Piles

Piles form when pressure builds in the small blood vessels in your rectum or anus so that the tissue around them enlarges and forms a lump.

Piles are very common and anyone can get them. Some piles are small, internal and cause no symptoms. However, sometimes you can have symptoms such as itching, sore skin, constipation, bleeding, pain, anal discharge or a lump you can feel on the outside of your anus. On rare occasions, chronic (long-term) blood loss from haemorrhoids may cause anaemia.

Piles often get better on their own in a few days or with over-the-counter treatments such as haemorrhoid cream. Easing constipation can help too, as straining on the toilet to pass stools (faeces) can make piles worse.

If these piles treatments don’t work, there are several types of surgery that have a high success rate in removing piles.

Your anus has a band of muscle (anal sphincter) that help keep your stools in. As an additional layer of protection to prevent loose stools from leaking out, your anus also has three anal cushions — spongy tissue with blood vessels. 

When these cushions become inflamed, you can develop piles. Piles usually appear as small, round, discoloured lumps, which you may be able to feel in or protruding out of your anus. 

Types of piles

Internal piles, also known as internal haemorrhoids, occur in the upper two-thirds of your anal canal but can protrude out of your anus (prolapse). They are graded according to their severity: 

• First-degree internal piles — these may bleed but do not protrude out of your anus
• Second-degree internal piles — these protrude out of your anus when you pass stools but afterwards, go back inside your anus on their own
• Third-degree internal piles — these protrude out of your anus when you pass stools and do not go back inside your anus on their own; you need to push them back inside yourself
• Fourth-degree internal piles — these always protrude from your anus and you can't push them back inside; if a fourth-degree pile develops a blood clot (thrombosed haemorrhoid) it can become very swollen and painful 

External piles, also known as external haemorrhoids, occur in the lower third of your anal canal, closer to your anus. They can sometimes, but not always, be seen outside your anus. As with internal piles, if they develop blood clots, they can become very painful. 

You can develop internal and external piles simultaneously. 

The most common symptom of piles is anal bleeding ie bright red blood you can see after you have passed a stool.

Other piles symptoms are:

• Anal pain
• Bowel incontinence
• Jelly-like discharge after passing a stool — you may notice this on your underwear or the toilet paper after wiping your bottom
• Lump outside or hanging down from your anus
• Pain during or after passing a stool
• Sore or itchy anus, or redness or swelling around your anus

You may also feel as if you need to open your bowels again, despite just having done so. 

Symptoms vary greatly between people and many of these symptoms overlap with other conditions, such as ulcerative colitis, Crohn's disease, anal cancer, bowel cancer, anal fistulas and anal fissures (tears). You should therefore see your GP if you have any of these symptoms as you may not have piles but another condition that needs treatment. 

See your GP about any bleeding from your bottom. They will be able to confirm if it is piles and rule out other causes, such as an anal fissure or bowel polyps.

Your GP will usually be able to diagnose piles by asking about your symptoms and medical history and by examining your bottom. During your physical examination, your GP will gently place a gloved finger into your anus — they may apply some gel to make this more comfortable.

If you are having a lot of anal bleeding, they may recommend a blood test to check for anaemia ie a low red blood cell count or low levels of haemoglobin which carries oxygen in your red blood cells. 

They may refer you for a proctoscopy, an examination to check the inside of your rectum using a tool called a proctoscope.

If after speaking with you, examining you and checking your test results, your GP suspects you have a condition other than piles, they may refer you to a hospital for further tests. These tests can help rule out conditions such as bowel cancer. 

Around half of people in the UK will have piles at some point in their life. They are caused by increased pressure in and around your anus. Piles are therefore common during pregnancy as the growing baby increases the pressure in the abdomen. Piles that occur during pregnancy usually go away after giving birth. 

Piles are also more common as you get older ie if you’re aged 45 or over, and if you are overweight or obese. 

It is not always clear why pressure builds up in the blood vessels in your rectum and anus, causing piles. However, other risk factors for developing piles or making your piles worse include: 

• A bowel condition such as Crohn’s disease or ulcerative colitis
• A persistent cough
• Chronic constipation, often straining when passing stools and/or delaying opening your bowels when you have the urge
• Chronic diarrhoea or vomiting
• Lifting heavy objects
• Sitting down for long periods

Although piles can be stressful, there is no evidence that stress causes piles or makes them worse. There is also no evidence to support the myth that piles are more likely in women just around the time of their period.

Although piles are usually not serious, they can cause discomfort and embarrassment. They may also affect your sex life, particularly if they are protruding or have discharge. However, piles often go away on their own within a month. There are things you can do at home to ease your symptoms as well as a range of treatments to resolve your piles. 

Home remedies for piles

If your piles are small, home remedies may be enough to ease your symptoms until your piles shrink and go away. You can try: 

Over-the-counter medications 

Applying corticosteroid cream can reduce inflammation. However, do not use them for more than a week as over time they may damage the skin onto which they are applied. Stronger corticosteroid creams (eg anusol HC and proctosedyl) are available on prescription only. 

Applying a haemorrhoid cream that contains local anaesthetic can relieve itching and pain. However, only use a haemorrhoid cream in the short term as over time it can cause the skin on which it is applied to become sensitive. 

