Piles (haemorrhoids) are swellings that develop inside and around the back passage (anus). Symptoms range from temporary and mild, to persistent and painful. In many cases, piles are small and symptoms settle down without treatment. If required, treatment is usually effective. There are various treatment options, detailed below.
What are piles (haemorrhoids)?
Piles (haemorrhoids) are swellings that can occur inside and around the back passage (anus) and the anal canal.
The anal canal is the last part of the large intestine and is about 4 cm long. At the lower end of the anal canal is the opening to the outside (usually referred to as the anus), through which faeces pass. At the upper end, the anal canal connects with the rectum (also part of the large intestine).
There is a network of small veins (blood vessels) within the lining of the anal canal. These veins sometimes become wider and engorged with more blood than usual. The engorged veins and the overlying tissue may then form into one or more small swellings called piles.
What are the different types of piles (haemorrhoids)?
Internal piles (haemorrhoids) are those that form above a point 2-3 cm inside the back passage (anus) in the upper part of the anal canal. Internal piles are usually painless because the upper anal canal has no pain nerve fibres. External piles are those that form below that point, in the lower part of the anal canal. External piles may be painful because the lower part of the anal canal has lots of pain nerve fibres.
The terminology can be a little confusing - you would have thought that external piles would mean outside of the anal canal (and so outside of the anus) but this is not always the case. There are external piles that are actually inside the anus. Internal piles can also enlarge and drop down (prolapse), so that they hang outside of the anus.
Some people develop internal and external piles at the same time.
Internal piles can be classified into grades 1 to 4 according to their severity and size:
- Grade 1 are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the anus. Grade 1 piles are common. In some people they enlarge further to grade 2 or more.
- Grade 2 are larger. They may be partly pushed out from the anus when you go to the toilet, but quickly spring back inside again.
- Grade 3 hang out from the anus when you go to the toilet. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.
- Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.
What causes piles (haemorrhoids)?
The exact reason why the changes in the veins within the lining of the anal canal occur and lead to piles (haemorrhoids) forming is not clear. Some piles seem to develop for no apparent reason. However, it is thought that an increased pressure in and around the back passage (anus) and anal canal can be a major factor in many cases.
About half the people in the UK develop one or more piles at some stage. Certain situations increase the chance of piles developing:
- Constipation, passing large stools (faeces), and straining at the toilet. These increase the pressure in and around the veins in the anus and seem to be a common reason for piles to develop.
- Pregnancy. Piles are common during pregnancy. This is probably due to pressure effects of the baby lying above the rectum and anus, and the affect that the change in hormones during pregnancy can have on the veins.
- Ageing. The tissues in the lining of the anus may become less supportive as we get older.
- Hereditary factors. Some people may inherit a weakness of the wall of the veins in the anal region.
What are the symptoms of piles (haemorrhoids)?
Symptoms can vary. Sometimes no symptoms may be present and a person may not realise that they have piles (haemorrhoids).
The most common symptom experienced is bleeding after going to the toilet to pass stools (faeces). The blood is usually bright red and may be noticed on the toilet tissue, in the toilet pan or coating the stools.
A haemorrhoid can hang down (prolapse) and can be felt outside the anus. Often, it can be pushed back up after you have been to the toilet. However, more severe piles remain permanently prolapsed and cannot be pushed back up inside.
Small internal piles are usually painless. Larger piles may cause a mucous discharge, some pain, irritation, and itch. The discharge may irritate the skin around the back passage (anus). You may have a sense of fullness in the anus, or a feeling of not fully emptying your back passage when you go to the toilet.
A possible complication of piles that hang down is that they can 'strangulate' (the blood supply to the haemorrhoid can be cut off). This can be intensely painful. Another possible complication is a blood clot (thrombosis) which can form within the haemorrhoid. This is uncommon, but again causes intense pain if it occurs. The pain usually peaks after 48-72 hours, and then gradually goes away over 7-10 days.
How are piles (haemorrhoids) diagnosed?
If you think that you may have piles (haemorrhoids), or have bleeding or pain from your back passage (anus), you should visit your doctor.
Piles are usually diagnosed after your doctor asks you questions about your symptoms and performs a physical examination. The examination usually includes an examination of your back passage. Wearing gloves and using a lubricant, your doctor will examine your back passage with their finger to look for any signs of piles or other abnormalities.
Sometimes, if your piles are not obvious after an examination of your back passage, your doctor may suggest a further examination called a proctoscopy. This is where the inside of your back passage is examined using an instrument called a proctoscope. A proctoscope is a short, hollow tube that has a light at one end and allows the doctor to see the lining of your back passage, and any piles, more clearly.
In some cases, a more detailed examination of your bowel may be needed to help rule out other conditions. Your doctor may refer you to a specialist for this.
What is the treatment for piles (haemorrhoids)?
Avoid constipation and straining at the toilet
Keep the stools (faeces) soft, and don't strain on the toilet. You can do this by the following:
- Eat plenty of fibre such as fruit, vegetables, cereals, wholegrain bread, etc.
