Is it haemorrhoids or something else?

Haemorrhoids – swollen blood vessels inside or around the rectum and the anus – are very common and thus, if you have symptoms, you might assume that it is haemorrhoids at first. In some cases, however, haemorrhoid symptoms indicate a different condition.

Here to provide an expert insight into haemorrhoids and the conditions that are mistaken for haemorrhoids is Mr David McArthur, renowned consultant colorectal, general and laparoscopic surgeon.

What are the common symptoms of haemorrhoids?

Haemorrhoids are so common that most people will, at some point in the life, experience haemorrhoidal symptoms, most likely.

Symptoms associated with haemorrhoids include:

• bright red rectal bleeding
• a sensation of fullness inside the anal canal
• discomfort, or pain, in the anal canal
• the sensation of something protruding from the anal canal that either goes back inside spontaneously or needs manual reduction to go back inside
• pruritis (itch) around the anal canal
• mucus discharge
• difficulties with cleanliness
• difficulties with fully evacuating bowels

What conditions are commonly mistaken for haemorrhoids?

Many people who visit a colorectal clinic with a perianal condition often present with what they assume is haemorrhoids as the cause of their ailment or what a GP has told them is haemorrhoids. However, this is not always the case and thus, my first job as a colorectal surgeon, is to accurately diagnose what the condition is.

Conditions that are often confused for haemorrhoids include:

• Anal skin tags, in which there is a redundancy of skin adjacent to the anal canal
• Anal fissure, which is a tear in the lining of the anal canal that presents with pain (this is the most common pathology that is confused with haemorrhoids)
• Anal fistulas, which are communications between the inside of the anal canal and the outside skin around the anal canal
• Perianal abscesses, which are infections around the anal canal

Besides these, there are more potentially serious conditions, including anal cancer and low rectal cancer that can sometimes present with similar symptoms to haemorrhoids.

What are the causes for some of these conditions?

The condition will obviously determine the cause.

For example, the most common condition other than haemorrhoids is an anal fissure. People will describe a pain in the anal canal, which usually occurs initially after passing a large stool or straining during constipation.

With respect to anal skin tags, they are often a consequence of having had haemorrhoids, whereby the haemorrhoidal tissue that originates inside of the anal canal (but protrudes down through the anal canal) stretches the anal skin. As the haemorrhoidal tissue reduces back inside the anal canal, excess redundant anal skin is left behind. This skin can be left as an anal skin tag.

Anal fistulas and perianal abscesses are linked together, often resulting from an infection in the anal glands inside the anal canal that then develops into a perianal abscess. After the abscess discharges, it can either heal up fully or lead to the development of an anal fistula.

Finally, anal cancer (cancer of the anal canal) often relates to an infection like HPV (human papillomavirus infection) whilst low rectal cancer has the same risk factors as bowel cancer.

Are these other conditions often misdiagnosed?

Very commonly, these conditions are misdiagnosed. Often people will seek medical attention for presumed haemorrhoids, and they actually have an anal fissure. The treatment for an anal fissure is different to that for haemorrhoids; likewise, the treatment for haemorrhoids is different to the treatment for a perianal abscess, an anal fistula, anal skin tags, and low rectal cancer.

It is crucial to receive the correct diagnosis, and this is why I urge people to always see a specialist who exclusively treats colorectal conditions.

How are these conditions treated?

Anal fissure:

The problem underlying an anal fissure is that there is a tear in the anal lining. Unlike a cut in the arm that scabs over and heals quickly, which it does due to a good blood supply providing the necessary oxygen and nutrients for healing, a tear in the anal lining gets stretched every time an individual goes to the loo. The initial stretching often gives pains described by patients as passing shards of glass or razor blades.

As a reflex consequence of the tear getting stretched, the internal sphincter muscle (the muscle around the anal canal) then goes into a spasm. This spasm does two things: firstly, it sets up deep-seated rectal pain that lasts from minutes to all day for some people; secondly, it restricts the blood supply that runs through the muscle to where the anal fissure is, preventing it from receiving the necessary constituents to help it heal.

It is a vicious cycle, with the tear getting stretched, then the spam, then the pain, and then the prevention of healing.

As a result, treatment for anal fissures usually involves trying to relax the internal sphincter muscle to restart the flow of blood that will promote healing. The first line of treatment is one of two creams - one is called glyceryl trinitrate (GTN) cream and the other is called diltiazem cream - that chemically relax the muscle and are applied around the anal canal morning and night. Around two out of three anal fissures will heal if these creams are used every day for eight weeks.

For the subset of anal fissures that do not heal, other treatment options are available, either a Botox injection into the internal sphincter muscle or a lateral sphincterotomy, a surgical procedure that divides some of the muscle fibres.

Anal skin tags:

Sometimes, people ask whether anal skin tags can be banded because that is a recognized treatment for haemorrhoids. However, banding is not an option for the treatment of external anal skin tags. The only way to manage anal skin tags is through surgical excision.

Anal fistulas:

The treatment for anal fistulas depends on the course of the tract running from the inside of the anal canal to the outside skin. More specifically, it depends on its relationship to the anal sphincter muscles that allow one to retain continence.

Thus, the most effective treatment for very low anal fistulas that involve little muscle is to lay them open, cutting down to where the tract is, and then allow everything to heal up from the base. This treatment gets rid of the fistula.

In contrast, a staged procedure is normally carried out for higher anal fistulas that involve more muscle. Firstly, a small drainage tube (called a seton) is placed through the fistula to allow the tract to mature. Subsequently, there are multiple procedures that can be performed, all with varying levels of success. These include: a ligation of internal fistula tract procedure; an advancement flap procedure; fistula plugs; glue; and video-assisted fistula tract surgery to obliterate the tract using different energy methods. There is not a single perfect procedure.

Can these conditions, or haemorrhoid symptoms, be caused by cancer?

Yes, occasionally people will present with what they assume are haemorrhoids but are actually low rectal cancer or anal cancer.

It is important to know that, unfortunately, every individual I have seen with cancer usually also has some degree of haemorrhoidal tissue. So, although most people with haemorrhoid symptoms will have an innocent source for these symptoms, a small proportion of people will have haemorrhoid symptoms caused by cancer. Without performing a complete investigation of the bowel, it can be simple to attribute things just to haemorrhoids.

Sadly, there are not infrequently cases where haemorrhoid symptoms have persisted for sometime, often over a year, among people who have received treatment or who have self-treated for haemorrhoids before seeking expert colorectal medical attention. In these cases, the underlying cause for the haemorrhoid symptoms was always cancer.

Whilst most people will not have a serious problem, I would advise people with haemorrhoid symptoms to get checked out so that they do not miss a serious underlying condition.

If you suspect haemorrhoids - or something else - do not hesitate to visit Mr McArthur’s Top Doctors profile today to receive expert diagnosis and assistance.