You can also take over-the-counter painkillers but avoid painkillers with codeine as these can cause constipation. Also, do not take ibuprofen if your piles are bleeding as taking ibuprofen too often over a short time can cause gastrointestinal bleeding. 

If you are constipated, you can take a laxative (eg ispaghula husk or lactulose) in the short term. Long-term use of laxatives is not recommended as they can cause other health problems.

Dietary changes

To avoid constipation, make sure you stay hydrated by drinking lots of fluids — avoid alcohol and caffeinated drinks (eg tea, coffee and cola). Also, follow a high-fibre diet. 

Exercise regularly

Regular exercise helps your bowel movements and therefore reduces your risk of constipation. However, certain exercises may be uncomfortable if you have piles, such as cycling. You can therefore use a cushioned seat pad if cycling or try a different form of exercise until your piles get better.

Practice good toilet habits

Do not delay the urge to open your bowels as this increases the risk of your stools drying out and becoming difficult to pass. Also, make sure you don't strain too much when passing stools and don't spend more time than needed sitting on the toilet. After opening your bowels, gently wipe your bottom with slightly damp toilet paper to avoid irritating your piles and keep your bottom clean and dry.

Other home remedies

To ease any discomfort, itching or pain, you can try having a warm bath or shower or placing an ice pack wrapped in a towel on your bottom. If your piles are protruding, you can gently push them back in with a clean finger — if they do not easily go back in, do not force them as this can cause more damage. 

Home remedies can take up to a month to work. If your symptoms persist after this time, see your GP again as they can refer you to a specialist for further treatment. 

Non-surgical treatments

For larger piles, your doctor may recommend a non-surgical treatment such as:

Banding 

This is the most common treatment for second-degree and third-degree piles but is also used for first-degree piles that have not responded to home remedies. General anaesthesia is not needed for banding but the area around your piles will be numbed. 

Your surgeon will hold your piles with forceps or a suction device. They will then place a tight rubber band at the base of your piles, which will cut off its blood supply. Your piles will shrivel up and fall off after a few days. 

Banding internal piles is usually painless. This is because the base of your piles starts in the upper two-thirds of your anal canal, which is less sensitive to pain. 

Diathermy and electrotherapy

No general anaesthesia is needed and the area around your piles will be numbed. A low-energy electric current or heat will be applied to shrink your piles. You can go home on the same day as your procedure.

Diathermy and electrotherapy are as effective as infrared coagulation in treating piles. Complications are uncommon. 

Infrared coagulation

No general anaesthesia is needed and the area around your piles will be numbed. The blood supply to your piles will be cut off using infrared light. Your piles will then shrink. You can go home on the same day as your procedure.

Infrared coagulation is as effective as banding and injection sclerotherapy in treating first-degree and second-degree piles.

Injection sclerotherapy 

A special chemical called phenol is injected into the tissue around the base of your piles, which causes scar tissue to form here through a process called fibrosis. This cuts off the blood supply to your piles, so your piles will shrivel up and fall off. 

Surgery 

One in 10 people with piles eventually needs an operation. Several procedures use different techniques to shrink piles by blocking their blood supply. They include:

• HALO (haemorrhoid artery ligation operation) — the small arteries that deliver blood to your piles are tied off (ligated), which causes your piles to shrink and fall off
• Rafaelo procedure (radiofrequency treatment under local anaesthetic)
• Stapled haemorrhoidopexy — a circular section of the lining of your anal canal that sits above your piles is cut out using a circular stapling gun; this pulls your piles back up into your back passage and reduces their blood supply so they shrink and fall off; this procedure is less painful than a haemorrhoidectomy as the cutting occurs above your piles
• THD (transanal haemorrhoidal de-arterialisation)

Your piles can also be removed via a traditional  haemorrhoidectomy, which is carried out under general anaesthetic. This surgery is used to treat third-degree and fourth-degree piles that have not responded to banding or other treatments. The procedure is very effective at treating piles however the recovery is very painful for the first two to three weeks after surgery.

You and your doctor can discuss which option would be best for you.

Piles are usually not serious but in some cases can cause the following complications:

• Inflammation and swelling — this is more common with external piles
• Skin tags — a flap of skin that remains after a pile shrinks
• Soreness — if your piles cause a jelly-like discharge (mucous), the surrounding skin can become sore
• Ulcers — ulcers usually form on external piles

In rare cases, you may develop a thrombosed pile. This is when a pile protrudes out of your anus and becomes twisted (strangulated). This cuts off its blood supply and can cause a blood clot to form. This is very painful with the pain being at its worst after two to three days and then easing off over seven to 10 days. 

Treatment for a thrombosed pile includes bed rest, painkillers, warm baths, applying ice packs and avoiding constipation (eg through dietary changes or laxatives). In rare cases, you may need surgery to remove the haemorrhoid, however as the recovery from haemorrhoid removal surgery is also very painful, this is not usually recommended.

Avoiding constipation can reduce your risk of piles. To do this, try to: 

• Drink lots of fluids — avoid alcohol and caffeine
• Eat a high-fibre diet
• Exercise regularly