Haemorrhoids - more commonly called piles - are sometimes the source of jokes, usually by those people who have never suffered with them. Those who have been bothered by this common condition and its complications tend not to find it a laughing matter. Most of us will suffer in silence rather than disclose this private part of our anatomy.
What is a haemorrhoid? At the upper end of the anus, where it meets the rectum, the smooth lining of the bowel bulges to form what are called the anal "cushions". Usually three in number, they are a mixture of elastic tissue and small blood vessels.
These cushions lie in contact with each other, sealing off the upper anus and helping us keep control over intestinal gas. However, they can become enlarged and congested under certain conditions. When they do, they are called haemorrhoids.
During or immediately after a bowel motion, haemorrhoids can bleed or they may prolapse (protrude) from the anus. This is because the passage of a stool - especially if it is hard and constipated - compresses and injures the piles. The bleeding that results is invariably bright red or "fresh" looking. Patients often report seeing it on the toilet paper, or they may notice it in the bowl after the stool has passed.
As the haemorrhoid gets larger, it literally slides down the anal canal and protrudes externally. Doctors refer to this as prolapse. Most of the time the prolapsed haemorrhoid retreats internally of its own accord. However, if the pile is especially large it may require gentle assistance to return. When haemorrhoids are very large they become permanently prolapsed, causing itching, discomfort and sometimes bleeding on contact with underwear.
Repeated prolapse of a pile leads to the development of a perianal skin tag. This is an irregular flap of skin around the anal opening - the skin's reaction to the protruding haemorrhoid.
While never life threatening, piles can becomes suddenly painful if a clot forms within (thrombosis). This tends to happen after they have been bleeding and prolapsing for months or even years. The pain is intense and the patient notices that the prolapsed haemorrhoid is extremely tender. Draining the clot produces good pain relief but once thrombosis has occurred, it is a sign that operative removal - haemorrhoidectomy - is needed.
One of the myths about haemorrhoids is that they are a varicose vein in the anal area. Many people believe that if you suffer with varicose veins in your legs you will be more prone to haemorrhoids. There is no evidence for this.
What causes them? The biggest factor is straining, which puts pressure on the cushions and encourages congestion, both of which cause enlargement. Heavy physical exertion, such as lifting, and the effort of straining to initiate a bowel movement also cause haemorrhoids. Menstruation and, in particular, pregnancy, which cause congestion in the pelvic blood vessels, are other causes.
As bowel habits change, so too do the symptoms of piles. The more pressure brought to bear on the upper anal canal, for example by a combination of straining and prolonged sitting on the toilet, the more likely haemorrhoids are to produce symptoms.
So in terms of treatment, having a regular bowel habit and avoiding constipation is the first and most important step. Creams and suppositories containing mild steroids and local anaesthetics will help occasional flare-ups in itch, discharge and discomfort.
Haemorrhoids can be made to shrink by injection with a solution of oil and alcohol. Larger haemorrhoids can be "strangled" using tiny rubber bands placed at the base of the pile using special instruments. Haemorrhoidectomy - the surgical removal of the haemorrhoid along with the nearby skin and anal lining - is the final solution.
On a more spiritual note, readers may wish to invoke the French St Fiacre, the patron saint of those suffering from piles. His reputation rests on the miraculous transformation of a stone he was sitting on which melted to assume the shape of his body, making him more comfortable. The French still use a laxative called "l'herbe de Sainte Fiacre".
Finally and most importantly, never, ever assume that bleeding from your back passage is the result of piles. Although they are the commonest cause of bright red blood, other more serious gastrointestinal illnesses can present with anal bleeding. This symptom must always be fully assessed by your doctor.