Haemorrhoids

Haemorrhoids are swollen veins at or near the anus, which are usually asymptomatic.In women with haemorrhoids, symptoms are usually mild and transient and include pain and intermittent bleeding from the anus. Depending on the degree of pain, quality of life can be affected, varying from mild discomfort to difficulty in dealing with the activities of everyday life. Treatment during pregnancy is mainly directed to the relief of symptoms, especially pain control. For many women, symptoms will resolve spontaneously soon after birth.Haemorrhoids can become symptomatic if they prolapse (the forward or downward displacement of a part of the rectal mucosae through the anus) or because of other complications such as thrombosis. Associated anal fissures (a break or slit in the anal mucosa) can also lead to symptoms.

Haemorrhoids can be classified by severity: first-degree haemorrhoids bleed but do not prolapse; second-degree haemorrhoids prolapse on straining and reduce spontaneously; third-degree haemorrhoids prolapse on straining and require manual reduction; and fourth-degree haemorrhoids are prolapsed and incarcerated. Diagnosis of haemorrhoids is based on history and examination. Symptoms include bleeding, mucosal or faecal soiling, itching, and occasionally pain. Fourth-degree haemorrhoids may become "strangulated" and present with acute severe pain. Progressive venous engorgement and incarceration of the acutely inflamed haemorrhoid leads to thrombosis and infarction. The diagnosis of haemorrhoids is confirmed by rectal examination, and inspection of the perianal area for skin tags, fissures, fistulae, polyps, or tumours. Prolapsing haemorrhoids may appear at the anal verge on straining. It is important to exclude more serious causes of rectal bleeding. Assessment should include anoscopy to view the haemorrhoidal cushions. Haemorrhoidal size, and severity of inflammation and bleeding should be assessed.Women often experience hemorrhoids during pregnancy. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.

Haemorrhoids result from impaired venous return in prolapsed anal cushionswith dilation of the venous plexus and venous stasis. Inflammation occurs with erosion of the anal cushion's epithelium, resulting in bleeding. Constipation with prolonged straining at stool, or raised intra-abdominal pressure as occurs in pregnancy, may result in symptomatic haemorrhoids.During pregnancy, delivery, and the puerperium, sphincteral muscles and pelvic floor structures could be modified in tone and position, leading to an alteration of the normal functioning of the haemorrhoidal cushion, which may predispose to symptoms.

The doctor examines the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.
Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.
To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.