Piles

Piles is a common condition, occurring in 50-60% of the general population, affecting both men and women with equal frequency, and located in the anal canal and rectum. It causes discomfort to more than half of individuals over 50 years of age. 

Piles occur primarily due to constipation and pressure while pooping, sometimes due to pregnancy and also due to being overweight. The size, thrombosis, and position of the haemorrhoids determine the degree of pain or discomfort (Mott et al., 2018). 

This overview will help you to go through the piles' definition, types, management, diagnosis, key facts, and other crucial aspects of the condition, equipping readers with the insights needed to comprehend and curb the management of this condition.

What are Piles?

Piles is an ordinary condition due to swollen, engorged veins that form both inside and outside the anus and rectum, which may cause pain, swelling, itching, redness, bleeding and a protruding hard lump outside the anus. Piles aren't communicable. Everyone has haemorrhoids, but they typically don't cause any issues unless they grow and become larger. Piles cause discomfort equally in both men and women only when there is an increase in pressure on the arteries. It is an easily manageable, curable, and preventable condition that can be treated with simple and basic home remedies, over-the-counter medicines, and lifestyle changes, as suggested by a physician  (NHS Nottingham, 2021).

Piles vs Anal Fissures: 

Piles and fissures both cause rectal bleeding, but they differ in cause and symptoms. Though discomfort can arise if piles prolapse or thrombose, they often appear as painless bleeding during bowel movements involving enlarged blood veins in the anal canal (Mott et al., 2018). Whereas an anal fissure is a little cut in the skin covering the anus, usually causing intense, burning discomfort during and after bowel movement, often with a little quantity of bright red blood on the tissue or stool. Unlike piles, cracks are more directly linked to trauma from hard stools or too much straining.

There are several types of haemorrhoids, depending on the location of the swollen veins (Mott et al., 2018). 

• Internal Haemorrhoids

These are inflamed veins forming inside the rectum. Usually, these are invisible and painless because the top rectum has few pain-sensing nerves. Frequently observed during or after a bowel movement, the most typical symptom is bright red rectal bleeding; it can be seen on toilet paper, in the toilet bowl, or covering the stool, a condition called 'haematochezia'  (NHS, 2025). Only if the haemorrhoid turns necrotic or thrombosed (clotted) can pain arise. 

• External Haemorrhoid

It manifests itself under the skin around the anus. Unlike internal haemorrhoids, they are situated in a region dense with somatic pain receptors, thus making them more likely to produce discomfort, itching, oedema, and annoyance. In numerous instances, they may be seen as little nodules near to the anus. External haemorrhoids can cause little symptoms or none at all if not thrombosed. But more severe external haemorrhoids might make hygiene difficult and cause secondary skin irritation or dermatitis. Post-recovery, skin tags may remain, creating ongoing pain or hygiene concerns. 

• Prolapsed Haemorrhoid 

If an internal haemorrhoid protrudes from the rectum and bulges out of the anus, it can become prolapsed. When compared to standing or lying down, prolapsed haemorrhoids are often more uncomfortable when sitting. During a bowel movement, they might also experience more pain. If a prolapsed haemorrhoid is strangulated, which occurs when its blood supply is cut off, it may also be quite unpleasant.

• Thrombosed Haemorrhoids

Thrombosed haemorrhoids, sometimes called perianal thrombosis, develop when a blood clot accumulates inside an external haemorrhoid, resulting in a painful, swollen bump close to the anus. Although they aren't hazardous, they may be extremely unpleasant and necessitate treatment to alleviate discomfort and pain. To alleviate the discomfort, a thrombosed haemorrhoid may need to be lanced and drained (Mott et al., 2018).

The following are the early signs to detect before the piles progress: 

• Bright red spotting after defecation in the pot, mild anal itching, swelling or pain in the anal region and occasional mucous discharge. 

Symptoms of haemorrhoids depend on the type of haemorrhoids, with bleeding being the most common symptom (Mott et al., 2018). Small internal piles may be symptomless until prolapsed. However, the following are the varied symptoms of piles based on their type:

• Internal Haemorrhoids

Unless they prolapse, internal haemorrhoids often go undetected and seldom cause discomfort. Many people with internal haemorrhoids are not aware of their existence because they are positioned deep inside the rectum,  where pain-sensing nerves are low. Bright red blood is the most obvious indicator; it may be visible coating the stool, in the toilet bowl, or on toilet paper during or after a bowel movement. Mild pain or discomfort can result from an internal haemorrhoid prolapsing through the anal opening; it can sometimes be delicately forced back inside.

• External Haemorrhoids

Symptoms usually include uncomfortable, hard lumps near the anus; bleeding while wiping; and anal irritation or itching. Sitting or bowel movements can make pain more acute. Swelling and inflammation would occur even. Though rubbing, straining, or overzealous cleaning near the anal region might aggravate the ailment, in many instances these symptoms clear on their own in a few days.

