Ever since the NICE report of July 2013 (NICE CG 168) we have known that one of the optimal ways to treat leg varicose veins is endovenous laser treatment (EVLT). However many of my patients ask if haemorrhoids (or "piles") can be treated in the same way. There are certainly some doctors who do so and some companies that make equipment for this procedure - but is it the right way to treat them or is it just a fad because "lasers are sexy"?
To answer this we need to know firstly if piles or haemorrhoids have any link to leg varicose veins and secondly what would be the optimal way to treat them.
Looking at the first of these questions, ever since I set up my first website on veins in 1999 (www.veins.co.uk) I have had a regular stream of enquiries asking if haemorrhoids are the same as varicose veins. Back in 1999 we thought they were very different, being varicose veins in the anal canal and nothing to do with the legs.
However, over the last decade, our understanding of how leg varicose veins are linked with pelvic varicose veins has increased significantly (See my previous post, Varicose Vein Surgery Fails One In Five Women), and we have discovered that vulval and vaginal varicose veins in women are just examples of how leg and pelvic varicose veins are linked as one condition (www.vulval-varicose-veins.co.uk).
Therefore it was only a progression of our studies that led us to our recent peer-reviewed research publication showing that haemorrhoids were associated with pelvic varicose veins in women who we tested ("Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux"). This research showed that just as leg varicose veins have a long hidden truncal vein feeding blood into the visible bulging varicose veins, haemorrhoids have a hidden underlying vein called the internal iliac vein, letting blood "reflux" or fall back into the haemorrhoid and causing it to bulge.
Over the last 100 years or so, it has become evident that to treat leg varicose veins successfully, we need to treat the underlying hidden vein first. This stops the blood from refluxing into the bulging varicose veins and so when they are treated, there is no pressure of flow from the deeper hidden vein trying to make them come back again.
A far as haemorrhoids are concerned, the anatomy has many parallels and so the principles of treatment should be the same or similar.
However, as haemorrhoids are usually treated by bowel surgeons with little research or interest in venous surgery, traditionally haemorrhoids have just been chopped out - not only a very painful operation but also leading to recurrence in a large proportion of cases.
More recently doctors have been treating the artery taking blood into the haemorrhoid (the "haemorrhoidal artery") either ligating this or closing it with laser. However this is totally illogical, as it does not get to the underlying cause - the deeper hidden internal iliac vein that is allowing blood to reflux backwards with gravity and straining into the haemorrhoid.
As the internal iliac vein lies within the pelvis, passing a laser into this vein itself would result in the risk of burning sensitive structures such as bowl or ureter. Hence research is now focussing on the treatment of these veins using techniques that destroy this pelvic vein and the haemorrhoid itself without heat - such as foam sclerotherapy and coil embolisation of the vein under x-ray control.
Thus despite the love that both the public and the medical profession have for any treatment that includes a "laser", when it comes to the future treatment of haemorrhoids (or "piles") it is likely that other treatments that destroy the underlying feeding vein in the pelvis and that do not cause heat to be produced, will turn out to be optimal.