Piles (haemorrhoids)

Everyone has haemorrhoids: they are cushions of blood vessels in the wall of the anal canal that help hold the bowel contents in. They become a problem when they fill with blood, enlarge and start to bleed or slip out. A flare-up often settles by itself within a few days once whatever caused it is dealt with. But bleeding when you open your bowels should never be put down to piles by default — first you have to be sure that is what it is.

What it feels like

• bright red blood, on the paper, dripping into the pan or streaked on the outside of the stool, but not mixed through it;
• a small lump or soft swelling by the anus, which may appear on straining and slip back in;
• itching, dampness, traces of mucus on underwear;
• a feeling that the bowel has not emptied completely;
• discomfort and burning, less often real pain.

Severe pain is precisely what piles do not usually cause. If it genuinely hurts, this is either a clotted pile or a completely different condition.

Internal and external piles: the difference that decides treatment

Internal piles sit above the zone where there are pain nerve endings. That is why they bleed but barely hurt. They are graded by how far they come down: at first they do not appear outside at all, then they slip out on straining and go back on their own, later they have to be pushed back by hand, and at the last grade they stay outside permanently. That grade decides directly whether creams and fibre are enough, whether an outpatient procedure is needed, or an operation.

External piles lie under the skin at the edge of the anus and are sensitive to pain. Their chief nuisance is thrombosis: blood clots inside the pile and within hours a firm, bluish, sharply painful lump appears at the anal margin. The pain peaks over the first two or three days, then eases, and the lump may resolve over two or three weeks. It is in those first days that a doctor can remove the clot with a small procedure and take the pain away quickly; later there is less point.

Skin tags are a separate matter — soft flaps of skin left behind after an old thrombosis. They do not hurt or bleed and need no treatment, but they get in the way of washing and are often mistaken for piles that never go away.

Bleeding is not always piles

Exactly the same complaints occur in other conditions, and some of them call for an entirely different approach.

• Anal fissure. Sharp, cutting pain during the bowel movement and for a long time afterwards, with a small amount of bright blood. A fissure hurts more than piles, and there may be no lump at all.
• Perianal abscess and fistula. Throbbing pain, swelling and hardening beside the anus, fever, discharge of pus. This needs a surgeon, not an ointment.
• Rectal prolapse. What comes out is not a single pile but a ring of lining with folds. The treatment is completely different.
• Inflammatory bowel disease. Blood and mucus with the stool, diarrhoea, abdominal pain, weight loss.
• Polyps and cancer of the bowel or the anus. The most important cause to rule out. Be suspicious of: dark blood or blood mixed through the stool; a change in bowel habit lasting more than a few weeks; unexplained weight loss; weakness and pallor; a constant urge to open the bowels; bleeding appearing for the first time in later life; bowel cancer in close relatives. Having piles rules nothing out: a great many people have them, and they can quite happily coexist with a tumour.

What really contributes

Piles have no single cause, but the set of contributing circumstances is well known:

• constipation and straining, the main contribution of all;
• the habit of sitting on the toilet for a long time, particularly with a phone in hand;
• loose stools and frequent trips to the toilet, which irritate just as much as constipation;
• pregnancy and childbirth: the growing womb presses on the veins and pushing causes a sharp rise in pressure;
• sedentary work and, at the other extreme, regular heavy lifting;
• too little fibre and fluid in the diet;
• excess weight;
• a long-standing cough.

Spicy food, alcohol and coffee do not create the piles themselves, but in many people they make the burning and itching of a flare-up worse.

When urgent help is needed

Go to an emergency department or call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number is 112) if:

• the bleeding does not stop, the water in the pan turns red, or large clots come out;
• you feel dizzy, suddenly weak, look pale or your heart is racing — signs of significant blood loss;
• the pain is so severe that you cannot sit, sleep or move;
• you have a temperature with shivering and the swelling and hardening beside the anus are increasing;
• a prolapsed pile will not go back and has turned purple or black;
• you have stopped passing urine.

See a doctor within the next few days if: bleeding has appeared for the first time; home measures have not helped within a week; flare-ups keep recurring; your bowel habit has changed; you take blood-thinning medicines.

What you can do yourself

Home measures have one purpose: to soften the stool and stop injuring the piles.

• add fibre to your meals — vegetables, fruit, grains, bran — and increase it gradually, or you will get bloating;
• drink enough water: without it fibre only makes the stool harder;
• do not put off the urge, and do not spend more than a few minutes on the toilet;
• do not strain; it is easier with the knees raised, so put a low stool under your feet;
• wash with cool water instead of wiping, and pat the skin dry rather than rubbing;
• a sitz bath in warm water for ten to fifteen minutes relieves the spasm and the itching;
• a cold pack wrapped in cloth helps in the first day of an acutely clotted pile;
• a prolapsed pile can be gently pushed back with a clean finger and some cream; if it will not go back or it hurts, do not force it — see a doctor;
• move every day, but during a flare-up leave the heavy weights and the bike alone.

From the pharmacy, gentle bulk-forming laxatives help, as do local creams and suppositories with a painkilling or anti-inflammatory action. Preparations containing a steroid are used in short courses of a few days: prolonged use thins the skin. Painkillers containing codeine are the wrong choice because they cause constipation. Anti-inflammatory medicines of the non-steroidal group are best avoided while piles are bleeding, as they increase the bleeding; paracetamol is safer in that respect.

What a doctor will offer

It starts with examination: the doctor looks at the area around the anus, performs a rectal examination and a proctoscopy — a brief look inside the anal canal through a short tube. Internal piles cannot be seen from outside and are not always felt with a finger, so without proctoscopy the picture is incomplete. Where there are warning signs, a changed bowel habit, or bleeding that starts in later life, a colonoscopy is arranged: examining the anus says nothing about what is happening higher up.

If home measures are not enough, there are outpatient procedures, done in a single visit with or without local anaesthetic:

• Banding — a rubber band is placed at the base of an internal pile and it drops off within a few days;
• sclerotherapy — a substance is injected into the pile so that its vessels collapse;
• infrared coagulation — the vessels of the pile are sealed with a pulse of light.

For large piles that prolapse constantly, surgery is offered: removing them, stitching the prolapsed lining back or tying off the feeding arteries under ultrasound guidance. Recovery after removal can be painful and takes several weeks, which is why that decision comes once the gentler options are exhausted. No procedure removes the need to work on the stool: without that the piles come back.

Online consultation

In an online consultation the doctor works out whether your symptoms fit piles or look more like a fissure, an infection or something that calls for investigation of the bowel, explains which preparations suit the current situation, helps to get the stool right, and says whether a proctologist needs to see you in person and whether a colonoscopy is due. It helps to note beforehand what the blood looks like and when it appears, whether there is pain and how bad it is, whether your bowel habit has changed over recent weeks, whether there have been similar episodes, and what medicines you take, blood thinners above all.

With bleeding that will not stop, severe pain, or a temperature with swelling beside the anus, an online consultation is not the right route: face-to-face care is needed without delay.

This material is for information only and does not replace medical advice.