Having a haemorrhoidectomy

What are piles (haemorrhoids)?

Piles are natural structures in the bottom (anus), consisting of blood vessels, connective tissue, and muscles, known as vascular (rich in blood vessels) cushions. These cushions help control poo (faeces or stool) and farting by contributing to the closure of the anal canal.

However, when these cushions become swollen or inflamed, they are referred to as piles. This can lead to symptoms such as:

• Bleeding. Often noticed during going to the toilet, bright red blood may appear on the toilet paper or in the toilet.
• Itching or irritation around the bottom.
• Prolapse. The piles may protrude (come out) from the bottom, particularly after going to the toilet, but it can often be pushed back inside manually.

While piles themselves are typically painless, the complications they cause can lead to significant discomfort.

Why are investigations needed?

Before surgery, your doctor may recommend a flexible sigmoidoscopy or colonoscopy. This is an examination of your lower bowel with a small camera attached to a thin tube. Medication called sedation can be given during this procedure to make this more comfortable. This camera examination is to ensure there is no other cause for the rectal bleeding or symptoms.

How do piles occur?

Piles develop when the vascular cushions become enlarged. Common factors include:

• Straining during going to the toilet, especially from constipation.
• Pregnancy, which increases pressure on pelvic and rectal veins.
• Sitting for long periods on the toilet.
• Obesity, which adds pressure to the pelvic area.

Some people may be more prone to developing piles due to genetics or lifestyle factors such as sitting for long periods on the toilet, though the specific reasons are often difficult to determine.

What if my piles are left untreated?

In general, piles are not dangerous, and not treating them will not typically lead to serious harm. However, if you experience significant or frequent bleeding, it’s important to seek medical attention, as this can lead to anaemia (a low red blood cell count).

Large piles may occasionally become thrombosed, which means they can clot and get stuck outside the anal canal. A thrombosed haemorrhoid is often very painful, but the pain usually improves within 7 to 10 days. Without any specific treatment, the thrombosed haemorrhoid typically shrinks over the following 4 to 8 weeks.

If you experience bleeding that seems unusual or different from what you’ve experienced with piles, it’s essential to contact your GP. In some cases, additional investigation with a procedure such as a colonoscopy (camera examination of the bowel) may be necessary to rule out other causes of bleeding.

Treatment choices

Piles don’t always need treatment unless they cause significant symptoms. Your options depend on the severity of your piles and how much they affect your quality of life.

Conservative measures

Piles can be managed with lifestyle changes that help relieve symptoms and reduce strain during going to the toilet. These include:

• Dietary changes: A high-fibre diet (fruits, vegetables, whole grains) and drinking enough water and liquids can help soften poos, reducing the need for straining.
• Laxatives: These may be recommended if constipation is an issue.
• Regular exercise: Physical activity can improve digestion and prevent constipation.
• Proper toilet habits: Avoid sitting for extended periods on the toilet and refrain from straining.

Over-the-counter treatments like creams, ointments, and suppositories can also help soothe symptoms.

Non-surgical procedures

If conservative measures are insufficient, there are minimally invasive options, such as:

• Banding: A small elastic band is placed around the base of the piles to cut off its blood supply. The haemorrhoid eventually shrinks and falls off.
• Sclerotherapy: An injection is used to shrink the haemorrhoid.
• These procedures can often be performed in an outpatient setting, with minimal recovery time.

Surgical treatment (haemorrhoidectomy)

If your piles are large, prolapsed, or have not responded to other treatments, your surgeon may recommend a haemorrhoidectomy. This is a procedure to remove them entirely.

When surgery is necessary

Surgery may be the best option if:

• You have large piles that protrude or prolapse.
• You experience frequent bleeding, pain, or discomfort.
• Other treatments have not been effective in managing your symptoms.

After your procedure

Recovery from haemorrhoid surgery can take a few weeks. Here’s what to expect:

• Pain or discomfort: It’s common to experience pain, especially when going to the toilet. Your doctor will prescribe pain relief to help manage this.
• Bleeding: Light bleeding or spotting is normal after surgery but should gradually decrease.
• Swelling: You may notice some swelling in the area, which should subside over time.
• Going to the toilet: You may be advised to take medication to soften your poo to avoid straining and discomfort during going to the toilet.

Risks and complications

Like all surgeries, a haemorrhoidectomy carries some risks. While the procedure is generally safe and effective, complications may occur. Being aware of these risks allows you to make an informed decision.

Some possible complications include:

• Pain: Haemorrhoidectomy is a painful procedure, and pain may persist for some time after surgery. It is typically most intense in the first few days but improves significantly within two weeks. To manage pain:
  • Local anaesthetic: Given during surgery for pain relief lasting approximately 8 hours.
  • Oral pain relievers: You will be prescribed painkillers like paracetamol, ibuprofen, or stronger medications such as dihydrocodeine.
  • Warm baths: You may be advised to take 15-minute warm shallow baths (immersing the hips and bottom in warm water) several times a day, especially after going to the toilet. This can soothe pain and reduce inflammation.
  • Laxatives: You will likely be prescribed a medication called laxatives to soften your poo to prevent constipation and reduce straining.
  • Antibiotics: In some cases, an antibiotic course like metronidazole is prescribed for a week. You should avoid alcohol while taking this medication.

