and reduces the potential for available rectal mucosa to prolapse. The procedure is referred to as a ‘pexy’ because the haemorrhoidal tissue is not excised as in conventional haemorrhoidectomy. Stapled haemorrhoidopexy is also known as ‘procedure for prolapse and haemorrhoids’ (PPH), stapled anopexy, stapled prolapsectomy and stapled mucosectomy. It has been used in the UK for several years. This is typically offered to treat the larger grade 4 prolapsing haemorrhoids and is carried out under general anaesthesia, most likely requiring an overnight stay in hospital.
Surgical haemorrhoidectomy is usually performed by the Milligan-Morgan (open) or Ferguson (closed) procedure. The Milligan-Morgan procedure involves dissection of the haemorrhoid and ligation of the vascular pedicle. The wounds are left open to heal naturally. The Milligan-Morgan procedure is thought to be relatively safe and effective for managing advanced haemorrhoidal disease, but because the anodermal wounds are left open healing is delayed, which may result in discomfort and prolonged postoperative morbidity. The Ferguson procedure is a modified version of the Milligan-Morgan technique, in which the wound is closed with a continuous suture to promote healing. A number of postoperative complications are associated with surgical haemorrhoidectomy. The short-term complications include pain, urinary retention, bleeding and perianal sepsis. Long-term complications may include anal fissure, anal stenosis, incontinence, fistula, and the recurrence of haemorrhoidal symptoms. Recovery can take at least 3 weeks (generally whilst suffering severe post-operative pain whilst the wound is allowed to heal). Haemorrhoidectomy is considered by NICE to be the gold standard in haemorrhoid treatment, with a relatively good success rate, but comes at the cost of considerable pain during and after the operation.