Piles, Fistula and Fissures – Symptoms and Treatment Methods

Piles are one of the most common problems that are usually witnessed in any person. Besides Piles, some of them face severe problems with Fistula and Fissures. Mostly, people with piles fistula and fissures often visit the Surgical Department to get the treatment.

Another term for Piles is Haemorrhoids. Piles are the enlarged veins in the anal canal comprising blood vessels, elastic fibers and tissues. They get enlarged causing severe bleeding and pain to the person. Hemorrhoids are actually painful as they come out of the anal canal.

Here is an excerpt from a video interview with Dr. Raja Prasad, Surgical Gastroenterologist, Omni Hospitals, Kukatpally on Piles, Fistula and Fissures, its causes, symptoms and various treatment options.

Q. What are Piles?

A. Piles are enlarged veins that form in a range of sizes. Piles can either form internal or external. They usually come out of the anal area due to the swollen tissues. This is a very common problem that can happen to any person.

Q. What are the Causes of Piles or Haemorrhoids?

A. Piles are actually caused due to constipation and hard stools. The increased pressure in the lower rectum causes piles in some people. If the patient has constipation and hard stools, they might suffer from Piles. The major cause of Haemorrhoids is pressure on the veins. The other common causes of Haemorrhoids or Piles include:

  • Constipation
  • Obesity
  • Smoking Habits – Lots of Tobacco Usage

Q. What are the Symptoms of Piles?

A. Mostly, the symptoms of piles are not very complicated. Piles can be resolved on their own after some days. However, check some of the symptoms that an individual with piles usually experience.

  • A person with piles may experience pain while passing a stool.
  • Bleeding because of Piles is actually painless.
  • After passing a stool, they may witness a few drops of blood.
  • Some will notice blood after a bowel movement due to the enlarged piles

People visit a doctor for a medical opinion only when they notice heavy bleeding after passing a stool or painful piles.

Q. What are the types of Piles?

A. There are 4 grades of Piles.

Grade I: At this level, piles may not be visible as they are inside the anus lining.

Grade II: In this grade, the piles are larger and may come out while passing a stool. This grade piles also cause bleeding and the person might notice the blood stuck to the undergarments.

Grade III: In this grade, the patient might experience external hemorrhoids. When the pile mass in the anal canal comes out of the area and forms swelling then, they are called external Haemorrhoids. These piles are mostly symptomless. They can be noticed only when there is a blood clot or when they are swollen in the Haemorrhoid.

Grade IV: This grade of piles shouldn’t be overlooked. They definitely require treatment as they are large and pops out of the anal canal. The swollen piles also remain outside of the anus for a long time.

People suffering from Grade III or Grade IV Piles require surgical treatment. However, even in these grades, there is a possibility to treat them through medical management. With medicine, the patients will be free from the pain for a certain period. In the meantime, they can decide about surgical options. In the first two grades of piles, they can be treated with appropriate medicine.

Q. How to Treat Grade I and Grade II Piles?

A. In general, the treatment methods actually depend on the grade of Piles that the person has. To some extent, piles can be treated with medicines depending on the severity of the symptoms. In case, if the symptoms are severe in the patient, they can be treated through surgical methods.

Banding: For the people with grade I and grade II piles, banding is one of the major treatments. The doctor places an elastic band around the base of the pile. As a result, they restrict blood flow. The Haemorrhoid will fall off after some days of treatment. This treatment is helpful for the people with Grade I and Grade II piles.

Sclerotherapy: It is a procedure in which a medicine is injected into the blood vessels to make the hemorrhoid shrink and collapse as the time passes. It is an effective treatment for grade I, II and grade III piles. This eventually causes less bleeding from the piles.

Q. What are the Surgical Options for Grade III and Grade IV Piles?

A. If the piles are Grade III or Grade IV, they definitely require surgical management. The surgical options include Open Haemorrhoidectomy, Stapled Haemorrhoidopexy or True Laser. These are the most common surgical procedures for treating Grade III or Grade IV Haemorrhoids. Some other procedures include Photocoagulation, Argon Plasma and Infrared Coagulation. But, these three are less commonly used surgical procedures.

Stapled Haemorrhoidopexy: It is a surgical procedure that removes the enlarged haemorrhoidal tissue. This procedure has lesser pain compared to the open Haemorrhoidectomy procedure. Moreover, patients who underwent stapled Haemorrhoidopexy procedure will recover faster and lesser pain compared to other surgical procedures.

In the current era, the stapled Haemorrhoidopexy has become a great standard for those who are suffering from Grade III and Grade IV Haemorrhoids. The patients with this grade of piles even have external piles and prolapsed piles. So, this surgical procedure helps in the removal and treatment of all sorts of external and prolapsed Haemorrhoids.

Laser Haemorrhoid Procedure: Instead of insertion and cutting of the mucosa, this procedure uses laser beads for coagulating the Haemorrhoidal tissue. The main benefit of the laser procedure is that it gives lesser pain compared to stapled Haemorrhoidopexy. The patients will recover soon and can get back to their work as early as possible if they undergo laser surgical treatment. The major problem with this procedure is the difficulty in controlling the bleeding problem. The second major problem with laser treatment is the higher cost.

Q. What is Fistula-in-ano?

A. Fistula is actually a tunnel that provides a connection between two cavities or two openings. Fistula-in-ano is sometimes referred to as an Anal Fistula. It is an abnormal connection or a channel between the anal canal and the external skin or perianal skin. Fistula can be treated only through surgical methods and there is no other option for it.

