Piles

What are piles?

Piles (haemorrhoids) are swollen veins that can cause lumps inside and around your bottom.

They may not cause any symptoms or may cause symptoms such as pain, itching and bleeding during bowel movements. There may be small amounts of bright red blood on your toilet tissue or in the toilet after a bowel movement.

Piles often get better on their own but may need treatment to remove them such as rubber band ligation or surgery.

How do you get piles?

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 swollen veins and the overlying tissue may then form into one or more swellings (piles).

Do piles go away on their own?

Piles often get better on their own but may need treatment to remove them such as rubber band ligation or surgery.

Types of piles

Piles can be divided into either internal or external piles. Some people develop internal and external piles at the same time.

Internal piles

Internal piles are deeper and initially form above a point 2-3 cm inside the bottom (anal canal) in the upper part of the anal canal or lower rectum (the last part of the large bowel that connects to the anal canal).

External piles

External piles start off nearer the surface, below a point 2-3 cm inside the bottom.

Despite the name, external piles aren't always seen outside of the opening of the bottom. Equally confusing, internal haemorrhoids can enlarge and drop down (prolapse), so that they hang outside of the bottom.

Whether internal or external, haemorrhoids often don't cause any problems but can cause bleeding and sometimes pain. If they do cause any bleeding or pain then you should seek medical advice.

Thrombosed piles (strangulated)

Strangulated or thrombosed haemorrhoids are uncommon but usually very painful. They are piles that have developed a blood clot within them, causing pain, swelling, and sometimes bleeding. They are most common in external piles.

You may need to be referred for assessment in hospital. Treatments usually include bed rest, medication for pain relief, hot baths, ice packs and keeping your poo soft. Surgery may be needed to remove the haemorrhoid.

Piles symptoms

The most common symptom of piles is bleeding after going to the toilet to poo. The blood is usually bright red and may be noticed on the toilet paper, in the toilet pan or coating the poo. Sometimes there are no symptoms and you may not realise that you have any piles.

What do piles look like?

Piles can look different depending on whether they are internal or external, and what grade they are. You often won't see anything if you have piles and look at the area round your bottom. This is because most piles are inside your bottom and rectum and don't protrude from your bottom.

Larger internal piles may hang down out of your bottom, where they look like a discoloured rubbery lump. An external pile will look like a soft lump on the edge of the opening of your bottom.

Piles (haemorrhoids)

Piles grading

Piles symptoms can vary depending on the size, position and grade of the piles.

• Grade 1 piles are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the opening of the bottom. Grade 1 piles are common. In some people they enlarge further to grade 2 or more.

• Grade 2 piles are larger. They may be partly pushed out from the bottom when you go to the toilet, but quickly go back inside again when you stop straining.

• Grade 3 piles hang out from the bottom (prolapse) when you go to the toilet. You may feel one or more as small, soft lumps that hang from the bottom. However, you can push them back inside the bottom with a finger.

• Grade 4 piles permanently hang down from within the bottom (prolapse), and you cannot push them back inside. They sometimes become quite large.

What do piles feel like?

Small internal piles are usually painless, because there are no pain-sensitive nerve fibres where they are located. External piles, however, can be itchy or painful. Larger piles may cause a mucous discharge, which may irritate the skin around the bottom.

You may have a sense of fullness in the bottom, or a feeling of not fully emptying when you go to the toilet.

What causes piles?

The lining of the anal canal contains many blood vessels (veins). Changes in the veins within the lining of the canal can cause the pile(s) to develop. The lining and the veins become much larger and this can then cause a swelling and develop into a pile.

There are certain situations that increase the chance of piles developing. These include:

• Constipation. Passing large poos, and straining on the toilet. These increase the pressure in and around the veins in the bottom and seem to be a common reason for piles to develop.

• A low-fibre diet.

• Being overweight. This increases your risk of developing piles.

• Pregnancy. Pelvic pressure from weight gain during pregnancy.

• Ageing. The tissues in the lining of the bottom may become less supportive as we become older.

• Hereditary factors. Some people may inherit a weakness of the wall of the veins in the anal region.

