Piles

What are piles?

Piles (haemorrhoids) are swollen veins that can cause lumps inside and around your bottom (anus). They are very common. People often feel embarrassed about going to the doctor with problems affecting that part of the body, but they are nothing to be embarrassed about.

They often get better on their own but may need treatment to remove them.

Why do piles happen?

Piles happen when the small veins in the lining of the anus become swollen or irritated.

These blood vessels can enlarge and fill with more blood than usual, causing the surrounding tissue to stretch. When this happens, one or more soft lumps (piles) can form inside or around the anus.

What do piles look like?

Most piles form inside the anus or rectum (known as internal piles) and don’t protrude, so you may not be able to see them.

Larger internal piles may hang down out of your bottom, where they look like a discoloured rubbery lump.

Some piles can develop on the edge of the opening of your bottom (known as external piles) and will look like a soft lump.

Piles (haemorrhoids)

Piles grading

Piles are graded based on their size and position.

• 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.

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 2-3 cm inside the bottom in the upper part of the anal canal or lower rectum (the last part of the large bowel that connects to the anal canal).

Internal haemorrhoids can become bigger and drop down (prolapse), so that they hang outside of the bottom.

External piles

External piles start off nearer the surface, below a point 2-3 cm inside the bottom. However, external piles aren't always seen outside of the opening of the bottom.

Some external piles can strangulate (called thrombosed piles), meaning they develop a blood clot within them, causing pain, swelling, and sometimes bleeding.

How to know if you have piles

Piles symptoms

Common symptoms of piles include:

• Bleeding after pooing (the blood is usually bright red and often on the paper after wiping, rather than mixed in with the poo.

• An itchy bottom.

• Feeling like you still need to poo, even after pooing.

• Pain around your bottom.

• Lumps around your bottom that may hang down.

• Mucus coming from your bottom.

Sometimes there are no symptoms and you may not realise that you have any piles.

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 mucus discharge, which may irritate the skin around the bottom.

What causes piles?

Piles are caused by the veins in your bottom swelling. There are certain situations that increase the chance of veins swelling and piles developing.

These include:

• Constipation. Passing hard 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.

Do piles go away on their own?

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

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. Most piles clear up on their own within days, however, larger piles can take longer to heal and may require medical treatment.

How to treat piles

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

Medicines

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.

Non-surgical treatment

All of these treatments are done after a referral to hospital - they can't be done at the GP surgery.

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.

• 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.

This technique has an 80% success rate.

Piles are less likely to come back after banding if you avoid straining on the toilet and becoming constipated.

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.

Surgical treatment

Haemorrhoidectomy

A haemorrhoidectomy is a surgical procedure to cut away the haemorrhoid(s). It is mainly used 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 and usually needs a couple of weeks off work, sometimes more if your job is very active.

Stapled haemorrhoidopexy

A circular stapling gun is used to cut out a circular section of the lining of the bottom 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.

When to see a doctor for 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 do some tests, or refer you to a specialist.

How do doctors check for piles?

Piles are usually diagnosed by a doctor asking about your symptoms and doing a physical check. This often includes:

At the GP surgery:

• Examining your bottom using a gloved, lubricated finger, to feel inside to check for piles or anything unusual.

In a hospital clinic:

• Sometimes using a small tube called a proctoscope to look further inside.

• Sometimes having a colonoscopy to rule out other bowel problems.

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.

Frequently asked questions

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 piles 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.

Do piles smell?

In themselves, piles don't smell. However they can make it harder to wipe yourself after going to the toilet and if there is any poo left behind, that might smell.

What should I avoid if I have piles?

It is really important to avoid being constipated, by making the changes to your diet already discussed, as well as taking laxatives if needed. Losing weight if you are overweight will also help.