Haemorrhoids & Anorectal Conditions

Pathophysiology

Key Concept Haemorrhoids are prolapsed anal cushions — not varicose veins of the rectum. Anal cushions are normal vascular structures that contribute to continence; they become pathological when they prolapse, bleed, or cause symptoms.

Internal vs External

• Internal haemorrhoids — above the dentate line; covered by insensate columnar mucosa; bleed but not painful unless strangulated
• External haemorrhoids — below the dentate line; covered by squamous skin; painful when thrombosed
• Mixed haemorrhoids — straddle the dentate line

Goligher Classification

Symptoms

• Bright red rectal bleeding — typically coats stool or drips post-defecation; fresh blood on tissue
• Mucus discharge — from prolapsed mucosa
• Pruritus ani — perianal itching due to mucus leakage and moisture
• Prolapse — tissue protruding on straining (Grade II–IV)
• Discomfort/heaviness — sensation of incomplete evacuation
• Pain — haemorrhoids alone are usually painless; severe pain suggests thrombosed external haemorrhoid or coexisting fissure

Thrombosed External Haemorrhoid

Presents as a tender, tense, purple perianal lump of sudden onset. If within 72 hours: excision under LA offers rapid relief. After 72 hours: conservative management (analgesia, warm baths, laxatives) as clot begins to resolve.

Risk Factors

• Straining at stool — most important modifiable factor
• Chronic constipation — hard stools, prolonged effort
• Pregnancy — raised intra-abdominal pressure + progesterone relaxes smooth muscle
• Low fibre diet — <20 g/day significantly increases risk
• Prolonged sitting — especially on toilet
• Portal hypertension — anorectal varices (not true haemorrhoids, but cause rectal bleeding)
• Obesity — raised intra-abdominal pressure
• Sedentary lifestyle — impairs gut motility

Conservative Management

Dietary Modification

• High fibre: 25–30 g/day — psyllium, oat bran, vegetables, legumes
• Fluid intake: 2 L/day — prevents hard stools
• Fibre supplements (ispaghula husk / Fybogel) if dietary changes insufficient

Behavioural

• Avoid prolonged straining — <3 minutes on toilet
• Respond promptly to defecation urge
• Regular physical activity to stimulate motility
• Sitz baths — warm water 10–15 min 2–3x/day for symptom relief

Topical Preparations

• Hydrocortisone + lidocaine (e.g. Proctosedyl) — short-term only (<7 days to avoid skin atrophy)
• Witch hazel — astringent, soothes pruritus
• Lidocaine gel — topical anaesthesia before defecation

Red Flags — Do Not Miss

The following features require urgent investigation before assuming haemorrhoids. Haemorrhoids are a diagnosis of exclusion in at-risk patients.

• Red flag Dark/altered blood — mixed with stool, suggests proximal source
• Red flag Change in bowel habit — looser/more frequent for >4 weeks
• Red flag Unexplained weight loss
• Red flag Age >40 years with rectal bleeding — colonoscopy first
• Red flag Iron-deficiency anaemia without obvious cause
• Red flag Palpable rectal mass
• Consider Family history colorectal cancer — lower threshold for colonoscopy

Per NICE NG12: 2-week wait (2WW) urgent referral for any patient meeting red flag criteria.

Rubber Band Ligation (Banding)

Outpatient First-line office procedure for Grade I–III internal haemorrhoids. A rubber band is applied 1–2 cm above the dentate line, causing ischaemic necrosis and fibrosis.

Procedure

• No GA required; performed via proctoscope
• Maximum 1–2 bands per session (reduce risk of pain)
• Band must be placed above dentate line — below = severe pain

Post-Procedure Nursing Care

• Mild discomfort expected for 24–48 hours — paracetamol
• Bleeding at 7–10 days is normal — sloughing of necrotic tissue; warn patient in advance
• Avoid aspirin/NSAIDs for 1 week — increased bleeding risk
• High fibre diet + fluids to prevent straining
• Avoid heavy lifting/strenuous activity for 48 hours

Serious Complications — Rare but Critical

Sclerotherapy

Injection of 5% phenol in almond/arachis oil into the submucosa above the haemorrhoid. Causes fibrosis and adherence of mucosa to underlying muscle.

