Piles, or haemorrhoids, are areas in the anal canal where the tissue,
which contains lots of blood vessels, has become swollen. They can be
internal, occurring inside the anus, or external, when they can be seen
and felt on the outside of the anus. When visible they look like round
pink swellings, the size of a pea or a grape. By the age of 50, up to
half the population of the UK will have suffered from piles at some
point. Piles are common in pregnant women, but are rare in children.
What causes piles?
The exact way piles form is controversial but it may be linked to excess
pressure in the anus and lower rectum.
This pressure can have one or more of several different causes:
Straining to empty the bowels when constipated.
Pregnancy the weight of the fetus on the abdomen and the
increased blood flow, as well as the effect of hormones on the blood
Childbirth pushing during childbirth increases the pressure
in the veins.
Straining to pass urine, especially in men with prostate problems.
Cancer or growths in the pelvis or bowel, which may exert pressure
in a similar way to a pregnancy.
Family history piles can run in families and are potentially
hereditary, perhaps because of weak veins in the anal area.
Varicose veins many people with these also develop piles,
although piles are not varicose veins.
Different types of piles
Piles are classified according to their position. First-degree piles
remain inside the rectum or anal canal. Second-degree piles protrude
(or prolapse) from the anus when the bowels are opened, but return of
their own accord afterwards. Third-degree piles are similar, but only
return inside when pushed back. Fourth-degree piles hang permanently
outside the anus.
What are the symptoms?
Most people affected have internal piles and may not have any symptoms
at all. The earliest symptom is often bleeding of fresh, red blood from
the anal passage when the bowels are opened. There may be itchiness
around the anal area. Third and fourth degree piles may be more painful
and tend to produce a slimy discharge of mucus that leaks from the exposed
lining of the pile.
There are conditions other than piles that can cause bleeding from
the anus, so anyone who notices bleeding in their stool should visit
a doctor for advice.
If there is pain, this usually means that some kind of complication
has occurred. These include:
This is when a prolapsed pile swells considerably and the blood flowing
into it cannot return to the body. This is very painful and can lead
This is when the blood in the swollen pile clots. A thrombosed pile
may be less painful than a strangulated pile and looks different, being
dark purple or black in colour.
Lack of blood supply to a pile may lead to severe pain and gangrene
(tissue death). This is a dangerous and rare complication
needing immediate surgery.
This is a rare but serious complication. An abscess may form around
the rectum and anus causing pain and swelling. Rarely, the infection
may spread, particularly to the liver. This is because the blood draining
away from the anal area passes through the liver.
Severe loss of blood from piles. Bleeding over a long period of time
can cause anaemia, when there are not enough blood cells to supply the
body with oxygen.
The doctor will ask about your health and carry out a physical examination.
If there are external piles, these will be spotted on examination.
A rectal examination, where a gloved finger is gently inserted into
the anal canal, will be performed. Internal piles cannot normally be
felt in this way, but the examination can reveal other problems such
as an anal fissure - a painful tear of the lining of the anus. These
other conditions need to be excluded before a diagnosis can be made.
One of the main investigations is a proctoscopy, where a small
telescope known as a proctoscope is passed into the anal canal. This
allows the doctor to see any internal piles. Some GPs may be trained
to use a proctoscope, but often at this stage it's necessary to see
a hospital specialist (usually a general or colorectal surgeon).
Other tests that may be carried out at the hospital include a sigmoidoscopy,
where a thin, telescope is inserted into the anus, allowing the doctor
to examine the rectum and the lower part of the large bowel (sigmoid
colon). Another test that might be done is a barium enema. A
liquid dye that shows up on x-rays is passed into the large bowel. This
make the bowel show up on x-ray pictures taken of the lower abdomen.
External piles that are causing irritation may be helped by application
of soothing creams, which are available over-the-counter from pharmacies.
These creams can lubricate the area and some contain a local anaesthetic
to provide short term relief from any discomfort.
Regular warm baths may relieve the irritation, but do not over-use
soaps, which can increase the irritation. Ice packs may help reduce
swelling, but should not be applied directly to the skin.
Piles can usually be treated at home. The most important element in
encouraging existing piles to clear up is to avoid constipation. By
having regular bowel movements, and avoiding straining, stools pass
easily and do not put pressure on the blood vessels in the anal area.
Eating plenty of fibre-rich foods such as fruit, vegetables and wholegrain
cereals (eg brown rice, wholemeal bread and wholemeal pasta), and drinking
plenty of fluids, especially water, should keep bowel movements soft.
It may help to take a fibre supplement such as ispaghula husk (Fybogel)
or mild laxatives such as lactulose solution (Duphalac), which soften
Do not use strong laxatives, such as the stimulant laxative senna,
on a routine basis unless on the advice of doctor, because long term
use of such laxatives can be harmful.
If these self-help measures do not work, there are treatments that
are carried out at hospital. These include:
This is injection of the piles with a chemical known as a sclerosant,
which causes the piles to shrink. This is quick and relatively painless,
but may have to be repeated once or twice.
The piles are treated by applying an elastic band above them, so the
blood supply to them is reduced. The piles then shrink and fall off
and in a few days they are are passed with a stool. Only two piles can
be treated during each procedure. The bands fall off with time.
Freezing the piles causes them to shrink and drop off.
Using infrared rays, this is a pain free treatment which can be used
for non-prolapsing piles.
Known as haemorrhoidectomy - this is usually reserved for third
degree piles or if the procedures mentioned above fail. Each pile is
tied off with a surgical stitch, or suture, and then the pile is cut
away. This leaves sore healing areas, or ulcers, which will heal in
about six weeks. There is a separate BUPA factsheet about haemorrhoidectomy.
Some cases of piles respond to stretching the anus, under anaesthetic,
which is thought to relieve the spasm of the anal sphincter and so reduce
pressure in the anus.
A good intake of dietary fibre, plenty of fluids, especially water,
and regular exercise can keep the bowel movements soft and regular,
making piles less likely. This is especially important for pregnant