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Examination of Piles (Haemorrhoids)

Definition & Background

• Internal piles arise from the internal haemorrhoidal plexus above the dentate line (covered by mucosa, insensate)
• External piles / skin tags arise from the external plexus below the dentate line (covered by skin, sensitive to pain)
• Primary internal piles are classically found at the 3, 7, and 11 o'clock positions with the patient in the lithotomy position, corresponding to the main branches of the superior haemorrhoidal vein (left lateral, right anterior, right posterior)
• Secondary piles (4-5) may develop between the primary positions

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Golden Rule of Examination Order

"The anal region must be INSPECTED firstly, PALPATED secondly, and DIGITAL EXAMINATION lastly."

• S Das, Manual on Clinical Surgery

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I. Positions for Examination

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II. Inspection

• Anal tags (external piles) - soft, skin-covered tags at the anal verge; can appear anywhere around the anus
• Sentinel pile - a specific, thickened skin tag at the lower end of a fissure-in-ano; almost always located on the midline posteriorly
• Prolapsed internal piles - pinkish-red vascular cushions protruding at the anus (seen in 3rd/4th degree)
• Fistula-in-ano - note the external orifice, its distance from the anus, and whether anterior or posterior (apply Goodsall's rule for determining internal opening position)
• Fissure-in-ano - a linear ulcer in the anal canal, mostly midline posteriorly; the lower end may be seen when anal margins are gently separated (causes extreme pain)
• Pilonidal sinus, condyloma, carcinoma - excluded on inspection

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III. Digital Rectal Examination (DRE)

Key Point

Uncomplicated internal piles CANNOT be felt with the finger - they are diagnosed by proctoscopy. Only chronically inflamed and thrombosed piles are palpable on DRE.

Technique

• Lubricate the examining (right index) finger well
• Place the pulp of the finger at the anus and press gently - allow the sphincter to relax before advancing
• Insert first toward the patient's umbilicus (direction of the anal canal), then curve posteriorly
• The examining finger can explore approximately 10 cm from the anus

What to Assess

• Tone of the sphincter (assess internal and external sphincters)
• Tenderness - severe pain suggests fissure-in-ano (may need to defer examination)
• A circular groove just inside the anus marks the intersphincteric groove (boundary between external and internal haemorrhoidal plexuses)
• The ano-rectal ring is felt approximately 3 cm above the anal verge, best felt posteriorly (puborectalis component of levator ani)

• Hard faeces (may need to give enema first for proper examination)
• Any prolapsed mass - if felt, ask patient to strain down to bring it lower

• Smooth mucosa = normal; loss of smoothness suggests ulceration
• The valve of Houston (soft mucosal fold) may be felt
• Note any thickening, induration, or mass

• Assess pelvic viscera (uterus, prostate, seminal vesicles, rectovesical/recto-uterine pouch)

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IV. Proctoscopy - The Key Investigation for Piles

Technique

1. Patient in left lateral or knee-elbow position
2. A warm, well-lubricated proctoscope (with obturator in) is gently inserted, first directed upward and forward toward the patient's umbilicus - this follows the axis of the anal canal
3. Once the anal canal is passed, the instrument is directed posteriorly to enter the rectum
4. The obturator is withdrawn and the interior is visualized under light
5. Piles prolapse into the lumen of the proctoscope as the instrument is slowly withdrawn - this is when they are best visualized
6. Note the position, size, and degree of the piles
7. Fissures, ulcers, polyps, growths, and the internal opening of a fistula can also be seen
8. Biopsy can be taken through the proctoscope if needed

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V. Sigmoidoscopy

• A 35 cm instrument that examines the whole rectum and a large part of the sigmoid colon
• Position: knee-elbow or left lateral
• Introduced along the axis of the anal canal; once the tip enters the rectum, all further passage is under direct vision (the obturator is removed)
• Important to exclude rectal carcinoma and inflammatory bowel disease in patients presenting with presumed haemorrhoidal bleeding

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VI. Grading of Internal Haemorrhoids (Four Degrees)

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VII. Additional Investigations

• Barium enema X-ray / colonoscopy: Mandatory in all cases of internal haemorrhoids to exclude carcinoma above the rectum as the true cause of bleeding
• Sigmoidoscopy / colonoscopy: If barium enema is negative but symptoms persist; to confirm positive findings; to take biopsy
• CT scan / ultrasound: Only in suspected rectal carcinoma - to detect lymph node enlargement and visceral spread

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VIII. Differential Diagnosis on Examination