Indications & Nursing Points

• Primarily for Grade I–II, especially bleeding haemorrhoids
• Outpatient; no anaesthetic required
• Warn: mild discomfort; occasional temporary impotence reported (very rare)
• Post-procedure: similar to banding — fibre, fluids, avoid NSAIDs
• Less effective long-term than banding — may need repeat

Other Office Procedures

• Infrared coagulation — photocoagulation, Grade I–II
• Bipolar diathermy — similar indications

Surgical Haemorrhoidectomy

Techniques

Post-Operative Nursing Care

• Pain management — significant pain expected; multimodal: regular paracetamol + NSAID + opioid PRN; suppositories (metronidazole + diclofenac) reduce pain and infection risk
• Wound care — foam dressings; sitz baths 2–3x daily
• First bowel motion — counsel patient; lactulose or softener from day 1; first motion can be frightening but reassure
• Urinary retention — most common complication (10–20%); monitor urine output in recovery; in/out catheter if >6 hours
• Discharge criteria — pain controlled orally, tolerating diet, passed urine, written wound care instructions, follow-up arranged

Post-Op Complications

• Primary haemorrhage — within 24 hours; return to theatre
• Secondary haemorrhage — 7–10 days; sloughing
• Urinary retention — most common; days 1–2
• Anal stenosis — late; inadequate skin bridges preserved
• Faecal incontinence — rare; sphincter injury
• Infection — uncommon; metronidazole prophylaxis often used

Nursing Key Points Summary

• Always warn patients about day 7–10 bleed after banding — prevents unnecessary ED attendance
• Post-banding fever + urinary retention = emergency sepsis until proven otherwise
• Post-haemorrhoidectomy pain is significant — do not underestimate; adequate analgesia is a nursing priority
• Urinary retention monitoring is essential in first 6 hours post-op
• All surgical patients require thromboprophylaxis assessment (TEDs + LMWH per protocol)
• Discharge education: high fibre diet, sitz baths, when to return (heavy bleeding, fever, inability to void)

Anal Fissure — Overview

A linear tear in the anoderm (squamous epithelium below the dentate line). Classified as acute (<6 weeks) or chronic (>6 weeks, with associated features).

Location

• Posterior midline — 90% of cases (relatively ischaemic area)
• Anterior midline — ~10% (more common in women post-partum)
• Lateral position — Suspect Crohn's disease, TB, HIV, STI, malignancy

Acute vs Chronic Features

Symptoms & Examination

• Severe pain on defecation — sharp/tearing; lasts minutes to hours; often described as "passing broken glass"
• Fear of defecation — avoidance worsens constipation, creating a vicious cycle
• Bright red blood — on tissue paper; small amount coating stool
• Pruritus ani — from discharge

Examination

• Gentle buttock separation reveals fissure — DRE usually avoided acutely due to pain
• Hypertonic internal anal sphincter — reflex spasm, reduces blood supply, prevents healing
• Sentinel pile — external skin tag at inferior end of chronic fissure

Pathophysiology

Ischaemia of the anoderm due to hypertonic sphincter → impaired healing → chronic fissure. Breaking the spasm is the goal of all treatments.

Conservative Management

• High fibre diet — 25–30 g/day to soften stool
• Increased fluid intake — 2 L/day
• Sitz baths — warm water relaxes sphincter, improves blood flow
• Stool softeners — lactulose, macrogol
• Topical lignocaine 5% — applied 15 min before defecation to reduce pain-spasm cycle
• Heals ~50% of acute fissures within 4–6 weeks

Pharmacological Treatment

All topical agents: apply twice daily for 6–8 weeks. Apply with gloved finger or applicator.