• Prolapsed Haemorrhoids

It arises when an internal haemorrhoid passes the anal aperture. These can produce obvious moist bumps, occasionally pinker than the surrounding skin. Pain, especially during defecation, from a prolapsed haemorrhoid can occasionally necessitate hand repositioning back into the rectum. Although prolapsed haemorrhoids can be unpleasant, some of them come back inside by themselves.

• Thrombosed Haemorrhoids

A blood clot grows within an external haemorrhoid, causing abrupt and intense pain that indicates a thrombosed haemorrhoid. Around the anus, this condition usually produces intense itching, pain and irritation. Near the anal opening, a noticeable blue or purple bulge can surface. Though bleeding can also happen, the defining characteristic is the terrible pain, which typically shows up suddenly and might need medical assessment for its severity.

Internal Haemorrhoids Classification according to Goligher’s Classification: 

As per Goligher's classification, internal haemorrhoids are further graded based on the degree of prolapse (Khan et al., 2020):

• Grade I: Blood vessels are visible but not prolapsed. 
• Grade II: Prolapse occurs during straining but goes away on its own. 
• Grade III: The prolapse requires manual reduction. 
• Grade IV: The prolapse cannot be reduced.  

How do piles impact your body?

Progressively, weak anal cushion support causes descending vessels, decreased continence, greater bleeding, and perhaps clotting or infection in late stages.

The actual cause of haemorrhoids is unknown; however, haemorrhoids result from rising pressure in the veins of the rectum and anus over time. Deoxygenated blood is returned to the heart by tiny blood arteries in this area. These vessels can become distended with blood when this flow is disturbed, resulting in haemorrhoids as well as growth. The following are the causes mentioned: 

• Constipation 

Straining during bowel movements is among the main causes. Irregular bowel patterns, such as chronic constipation or ongoing diarrhoea, may increase the risk of developing symptomatic haemorrhoids (Mott et al., 2018). 

• Prolonged Pooping Time

Sitting on the toilet for extended periods, particularly when pushing, can also exacerbate the condition. 

• Pregnancy

One also plays a big part in pregnancy. The growing weight of the foetus presses on the abdominal veins, and hormonal changes during pregnancy can cause the haemorrhoidal vessels to swell. The strain of childbirth raises intra-abdominal pressure further, but most pregnancy-related haemorrhoids improve after delivery without requiring intervention.

• Involuntary Activities

Chronic coughing, sneezing, and even vomiting can aggravate the pressure in this area. 

• Diet and Lifestyle

Low-fibre diets can produce tough stools and straining; lack of exercise and obesity can impede good bowel activity and circulation. Furthermore, sitting on hard surfaces for long periods might raise local pressure on the rectal veins. 

• Other Factors

Pelvic floor dysfunction, genetic inclination, and lack of valves inside the haemorrhoidal veins, which may impair blood flow. Though the data is scant, more serious cases have been linked to squatting while defecating. Frequently lifting heavy weights could also be a cause. Though the evidence is unclear, being a receptive partner for anal intercourse may be a risk factor. 

There are various contributing factors for the development of piles (Mott et al., 2018):

• Gastric Issues: Prolonged constipation, difficulty pooping, and irregular bowel movements could be directed towards piles. 
• Genetics: If other family members, such as your parents, have had them, you may be more prone to getting haemorrhoids (Sandler & Peery, 2019)
• Obesity: The obese patients, due to the load on the veins, may develop piles. 
• Age: Because the tissues in the anal region tend to become less robust with age, older adults may be more susceptible to them.
• Pregnancy: Pregnancy increases your risk in a few different ways. The additional pressure on your rectum is caused by the weight of the foetus. You are also more likely to get constipation.
• Excessive Sitting: Having a job that requires you to sit for long periods of time or living a mostly inactive life also increases your risk. Blood can accumulate in your anal area and exert pressure on the blood vessels when you don't move about much.

Who is at risk? 

The people who remain chronically constipated, pregnant women, prolonged sitters, heavy weightlifters, older individuals, individuals with a family history, and obese persons are at risk of acquiring piles (Mott et al., 2018).

Although some cases call for consequences, haemorrhoids are usually not harmful. 

• One potential problem is thrombosis, or the development of blood clots within external haemorrhoids, which can be extremely painful and might need surgical excision. 
• While uncommon, severe or protracted haemorrhoidal bleeding can eventually cause iron-deficient anaemia from ongoing blood loss.
• Occasionally, haemorrhoids may develop skin tags or become infected post-healing. 
• Strangulated hemorrhoids can occasionally develop when anal muscles stop the blood supply to a prolapsed internal hemorrhoid, hence causing tissue damage (Mott et al., 2018)
• Methods of therapy might also cause problems and discomfort. 
• A few individuals having banding surgeries can develop ulcers at the treatment site, urinary issues, bleeding, infection, or ulceration. 