• Bleeding: Some bleeding is normal after surgery. You may see bright red blood for a few days after the operation. Rarely, bleeding may occur 10 days post-surgery. This often resolves on its own but occasionally requires further treatment.
• Infection: In rare cases, the surgical wound may become infected. This might require treatment with antibiotics and, very occasionally, further surgery.
• Difficulty urinating: After the procedure, some patients may find it temporarily difficult to urinate and require a temporary catheter (insertion of tube into bladder to drain the urine). This is often due to swelling in the area but usually resolves on its own.
• Urgency: With all haemorrhoidal surgery it is possible that you may get the feeling of urgency and need to rush to the toilet. This usually settles in time. Some people find that their ability to tell apart gas from liquid or solid poo is decreased and they have some minor leakage. Very rarely the muscle around the bottom is injured.
• Stricture or narrowing: Rarely, the area may scar and narrow, causing difficulty going to the toilet. This may require additional treatment.

The day of your procedure

On the day of your haemorrhoidectomy, please follow the instructions provided by the pre-assessment team. You will be advised to:

• Fasting: Do not eat for 6 hours before the operation and avoid drinking for 2-3 hours beforehand. The doctor on the day of surgery may allow you to have small sips of water within 2 hours of the surgery.
• Preparation: You may be given a medication via the bottom called a suppository or enema before surgery to empty your bowels.

Before surgery

• An anaesthetist (the doctor responsible for putting you to sleep) will visit you on the ward to ask some questions and explain the anaesthesia process. They will ensure you are ready for the procedure.
• A member of the surgical team will also visit to confirm your consent and answer any last-minute questions.
• The hospital advises that you do not wear jewellery or makeup on the day of the operation.
• You will be asked to remove any, dentures, contact lenses and change into your surgical gown.
• When it’s time for your operation, you will be taken to the theatre department:
• The theatre team will ask similar questions to those asked earlier as a routine safety check.
• In the anaesthetic room, monitoring equipment will be attached to you to ensure your safety during surgery.
• If you’re having a general anaesthetic, you will be given medication to put you to sleep. If general anaesthesia is not suitable for you, the anaesthetist will discuss other options with you.

General anaesthesia

General anaesthesia is used to put you to sleep during the operation, so you will not feel anything.

How it works

Anaesthetic drugs are injected into a vein or inhaled through the lungs as a gas. These drugs travel to the brain via the bloodstream, where they stop the brain from receiving pain signals or messages from the nerves in your body.

During surgery

Once you are unconscious, the anaesthetist will remain with you throughout the procedure, continuously monitoring and adjusting the medication to ensure you remain safely anaesthetised. After the operation is complete, the drugs will be reduced or stopped so that you can wake up gradually.

General anaesthesia risks

The risks associated with general anaesthesia depend on your overall health, the type of surgery, and its complexity. Serious complications are rare but can occur. The most common risk is a sore throat caused by the breathing tube used during the procedure. This usually resolves with simple home treatments like saltwater gargles.

Another potential risk is deep vein thrombosis (DVT), which occurs when blood clots form in the legs due to prolonged inactivity. To reduce this risk:

• You will be encouraged to move your legs and feet soon after surgery.
• Walking as soon as possible after the procedure is also recommended to improve blood circulation.

Your anaesthetist will take all necessary precautions to minimise these risks and will discuss any concerns with you beforehand.

After your procedure

After your haemorrhoidectomy, you will be taken to the recovery room, where you will be closely monitored until you are fully awake. Once stable, you will return to the ward for further observation. Most patients can go home the same day, although you may experience some pain and discomfort, which can be managed with pain relief medications. Your healthcare team will provide you with painkillers to take home.

Care at home after discharge

When you are discharged, it is important to follow these guidelines to ensure a smooth recovery:

• Transportation: You should have a responsible adult to accompany you home, whether by car or taxi. We do not recommend using public transportation even if you accompanied by a responsible adult.
• Initial recovery: For the first few days, you may feel tired easily. This is normal and will pass with rest and gentle activity.
• Swelling or bruising: It is normal to experience some swelling and bruising around the surgical area. This usually resolves over a few days or weeks. However, if the area becomes hot, very painful, or shows signs of infection (such as redness or discharge), contact your GP.

Activity restrictions

• Avoid heavy lifting or strenuous exercise such as fast running, cycling or horse riding which could be uncomfortable or cause the wound to bleed for 1 week after surgery.
• Depending on the nature of your job, you can return to work as soon as you feel comfortable:
  • Typically, 2 weeks for desk-based jobs.
  • 4 weeks for more manual or physical jobs.
• You can self-certify sick leave for 7 days; beyond this you will need a fit to work note for your employer. This can be completed by the hospital doctor at discharge or by your GP if you require more time off than anticipated on discharge.
• Driving: You should not drive for at least 48 hours after surgery because of the anaesthetic and pain medications. Only begin driving when you feel confident and comfortable to do so. Check with your insurance provider regarding any specific guidelines they may have.
• General movement: Gentle walking is encouraged as soon as possible after surgery to promote circulation and prevent complications like blood clots. Avoid staying in bed for prolonged periods. If you have impaired mobility, we recommend you return to your normal level of activity as soon as possible after surgery.

Important points to remember

• Anaesthetic effects: The effects of the anaesthetic may influence your system for 24-48 hours. During this time, it’s important to have someone available to help you at home.
• Pain management: Follow the pain relief instructions provided by your healthcare team. If you experience significant or increasing pain, contact your doctor.
• Assistance at home: You will require someone at home the day after surgery to help assist you, please let your team know if this is not possible as we can arrange for you to stay in hospital for this period.
• Avoidance of constipation: You will likely require medication to keep your poo soft – this may be prescribed as part of your discharge medication.

By following these recommendations, you will help ensure a safe and comfortable recovery.

What should I do if there is a problem?

If you experience persistent pain, bleeding, or any symptoms that seem unusual or unexpected after your surgery, it is important to seek medical advice.

• Contact your GP for any concerns or ongoing symptoms.
• Alternatively, you can contact your consultant’s secretary please contact your consultant’s secretary at the Royal Free London on 020 3758 2000.