If you don’t want to increase your risk of getting piles, refrain from using your electronic gadget in the toilet.
You can be king of the throne, but make sure you don’t overstay your “visit”, because prolonged use of smartphones while on the toilet seat is a contributor to haemorrhoids, also known as piles.
This “Toilet Newspaper Syndrome” is described as long hours of sitting on the toilet seat because the individual is engrossed with reading materials.
“People have this habit of reading seated on the toilet and this should be avoided.
“Make sure there are no reading materials or gadgets in the toilet.
“Just go in, do your stuff and come out. Retrain your toilet habits to prevent haemorrhoids, ” says consultant general and colorectal surgeon Datuk Dr Meheshinder Singh.
Haemorrhoids are the displacement of cushions of blood vessels under the anal wall lining.
When the walls of these vessels are stretched, they become irritated, inflamed and start bulging.
Then the haemorrhoidal cushions, which are a natural part of the body’s anatomy that aids bowel movement, either swells inside (internal haemorrhoids) or outside (external haemorrhoids).
Internal haemorrhoids don’t cause any pain and usually don’t require treatment unless they start to bleed, while external haemorrhoids are painful and cause discomfort and bleeding.
Haemorrhoids can develop from increased pressure in the lower rectum due to excessive straining during bowel movements, sitting for long periods of time on the toilet, being sedentary, having chronic diarrhoea or constipation, obesity, pregnancy, having anal intercourse, eating a low-fibre or high-spice diet, regular heavy lifting, family history and ageing.
Although haemorrhoids can be unpleasant and painful, they can be easily treated in the early stages.
Unfortunately, the majority of patients are too embarrassed to consult a doctor.
Why so shy?
As with most healthcare issues in Malaysia, we often wait until we reach a dire situation before seeking medical intervention.
By then, extreme measures have to be taken to remedy the situation.
Dr Meheshinder says, “Patients delay treatment because they are embarrassed, as nobody likes showing their backsides; they also relate it to surgery or they fear incontinence.
“So they seek treatment elsewhere and are misdiagnosed, which is sad.
“They might have had the symptoms for years and when I examine them, they have stage 4 colorectal cancer.
“Piles don’t turn cancerous, but they may coexist with cancer, hence if you have bleeding, it is important to go for a rectal examination with a clinician to make sure you’re not missing out anything,
“Patients above 45 should perform a colonoscopy to rule out the risk of malignancy.
“I’m paranoid about this because a lot of times, I’ll catch a polyp or a tumour.”
The ageing process is also a risk factor as the ligaments in the area tend to disintegrate.
Thus, the mechanism that holds them in place weakens and prolapses, causing the patient to strain while defecating.
“Even if you have a little thread sitting in your anal canal, you will feel uneasy; that’s how sensitive the area is.
“With internal haemorrhoids, we can solve the problem in the clinic by using rubber band ligation, ” he says.
Rubber band ligation is a procedure in which the haemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the haemorrhoid.
The choice of procedure depends on the symptoms and severity of the problem, but usually, a conservative approach is taken, i.e. dietary changes, drinking adequate water, eating fibre, etc.
If all these have been addressed and no improvement is seen, then drugs are prescribed.
“If things still don’t work, then we advocate something more invasive, such as surgical modalities.
“There are so many techniques out there to address the issue of pain, but despite the procedures, the incidences of recurrence are still there if no lifestyle modifications are made.
“If it is not bothering you, there is no need for surgery.
“When you overdo things, that’s when you run into problems, ” points out Dr Meheshinder.
He was speaking at the Don’t Sit On It Lah roundtable session organised by French-based pharmaceutical company Servier Malaysia recently.
Also at the session was consultant general and vascular surgeon Datuk Dr Ho Teik Kok, who adds, “Most of the time, patients suffer from constipation, and when they strain, the pressure is transmitted downwards to the legs and veins, and can lead to chronic venous disease (CVD).”
Pressure on the veins
Those with occupations involving a lot of standing, such as hawkers, teachers, chefs, factory workers, those in the food and beverage, and retail service, cabin crew, nurses and those who wear heels for long durations, are at risk of developing CVD.
Pregnant women are the subset of patients at risk of developing both haemorrhoids and CVD.
According to the 2019 Chorus (Chronic Venous And Haemorrhoidal Diseases Evaluation And Scientific Research) Study published in the Wiley Online Library, more than 50% of patients seeking help for piles also have CVD.
“Most patients are unaware of CVD (they only know of varicose veins) and how it can progress to more severe stages leading to leg ulcers.
“They often present at very late stages, ” says Dr Ho.
In both haemorrhoids and CVD, there is increased pressure in the veins that could be caused by various factors, such as damage to the valves – these send blood back to the heart in one direction and prevent backward flow.
He explains: “When the veins get distended due to prolonged standing etc, it leads to reflux where blood is not able to go back to the heart.
“The blood then pools back to the leg and increases pressure, leaving more white cells in the blood.
“This damages the valves and causes the white cells to go out through the skin. That’s when the skin starts to darken.
“Initially, just the veins are visible (spider veins, varicose veins).
"There may also be pain or cramps in the leg, especially in the evening. This gets better in the morning as the fluids are drained while sleeping.
“When it gets worse, patients start getting venous eczema, itchiness and skin ulcers.
“A minor knock can cause bleeding because of the high pressure in the veins.”
Treatment for CVD also depends on its stage.
Oral drugs are effective in relieving pain and swelling.
Factors to work on include losing weight, not wearing tight clothing, especially in the tummy/thigh areas, wearing proper shoes (avoid high heels) and wearing compression stockings.
Dr Ho says, “If it’s more serious, when there are ulcers, patients need surgical intervention or injections.”
No urge to poo
Three years ago, freelance writer Yvonne Lee Shu Yee, 47, embarked on a guided tour to Japan, and for seven days, she didn’t poo!
She had always suffered from constipation due to prolonged sitting to teach music, but never sought medical advice, preferring to get solutions from the pharmacy.
“I always read in the toilet whenever I tried to pass motion. It was a struggle so I would always strain and bleed.
“I was ‘successful’ once every four or five days, ” she recalls.
But in Japan, Lee just didn’t have the urge, despite feasting on all sorts of Japanese delights.
“On the return flight, I wanted to poo, but I couldn’t, so when I arrived home, I bombed seven days worth of sushi!
“From all that straining and bleeding, I nearly collapsed and my husband rushed me to the clinic.”
She eventually saw a surgeon and was diagnosed with Grade 4 haemorrhoids. Surgery was the only option.
Today, Lee has learnt her lesson and has made numerous lifestyle modifications.
One thing for sure is no more reading in the toilet!
On how often one should have a bowel movement, Dr Meheshinder says, “If your pattern has been like that, e.g. five days once all the time, I wouldn’t worry about it, but if the pattern changes, then seek advice.”
Adds pharmacist Datin Mariani Ahmad Nizaruddin, “A lot of clients don’t really present all their symptoms to us. They don’t tell until we ask.
“They prefer anything topical instead of drugs. Often, they like to use enemas, which can complicate matters.
“Pharmacists are trained to understand the patient’s complaint and medical history before providing the right advice or encouraging them to see a doctor.
“It would be ideal to have a system sharing these medical information between patients, pharmacists and doctors, ” she says.
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