- Have lots to drink. Adults should aim to drink at least two litres (6-8 glasses) per day. You will pass much of the fluid as urine, but some is passed out in the gut and softens faeces. Most sorts of drink will do, but alcoholic drinks can cause the body to lose fluids (they are dehydrating) and may not be so good. Too much caffeine should also be avoided.
- Fibre supplements. If a high-fibre diet is not helping, you can take fibre supplements (bulking agents) such as ispaghula, methylcellulose, bran or sterculia. You can buy these at pharmacies or get them on prescription. Methylcellulose also helps to soften faeces directly which makes them easier to pass.
- Avoid painkillers that contain codeine such as co-codamol, as they are a common cause of constipation. However, simple painkillers such as paracetamol may help.
- Toileting. Go to the toilet as soon as possible after feeling the need. Some people suppress this feeling and plan to go to the toilet later. This may result in bigger and harder faeces forming which are then more difficult to pass. Do not strain on the toilet. Piles may cause a feeling of fullness in the rectum and it is tempting to strain at the end to try to empty the rectum further. Resist this. Do not spend too long on the toilet, which may encourage you to strain. (For example, do not read whilst on the toilet.)
The above measures will often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small and non-prolapsing piles (grade 1). Small grade 1 piles often settle down over time. There are separate leaflets called Constipation in Adults, Constipation in Children and Fibre and Fibre Supplements that provide more details about fibre and constipation.
Ointments, creams and suppositories
Various preparations and brands are commonly used. They do not cure piles. However, they may ease symptoms such as discomfort and itch.
- A bland soothing cream, ointment, or suppository may ease discomfort. Several brands are available without a prescription. Ask a pharmacist to advise. Follow the instructions on the packet on how to use.
- One that contains an anaesthetic may ease pain better. You should only use one of these for short periods at a time (5-7 days). If you use it for longer, the anaesthetic may irritate or sensitise the skin around the back passage (anus). A pharmacist can advise.
- Preparations for piles containing a corticosteroid may be advised by a doctor if there is a lot of inflammation around the piles. Steroids reduce inflammation and may help to reduce any swelling around a haemorrhoid. This may help to ease itch and pain. You should not normally use a steroid cream or ointment for longer than one week at a time.
- Piles of pregnancy usually settle after the birth of the child. Treatment is similar to the above. Ask your doctor for advice.
Banding is a common treatment for grade 2 and 3 piles. It may also be done to treat grade 1 piles which have not settled with the measures described above (such as an increase in fibre, etc).
This procedure is usually done by a surgeon in an outpatient clinic. A haemorrhoid is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid which then dies and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.
Banding of internal piles is usually painless, as the base of the haemorrhoid originates above the anal opening in the very last part of the gut where the gut lining is not sensitive to pain. Up to three piles may be treated at one time using this method.
In about 8 in 10 cases, the piles are cured by this technique. In about 2 in 10 cases, the piles come back (recur) at some stage. (However, you can have a further banding treatment if this occurs.) Banding does not work in a small number of cases. Piles are less likely to recur after banding if you do not become constipated and do not strain on the toilet (as described above).
A small number of people have complications following banding, such as bleeding, urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid.
Other treatment options
Banding (described above) is perhaps the most common procedure done to treat piles. However, a variety of other surgical procedures are sometimes used. Some surgeons prefer one procedure over another. Your surgeon will advise of the pros and cons of the different procedures. Although each procedure is usually successful, as with any surgical procedure, there is some risk that complications or problems may occur during, or following, the procedure.
The more commonly done procedures include the following:
Injection sclerotherapy - phenol in oil is injected into the tissues at the base of the piles. This causes a scarring (fibrotic) reaction which obliterates the blood vessels going to the piles. The piles then die and drop off, similar to after banding.
Infrared coagulation/photocoagulation - this method uses infrared energy to burn and cut off the circulation to the haemorrhoid, which causes it to shrink in size. It seems to be as effective as banding treatment and injection sclerotherapy for first- and second-degree piles.
Diathermy and electrotherapy - use heat energy to destroy the piles. They appear to have similar success rates as infrared coagulation and the risk of any complications is low.
Haemorrhoidectomy (the traditional operation) - an operation to cut away the haemorrhoid(s) is an option to treat grade 3 or 4 piles or for piles not successfully treated by banding or other methods. The operation is done under general anaesthetic and is usually successful. However, it can be quite painful in the days following the operation.
Stapled haemorrhoidopexy - a circular stapling gun is used to cut out a circular section of the lining of the anal canal above the piles. This has the effect of pulling the piles back up the anal canal. It also has the effect of reducing the blood supply to the piles and so they shrink as a consequence. Because the cutting is actually above the piles, it is usually a less painful procedure than the traditional operation to remove the piles.
Haemorrhoidal artery ligation - the small arteries that supply blood to the piles are tied (ligated). This causes the haemorrhoid(s) to shrink.
Strangulated or thrombosed piles
Very painful strangulated or thrombosed piles are uncommon. The pain may be eased by an ice pack (wrapped in a cloth) pressed on for 15-30 minutes. Strong painkillers and medication to soften the stools may also be needed. Surgery (rarely) is needed to remove the haemorrhoid.
Dr Tim Kenny
Dr Michelle Wright
Dr John Cox