Piles Haemorrhoids

What are piles?

Piles (haemorrhoids) are common swellings that develop inside and around the back passage (anal canal).

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).

What are the different 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 are deeper and initially form above a point 2-3 cm inside the back passage (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 start off nearer the surface, below a point 2-3 cm inside the back passage.

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

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.

Piles are also graded by their size and severity.

What are the symptoms of piles?

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

• Grade 1 are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the opening of the back passage (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 go back inside again when you stop straining.
• Grade 3 hang out from the anus (prolapse) 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 (prolapse), and you cannot push them back inside. They sometimes become quite large.

Piles (haemorrhoids)

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

The most common symptom of piles is bleeding after going to the toilet to pass stools (faeces). The blood is usually bright red and may be noticed on the toilet paper, in the toilet pan or coating the stools.

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 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.

What do piles look like?

You often won't see anything if you have piles and look at the area round your back passage. This is because most piles are inside your anus and rectum and don't protrude from your bottom.

Larger internal piles may hang down out of your back passage, 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 back passage.

What causes piles?

The lining of the back passage (anal canal) contains many blood vessels (veins). There seem to be certain changes in the veins within the lining of the back passage that cause the pile(s) to develop. The lining of the back passage and the veins become much larger and this can then cause a swelling and develop into a pile.

However, we don't know exactly what causes a pile. Some piles seem to develop for no apparent reason. It is thought that there is an increased pressure in and around the opening of the back passage (anus). This is probably a major factor in causing haemorrhoids in many cases.

If you delay going to the toilet and need to strain when passing stool then this can increase the pressure and so makes it more likely that a pile will develop. Other risk factors are listed below.

How long do piles last?

There's no set duration for how long piles will last. Some small flare-ups get better on their own after a few days, while some large external haemorrhoids can take longer to heal and may require medical treatment.

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 (see below).
• 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.

What are possible complications of piles?

A possible complication of piles that hang down is that they can 'strangulate'. This means that the blood supply to the pile has been cut off. A blood clot (thrombosis) can form within the pile. This causes really severe pain if it occurs. The pain usually reaches a peak after 48-72 hours and then gradually goes away over 7-10 days.

Other complications include skin tags around the anus, irritation and breaks in the skin (which may very rarely lead to serious infection), discharge, and closing up of the back passage (stenosis).

What makes piles more likely?

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

• Constipation, passing large stools (faeces), and straining on 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.
• A low-fibre diet.
• Being overweight. This increases your risk of developing piles.
• Pregnancy. Piles are common during pregnancy. This is probably due to pressure effects of the baby lying above the rectum and anus, and also the affect that the change in hormones during pregnancy can have on the veins. Piles occurring during pregnancy often go away after the birth of the child.
• Ageing. The tissues in the lining of the anus 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 I need any tests for piles?

If you think that you may have piles, or have bleeding, pain or discomfort from your back passage (anal canal) when passing a stool, you should contact 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.

Your doctor may suggest a further examination called a proctoscopy. In this procedure, the inside of your back passage 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 treat piles

Various preparations and brands are commonly used as piles treatment options. They do not cure piles. However, they may ease symptoms such as discomfort and itch.

Avoid constipation and straining during bowel movements

Keep the stools 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.

Ointments, 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.

How to get rid of piles

Banding treatment (rubber band litigation)

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.

What are the surgical treatments for piles?

Haemorrhoidectomy (the traditional operation)

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 back passage (anal canal) above the piles. This has the effect of pulling the piles back up the back passage.

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.

What about strangulated or thrombosed piles?

Strangulated or thrombosed haemorrhoids are uncommon but usually very painful. 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 stools (faeces) soft (see above). Surgery may be needed to remove the haemorrhoid.