In a healthy person, there are cushions just above the dentate line in the anal region, which contain veins, connective tissue, and smooth muscle. However, these cushions can turn into hemorrhoids due to chronic constipation or diarrhea, excessive straining, incorrect toilet habits, or pregnancy. Initially, hemorrhoids were defined as the dilation or varicose veins of the rectal and anal region. Hemorrhoids or piles affect one in two individuals around the age of 50.

What are the types of hemorrhoids (piles)?

Hemorrhoids or piles are classified into internal and external types based on their location.

External Hemorrhoids (Piles):

They are located in the most sensitive and pain-sensitive area of the anal region. If the veins here become thrombosed, they create an extremely painful swelling (thrombosed hemorrhoids).

Internal Hemorrhoids (Piles):

The most common symptom is painless swelling protruding from the anus. They are usually noticed by patients during cleaning after defecation. If these hemorrhoids protrude fully or become incarcerated and cannot be pushed back inside, they can cause severe pain.

What causes hemorrhoids or piles?

According to the widely accepted view today, hemorrhoids occur due to the disruption of the integrity of the cushions that provide protection around the anus. In individuals with hemorrhoids or piles, veins dilate compared to healthy individuals, blood clots form in the veins (thrombosis), and there is sagging in muscle and connective tissues. In some patients, in addition to these changes, ulcers, thrombosis, and ischemia (malnutrition) may occur in the mucosa of the lower rectum within the anal canal.

What factors facilitate the formation of hemorrhoids or piles?

• Occupations that require prolonged sitting: secretarial work, architecture, engineering, banking, etc.
• Certain sports: bodybuilding, cycling, motorcycle riding, horseback riding
• Advanced age
• Chronic diarrhea
• Chronic constipation
• Pregnancy
• Genetics
• Excessive straining
• Excessive use of laxatives or enemas
• Prolonged sitting on the toilet, reading while on the toilet

How is the diagnosis of hemorrhoids or piles made?

The definitive diagnosis of hemorrhoids or piles is made through clinical examination as well as anoscopy, rectoscopy, sigmoidoscopy, or colonoscopy. It is possible to get rid of discomfort with short and painless methods. However, starting treatment early allows for medication management of the condition. Through these examinations, other diseases that may be mistaken for hemorrhoids (piles) can be ruled out.

What are the symptoms of hemorrhoids or piles?

• Bleeding from the anus during straining
• Prolapse of the anus during straining
• Itching in the anal region
• Pain in the anus
• Painful swelling felt in the anal region

How does the disease progress?

In the initial stages of the disease, there may only be complaints of bleeding from the anus, while in later stages, swelling in the anus during defecation accompanies the bleeding. As hemorrhoids (piles) progress, these swellings no longer return inside. Especially in advanced stages, as hemorrhoid (pile) cushions protrude outward, the anus remains constantly moist. Itching due to anal moisture adds to other discomforts. Additionally, there are acute phase characteristics of hemorrhoids (piles). Internal hemorrhoids (pile cushions) protrude outward, cannot retract, and swell. They fill with blood. During this period, a large, swollen mass forms in the anus, and this stage is very painful.

What are the stages of hemorrhoid (pile) disease?

• Stage I hemorrhoid: Internal hemorrhoids that cause bleeding but do not protrude outside the anus
• Stage II hemorrhoid: Internal hemorrhoids that protrude outside the anus but retract spontaneously
• Stage III hemorrhoid: Internal hemorrhoids that protrude outside the anus and can be manually pushed back inside by the person
• Stage IV hemorrhoid: Internal hemorrhoids that protrude outside the anus and cannot be manually pushed back inside by the person

What is the treatment for hemorrhoids or piles?

We observe that patients are becoming increasingly aware and seeking medical attention earlier. According to our observations, men tend to delay consulting a specialist surgeon due to embarrassment about the examination. Hemorrhoid disease (piles, hemorrhoids, babasıl) can be treated without surgery or with surgery. Treatment methods can be classified under three main headings: simple methods, painless methods, and surgery. Non-surgical methods include sitz baths (sitting in warm water for 10-15 minutes), applying certain ointments, or taking hemorrhoid (pile) pills orally. There are also some treatment methods that can be performed in the doctor's office.