Interventional & Surgical

Botulinum Toxin Injection

• Injected into lateral internal sphincter (or external sphincter)
• Causes temporary chemical denervation (3–4 months of sphincter relaxation)
• Healing rate ~60–80%
• Risk: temporary minor incontinence in ~5–10%
• Can repeat if fissure recurs

Lateral Internal Sphincterotomy (LIS)

Gold Standard surgical treatment for chronic fissure

• Division of the distal 1/3 of the internal anal sphincter laterally (not at fissure site)
• Healing rate: ~95%
• Risk of incontinence — 5–10% minor (wind/mucus); 0.3–0.5% major (faeces) — must be counselled
• Post-op nursing: sitz baths, pain management, wound care

Crohn's-Associated Fissure

Anorectal Abscess

Infection arising from the cryptoglandular epithelium (anal glands at dentate line). Pus spreads through the intersphincteric space to various anatomical spaces.

Classification

Acute Management

Post I&D Nursing Care

Wound Care Protocol

• Sitz baths — warm saline 2–3x daily; after each bowel motion
• Saline irrigation — using 20 mL syringe; gently irrigate wound cavity
• Pack removal — if packed in theatre, nurse removes at 24–48 hours; patient education for self-care
• Secondary healing — wound heals from inside out over 2–6 weeks depending on size
• Assess for: discharge type/amount, odour, granulation tissue, surrounding skin condition

Community Nursing Considerations

• Daily or every-other-day wound checks initially
• Patient/family education on dressing technique
• Signs of recollection: worsening pain, swelling, fever → return to ED
• ~50% develop a fistula-in-ano after abscess — advise follow-up
• Diabetic patients — more severe infections, unusual organisms (Klebsiella, mixed flora); closer monitoring; consider Fournier's gangrene risk

Fistula-in-Ano

An abnormal connection between the internal opening at the dentate line and the external opening on perianal skin. Develops in ~50% after anorectal abscess.

Park's Classification

Goodsall's Rule

Used to predict the internal opening location from the external opening:

• External opening posterior to transverse anal line → curved tract → internal opening at posterior midline
• External opening anterior to transverse anal line → direct radial tract → internal opening at nearest crypt
• Exception: anterior external opening >3 cm from anal margin — may curve posteriorly (horseshoe fistula)

Fistula Surgery

Primary goal: continence preservation — dividing too much sphincter muscle causes incontinence.

Pruritus Ani

Exclude Secondary Causes First

• Parasites: threadworm (Enterobius vermicularis) — common; nocturnal itching; tape test diagnosis
• Fungal: Candida — in immunocompromised, diabetics, post-antibiotic
• Skin conditions: psoriasis, lichen sclerosus, contact dermatitis (wet wipes, soaps)
• Anorectal pathology: haemorrhoids, fistula, incontinence
• Systemic: diabetes, jaundice

Management

• Hygiene — gentle cleansing; pat dry; cotton underwear; avoid wet wipes with fragrance
• Barrier cream (zinc oxide) after cleansing
• Short course topical mild steroid (1% hydrocortisone) if dermatitis — <7 days
• Treat specific cause (mebendazole for worms; clotrimazole for Candida)

Pilonidal Sinus Disease

A hair-containing cyst, sinus, or abscess in the natal cleft (intergluteal fold). Hairs invade the subcutaneous tissue through suction forces created by gluteal movement.

Risk Factors

• Young males aged 15–35 (3:1 male:female)
• Sedentary occupation — drivers, office workers
• Coarse, dark body hair — increased in certain ethnicities
• Obesity — deep natal cleft
• Poor hygiene or excessive sweating

Presentations

• Asymptomatic sinus — pit(s) in natal cleft
• Pilonidal abscess — acute; painful, fluctuant, tender swelling off-midline
• Chronic pilonidal disease — recurrent discharge, sinus tracts

Pilonidal Management

Acute Abscess

• I&D under LA or GA — off-midline incision for drainage
• Do not lay open or excise primarily in acute setting
• Wound heals by secondary intention

Chronic Disease — Elective Surgery

• Wide excision and laying open — simple; high recurrence
• Karydakis flap / Bascom procedure — off-midline flap repair; lower recurrence (<5%); preferred
• Rhomboid flap (Limberg) — for complex/recurrent disease

Nursing Care — Wound Management

• Daily wound packing — ribbon gauze or cavity foam; prevents bridging
• Measure wound cavity at each visit (depth, width) — photograph progress
• Sitz baths / showering to clean wound
• Hair removal around wound — shave 2–3 cm margin weekly while healing; reduces recurrence
• Advise permanent hair removal (laser) post-healing to prevent recurrence
• Patient education: weight loss if obese; avoid prolonged sitting; hygiene