• Rectal prolapse (procidentia) - full-thickness protrusion with concentric mucosal rings
• Anal fissure - sentinel pile at the lower end; extreme pain on examination; linear ulcer in anal canal
• Rectal polyp - single soft pedunculated mass
• Carcinoma of the rectum - hard, irregular, ulcerated mass on DRE; does not prolapse into proctoscope
• Fistula-in-ano - track palpable; external opening visible on inspection

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IX. Complications Visible on Examination

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History Taking for a Patient Undergoing Hysterectomy

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1. Presenting Complaint and History of Present Illness

• Site - uterus, pelvis, lower abdomen
• Onset - when did it start, sudden or gradual
• Character - nature of pain/bleeding
• Radiation - does pain radiate to back, thighs, rectum
• Associated symptoms - see below
• Timing - relation to menstrual cycle, constant or intermittent
• Exacerbating/relieving factors - posture, intercourse, defecation
• Severity - impact on daily life, work, sleep

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2. Gynaecological History (Core Component)

A. Menstrual History (PALM-COEIN approach is helpful)

B. Pain History

• Location, character (crampy, constant, burning)
• Relation to menstrual cycle - cyclical (endometriosis, dysmenorrhoea) vs non-cyclical (fibroids, PID)
• Dyspareunia - superficial or deep; deep dyspareunia suggests endometriosis, PID, adenomyosis
• Chronic pelvic pain - duration; prior investigations; response to treatment

C. Vaginal Discharge

• Color, odor, consistency, associated itch or irritation
• Suggestive of infection (PID, cervicitis)

D. Urinary Symptoms

• Frequency, urgency, incontinence, dysuria
• Important because hysterectomy can affect bladder function (especially total/radical hysterectomy)
• Stress incontinence may be treated concurrently or may worsen post-operatively

E. Bowel Symptoms

• Constipation, dyschezia (pain on defecation - suggests posterior endometriosis/deep infiltrating endometriosis)
• Rectal bleeding - must be excluded as a separate pathology

F. Sexual History

• Dyspareunia (as above)
• Current sexual activity - relevant to post-operative counselling and choice of route (vaginal vs abdominal)
• Partner status - relevant for vaginal vault prolapse counselling

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3. Obstetric History

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4. Gynaecological Surgical and Medical History

• Previous abdominal/pelvic surgeries (adhesions, anatomical distortion)
• Previous hysteroscopy, D&C, laparoscopy
• Known uterine fibroids - size, number, symptoms, previous treatments
• Known endometriosis - extent, previous surgeries
• Known pelvic inflammatory disease (PID) - chronic PID increases adhesion risk
• Cervical screening history - last Pap smear result; any previous CIN treatment (LLETZ, cone biopsy)
• History of ovarian cysts or adnexal pathology
• Known malignancy (cervical, endometrial, ovarian) - determines extent of surgery (simple vs radical hysterectomy)

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5. Prior Medical and Surgical History (Pre-operative Assessment)

Medical History

Surgical History

• Any prior abdominal or pelvic surgery (laparotomy scars, adhesions)
• Complications of previous anaesthesia (awareness, difficult intubation, PONV, malignant hyperthermia in family)
• Previous DVT or PE (VTE prophylaxis planning)

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6. Drug and Allergy History

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7. Family History

• Ovarian, endometrial, or breast cancer (BRCA1/BRCA2 mutation - influences decision on concurrent oophorectomy)
• Colon cancer (Lynch syndrome - endometrial cancer risk)
• Bleeding or clotting disorders
• Anaesthetic complications (malignant hyperthermia - autosomal dominant)

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8. Social History

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9. Review of Systems (Relevant to Surgery)

• Exercise tolerance - functional capacity (METs); can she climb 4 flights of stairs without stopping? (relevant to cardiac risk)
• Anaemia symptoms - fatigue, breathlessness, palpitations (common with menorrhagia)
• DVT/PE symptoms - current leg swelling, chest pain
• Nutritional status - weight loss, poor appetite (malignancy workup)
• Urinary incontinence - may be addressed concurrently

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10. Specific Considerations by Indication

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11. Counselling Points to Address During History

• Fertility - Has the patient completed her family? Does she understand that hysterectomy is irreversible?
• Menopause - If bilateral salpingo-oophorectomy is planned concurrently, explain surgical menopause (hot flushes, bone density loss, cardiovascular risk, need for HRT if premenopausal)
• Route of surgery - Abdominal (TAH), vaginal (VH), or laparoscopic (TLH/LAVH) - discuss preferences and expectations for recovery
• Expected outcomes - symptom relief, risks (bleeding, infection, bladder/ureter/bowel injury, VTE, vault prolapse)

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