HEMORRHOID SURGERY

What are the surgical methods for hemorrhoid (pile) disease?

If hemorrhoids or piles have progressed, surgical methods are considered. These include:

Classic surgical techniques: Milligan & Morgan (an open technique described in 1937), Ferguson (closed technique), and Whitehead surgeries. These aim to remove hemorrhoid cushions by cutting them with scissors, a knife, monopolar electrocautery, bipolar cautery (BICAP), "Ligasure," or "Ultracision -harmonic scalpel" which can deactivate veins up to 7 mm in diameter, using devices for vessel closure or laser. This technique is called "hemorrhoidectomy." Dilating the anus or "anal dilatation" during the procedure provides significant relief, especially in third-degree hemorrhoids. If hemorrhoid cushions are removed from inside the anal canal, it is called "closed hemorrhoidectomy," and in this technique, there are no wounds or scars on the skin around the anus. The removal of hemorrhoid cushions from outside the anal canal and skin is called "open hemorrhoidectomy."

Longo method: One of the surgical methods for treating hemorrhoids (piles) is the Longo technique. In the method developed by Longo, there is no external wound, and the surgery is performed entirely inside the anus, which is a region much poorer in nerve endings compared to the anus (anoderm), reducing postoperative pain sensation. Moreover, in advanced cases of hemorrhoids (third and fourth-degree hemorrhoids) or with rectal prolapse, the Longo technique is reported to provide the most successful results.

Laser method: CO2, Argon, NdYag, and Diod lasers can be used for this purpose. The main purpose of all lasers can be described as sealing the veins with glue. In various studies, this method has been shown to have advantages in terms of pain and recurrence rates compared to the classic method. In recent years, a circular (radial fiber) hemorrhoid removal technique using a thin laser rod with a wavelength of 1,470 nm and a power of 13 watts has been developed, and this method is called "laser hemorrhoid ablation" or "laser hemorrhoidoplasty." The advantages of this method include:

• Since the surgery is performed without stitches, there is considerably less bleeding and pain complaints during the postoperative period compared to other methods.
• There is no loss of work capacity after the surgery. Patients can return to their work within a few days without engaging in heavy physical activity.
• No dressing changes are required during the postoperative period. Avoiding constipation is sufficient.

Can hemorrhoids (piles) recur?

Even if hemorrhoids (piles) are treated, they can recur in 10-50% of cases with non-surgical methods and in 1.5-15% of cases with surgical methods. Reasons for recurrence include the surgical technique used, ongoing constipation, and dietary errors, among others. In extensive meta-analyses by Jayaraman et al., it was reported that after Longo technique, hemorrhoid disease recurs within one year in 5.7% of cases and in the late period in 8.5% of cases, while after classic hemorrhoid surgery, recurrence rates within one year are 1% and in the late period are 1.5%. Therefore, especially in cases of recurring or complicated hemorrhoids, having a proctologist manage the patient offers significant advantages.

How should hemorrhoid (pile) patients eat?

In hemorrhoid (piles, hemorrhoids, babasıl) disease, it is very important for patients to follow a suitable diet both to prevent the disease and to be comfortable during flare-ups. It is observed that hemorrhoid patients use laxatives intensively. Instead of using laxative drugs to facilitate defecation, it is recommended to consume around 2 liters of water per day and to prefer a diet rich in fiber and natural foods. The daily fiber intake in the diet of individuals aged 20-50 should be around 40 grams for men and 25 grams for women. It is not recommended for the daily fiber intake to exceed 50 grams to avoid some dietary irregularities. Consuming grains, legumes, soybeans, barley, rice, and wheat, as well as vegetables and fruits in a balanced manner, increases intestinal motility and is very beneficial in combating constipation. It is beneficial for hemorrhoids to regularly consume vitamins A, B, C, E, zinc, and bioflavonoids from fruits.