Rectal Prolapse

Classification

• Full-thickness (complete) prolapse — all layers of rectal wall protrude; circular mucosal folds
• Mucosal prolapse — only mucosa prolapses; radial folds; associated with Grade III–IV haemorrhoids
• Internal (occult) prolapse — intussusception within rectum; does not protrude

Risk Factors

• Elderly women — pelvic floor weakness, multiparity
• Chronic straining / constipation
• Neurological conditions (multiple sclerosis, spinal cord injury)
• Institutionalised elderly patients

Acute Prolapse — Manual Reduction

Rectal Prolapse — Surgical Repair

Biofeedback Therapy

For internal (occult) prolapse and pelvic floor dysfunction — specialist physiotherapy; improves coordination of defecation and pelvic floor muscles.

Anal Cancer

SCC — Squamous Cell Carcinoma HPV-associated (HPV 16, 18); risk increased in MSM, immunocompromised, receptive anal intercourse, cervical cancer history.

Treatment

• Nigro protocol (chemoradiotherapy) — definitive treatment; mitomycin C + 5-fluorouracil (5-FU) + concurrent radiotherapy
• Surgery (APR) reserved for residual/recurrent disease only
• Colostomy may be needed temporarily during treatment

Nursing: Rectal Mucositis Care

• Assess bowel frequency, consistency, blood/mucus
• Antidiarrhoeal agents (loperamide) — titrate to symptoms
• Perianal skin care — barrier cream, gentle cleansing; AQUACEL/silicone dressings for radiation dermatitis
• Pain management — topical anaesthetics, oral analgesia
• Nutritional support — dietitian referral; ensure adequate intake during treatment
• Psychosocial support — sexual health, stoma counselling if applicable

GCC Clinical Context

Haemorrhoids in the Gulf

• Very common in GCC — driven by low fibre diet (white rice, refined carbohydrates), dehydration in hot climate, and sedentary lifestyle
• Constipation endemic in Gulf populations — particularly in women and elderly
• Squat vs seated toilet — traditional squat position (180° anorectal angle) facilitates defecation; Western toilet requires more straining; important patient education point
• Pilonidal sinus particularly common in young Arab males — higher body hair density, sedentary study/work culture, and prolonged driving

Ramadan-Specific Considerations

Cultural & Systemic Factors

Cultural Reluctance

• Shame and embarrassment are significant barriers to seeking colorectal healthcare in GCC populations
• Patients often present late with advanced disease (prolapsed Grade IV, complex fistula)
• Nursing approach: maintain absolute privacy, use same-gender healthcare providers where possible, use patient-friendly Arabic terminology
• Normalise the condition: explain haemorrhoids affect approximately 50% of people over 50 worldwide
• Family-centred care model common in GCC — involve family in discharge education with patient consent

Diabetic Patients & Anorectal Infection

DHA / DOH / SCFHS Exam Prep

Key Exam Topics

Regulatory Framework & Competencies

DHA (Dubai Health Authority)

• Surgical nursing competencies include pre- and post-operative colorectal care
• Wound care certification required for complex wound management (pilonidal, fistula)
• Nurses must demonstrate competency in stoma and perianal wound care per DHA nursing standards

DOH (Department of Health — Abu Dhabi)

• Nursing scope of practice defines wound assessment and management competencies
• Colorectal nursing procedures under DOH Scope of Practice for RN/CN levels
• Referral pathways for 2WW colorectal cancer screening as per DOH oncology protocols

SCFHS (Saudi Commission for Health Specialties)

• Surgical nursing exam includes haemorrhoid grading, post-op colorectal care
• Perianal wound care and abscess management post-I&D within nursing scope
• SCFHS Surgical Nursing specialty: anorectal topics appear in both written and OSCE stations

Infection Control

• Standard precautions for all perianal wound care — gloves, apron, eye protection for irrigation
• MRSA screening per hospital policy pre-elective anorectal surgery
• Surgical site infection bundle compliance — skin prep, antibiotic prophylaxis timing