• Other possible causes of piles include heavy lifting or a persistent (chronic) cough.

Piles treatment

Piles are treated based on their type and severity. Treatment ranges from simple home remedies to surgery for severe cases.

Creams and suppositories

• A bland soothing cream, ointment, or suppository may ease discomfort.

• 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).

• Preparations which contain a corticosteroid for treating piles may be advised by a healthcare professional if there is a lot of inflammation around the piles. 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.

• Most haemorrhoid preparations should be used in the morning, at night, and after a bowel movement.

Banding treatment (rubber band ligation)

Banding is the most commonly used piles treatment, especially for grade 2 and 3 piles. It may also be done to treat grade 1 piles which have not settled with the simple advice and treatment outlined above.

• This surgical procedure is usually done in an outpatient clinic.

• A rubber or elastic band is placed around 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 from a place in the gut lining that is not sensitive to pain.

In about 8 in 10 cases, the piles are cured by this technique. In about 2 in 10 cases, the piles come back at some stage. (However, you can have a further banding treatment if this occurs.) Piles are less likely to come back after banding if you avoid straining on the toilet and becoming constipated (as described above).

A small number of people have complications following banding, such as bleeding, infection or ulcers forming at the site of a treated haemorrhoid, or urinary problems.

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 of piles treatment uses infrared light to burn and cut off the circulation to the haemorrhoid, which causes it to shrink in size. It may be as effective as banding treatment and injection sclerotherapy for first- and second-degree piles.

Diathermy and electrotherapy

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

A surgical procedure 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 bottom (anal canal) above the piles. This has the effect of pulling the piles back up the bottom.

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.

Do I need to see a doctor about piles?

Although piles can often be treated at home, it’s best to see a doctor if you are experiencing any pain or rectal bleeding:

• Pain may indicate that there is a complication caused by the piles.

• Pain or rectal bleeding can be a sign of other more serious conditions such as inflammatory bowel disease or bowel cancer.

If your doctor is concerned about whether there may be a diagnosis other than piles, or if the piles may need specialist treatment, then your doctor may refer you to a specialist.

How are piles diagnosed?

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 bottom. Wearing gloves and using a lubricant, your doctor will examine your bottom with their finger to look for any signs of piles or other abnormalities.

Your doctor may suggest a further examination called a proctoscopy. In this procedure, the inside of your bottom is examined using an instrument called a proctoscope. You may be referred to a specialist for more detailed bowel examination (colonoscopy) to help rule out other conditions.

How to prevent piles

You can help prevent piles by avoiding constipation and straining when pooing. Keep the poo soft, and don't strain on the toilet. You can do this by:

• Eating plenty of fibre (for example, fruit and vegetables, cereals, and wholegrain bread).

• Having lots to drink. Ideally water, although most sorts of drink will do. Avoid too much alcohol, caffeine, and sugary drinks.

• Taking fibre supplements. If a high-fibre diet is not helping to prevent constipation, you can take fibre supplements (bulking agents) such as ispaghula, methylcellulose, bran or sterculia.

• Avoiding 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 (don't hold it in). Equally, do not strain on the toilet.

• Getting regular exercise. This helps to reduce constipation.

These measures will often ease symptoms of piles 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.

See the separate leaflets called Constipation, Constipation in children and Fibre and fibre supplements for more digestive health information.

Frequently asked questions

How long do piles last?

Piles can last for a few days to several weeks or months depending on what grade they are. Most piles clear up on their own within days, however, larger piles can take longer to heal and may require medical treatment.

Are piles dangerous?

Piles are rarely dangerous, but complications can occur. In some cases, the blood supply may be cut off (strangulation) or a clot can form (thrombosis), causing pain. Other complications include skin tags, irritation, infection, discharge, or narrowing of the bottom (stenosis).

Can you push piles back in?

Small grade 3 can sometimes be gently pushed back in, but larger or painful grade 4 piles should not be forced back in and should be treated by a doctor.

Can piles burst?

Piles can sometimes burst and bleed. Although this can be alarming, it usually settles on its own. You should see a doctor if bleeding is heavy or ongoing.