Q. What Causes Fistula?

A. Fistula causes after a patient have perianal abscess or accumulation of pus near the perianal area which leads to rupture of the pus. In some people, it might cause due to the surgical interruption when insertion and drainage are performed. The fistula will be formed and the wound doesn’t heal for several days. The anal canal has a muscle namely external sphincter muscle allows us to voluntarily control our bowel movements. Whenever Fistula connections happen between the perianal area and anal canal, the tract passes through this canal.

If we cut this sphincter then, it turns out to become a problem. As a result of cutting the sphincter, there won’t be any control over the bowel movement. So, patients with Fistula must be evaluated accurately. Before treating the Fistula, the doctors must identify the type of fistula and symptoms through various procedures. Some of them include transrectal ultrasound or MRI Pelvis. With the help of these procedures, it is possible to find out how a tract is going.

Q. Is there a risk of Recurrence in Fistula-in-ano?

A. The recurrence risk of Fistula surgery and the results will depend on the type of a fistula. If it is a simple fistula then, the recurrence risk is very less. But, in the case of complex fistula, the chances of recurrence are very high. The treatment for fistula must be done in a proper way with utmost care in order to prevent the recurrence of fistula. If open surgical procedures are done then, the Haemorrhoids can recur. If we perform Stapled Haemorrhoidopexy surgery, the chances of recurrence are quite less.

Q. What is the surgery for Fistula-in-ano?

A. VAAFT is a popular surgery for treating Anal Fistula. The full form of VAAFT is Video-Assisted Anal Fistula. This surgery is quite similar to laser surgery. During this surgery, the surgeon can view inside the anal fistula tract alongside the internal and external opening and perform coagulation.

Q. What is the Diet to Follow?

A. People must follow a diet that includes high-fiber food such as vegetables and fruits. By the intake of high-fiber food, it prevents constipation problems. As long as constipation and hard stools are prevented, the chances of developing piles or Haemorrhoids can be reduced.

Q. What is a Fissure-in-ano or Anal Fissure?

A. Fissure-in-ano is a simple tear or break caused in the skin near the anal canal. This is also caused due to constipation and hard stool. As a result of the overstretching of anal canal skin, it leads to a skin tear in that region. The skin around the anal canal is very sensitive. Whenever the person with Fissure-in-ano tries to pass the stool, he or she will experience severe pain associated with bleeding. The reason is the skin tends to be teary causing pain to the patient.

Q. What is the Treatment for Fissure-in-ano?

A. Fissure-in-ano is an acute problem for patients suffering from it. Mostly, 50 to 60 percent of people can cure this problem with proper medication. It is also required to take care of the region with simple conservative management. By applying the topical gel, it can soothe the pain and relax the sphincter. This particular treatment is advised to the patients who have fewer symptoms.

In case, if the patient has critical symptoms like severe pain then, they are advised to go for a surgical option. The name of this surgery to treat Fissure-in-ano is Sphincterotomy. In this surgery, the surgeon will cut the internal sphincter and relaxes the anal opening.

Q. How to Get Rid of Fistula or Piles without Surgery?

A. If it is Grade I or Grade II of piles then, it is possible to resolve or recover on its own through proper high-fiber diet with lots of liquids. Make sure that you don’t strain much while passing stools. Piles of Haemorrhoids require surgery only if they are bleeding and painful or if they become external Haemorrhoids.

The Grade I and Grade II piles don’t need any surgery if they are asymptomatic. But, for Fistula, there is no other medication possible for treating it. People with Fistula must and should undergo surgical treatment as there is no medical management for it.

Another main thing to be mentioned to get rid of Piles, Fistula and Fissures are to follow some proper hygiene while passing stool. Some of them prefer carrying newspapers and mobile phones to washrooms. They sit for a long time and places immense pressure during the bowel movement.

It eventually results in placing immense pressure in the perianal region. Due to such strain, it gives some pain and bleeding near the area. This straining eventually pushes more blood into the Haemorrhoidal veins and results in the enlargement of piles. One must prevent constipation and avoid sitting a long time in washrooms to get rid of Fistula and Piles. The initial sign or symptom of a Fistula is perianal abscess [pus formation].

Q. Is there a recurrence chance of Fissure?

A. Yes, if the patient develops constipation even after curing a Fissure initially, there are recurrence chances of the fissure. They might once again get a tear in the skin near the anal canal and develops a fissure. So, these are some of the vital things that one must remember to avoid constipation and straining at stools.

Q. How to overcome Pain Management in Fistula?

A. People with Fistula might confront a lot of pain when there is a pus formation. Otherwise, there will be just a small amount of pus that can be seen in the patients. By taking painkillers, it is possible to reduce the pain of Fistula in a couple of days. After undergoing Fistula surgery, patients can be treated based on the type of Fistula i.e., low fistula or high fistula. If the wound is large near the perianal region, they might have pain. That pain can be reduced within 2 to 3 weeks. It is not actually possible to overcome Fistula pain all on its own after undergoing surgery. You definitely require medical attention post-surgery.

Q. What tests are done before Fistula or Piles surgery?

A. Before heading to Fistula or Piles surgery, the surgeon will perform Sigmoidoscopy or Colonoscopy tests. This test is performed by placing a camera to view the large intestine. To examine the descending colon and sigmoid colon, these two tests are done. In some cases, Haemorrhoids or piles can be the initial sign of some malignancy like cancer or some ulcerative conditions in the colon.

Dr Raja Prasad

Sr. consultant – Dept. of minimal access and Surgical Gastroenterology

OMNI Hospital, Kukatpally