The following are the ways you can adopt to eliminate the factors contributing to the development of piles: 

• Consume plenty of water, juices, and fluids. 
• Use moist toilet paper to wipe your bottom.
• Maintain a clean and dry bottom.
• Reduce your intake of alcohol and caffeine (such as tea, coffee, and cola) to prevent constipation.
• After you defecate, avoid wiping your bottom too forcibly.
• Don't disregard the need to poop.
• Don't strain too much when defecating. 
• Do not sit on toilets for longer periods. 
• NSAIDs like ibuprofen can increase the risk of bleeding. Avoid them if you're experiencing active rectal bleeding, unless advised by a healthcare provider.
• Increase your fibre intake from whole-grain rice, fruits, and veggies.
• If you're overweight, lose weight by exercising regularly. 
• Take laxatives and enemas to soften stools till symptoms resolve. 
• Avoid taking medications that cause constipation. 
• Refrain from using scented wipes. 
• Sit on a cushioned surface rather than on a hard chair. 
• Manage flares with a sitz bath conservatively. 

 Haemorrhoids are typically diagnosed through a combination of medical history, physical examination, and specialised diagnostic methods. The diagnosis aims to verify the presence of haemorrhoids, evaluate their severity, and rule out other severe disorders such as tumours or polyps. The findings help in selecting the most appropriate treatment options based on symptoms, grading, and patient preference.

• Physical Examination: In most cases, a healthcare provider may identify prolapsed or external haemorrhoids simply by inspecting the anal region.
• A Digital Rectal Exam (DRE): It is frequently performed to search for abnormalities such as internal haemorrhoids, rectal tumours, or other causes of rectal bleeding. In this procedure, the doctor examines the rectum for lumps, muscular tone, tenderness, swelling, or pain by inserting a gloved, lubricated finger. 
• Anoscopy: To directly observe internal haemorrhoids or eliminate other possibilities, doctors might perform an anoscopy. It involves inserting a small, lighted plastic tube into the anal canal. 
• Sigmoidoscopy: If more extensive testing is needed, a sigmoidoscopy can be performed using a flexible, illuminated tube to examine the lower portions of the colon and rectum. If necessary, this also enables tissue sampling. 
• Colonoscopy: If the patient is prone to colorectal disorders or has other gastrointestinal symptoms, a colonoscopy may occasionally be suggested to examine the entire colon.
• Sedation may be required for some diagnostic procedures when a woman is pregnant or experiencing severe pain. Since internal haemorrhoids usually only cause pain when they are thrombosed or prolapsed. Pain during the examination typically suggests conditions like external haemorrhoids or anal fissures. 
• Differential Diagnosis: Rectal bleeding can occasionally be caused by anal cancer, colorectal cancer, ulcerative colitis, and Crohn's disease. Also, fissures, fistulae, abscesses, rectal varices, and itching are just a few anorectal issues that might be misdiagnosed as haemorrhoids because they have similar symptoms. Skin tags, anal warts, rectal prolapse, polyps, and swollen anal papillae are among other factors that can lead to an anal mass. Anorectal varices caused by portal hypertension (blood pressure in the portal venous system) might resemble haemorrhoids, but they are a separate illness.  

Conservative (Lifestyle and Medical) Management: 

For Grade I or minor Grade II haemorrhoids, these actions are normally adequate (Mott et al., 2018). Minor haemorrhoids typically get better with easy at-home treatments (NHS Nottingham, 2021). These measures aim at helping, healing and alleviating pain:

• Warm Sitz Baths: To calm irritation, itching, and discomfort, soak the afflicted area in warm water for 10-20 minutes several times a day using warm Sitz Baths.
• Increased Fibre Intake: Include more fruits, veggies, whole grains, and fibre supplements in your meals to lessen straining and ease bowel motions.
• Hydration: Drink lots of water to soften stools and support normal bowel activity.
• Cold Compresses: To alleviate swelling and pain, use cold compresses on the rectal region.
• Good Hygiene: Employ flushable wet wipes or odourless, soft toilet paper. Stay away from fragrant goods that could cause aggravation.
• Avoid Straining: Avoid sitting on the toilet for long or straining during bowel movements.
• Manage Constipation: When necessary, control constipation with fibre supplements (e.g., Fybogel, psyllium husk) or mild stimulant laxatives (e.g., senna). Steer clear of constipation causes, such as codeine-containing painkillers (e.g., co-codamol).

Over-the-counter medicines:

• Topical Creams and Ointments: Hydrocortisone, lidocaine, or witch hazel assist in lowering inflammation, numbing discomfort, and soothing irritation.
• Suppositories and Pads: Medicated alternatives provide immediate relief to internal haemorrhoids 
• Stool Softeners and Fibre Supplements: They can lessen further damage to the region and facilitate bowel movements.
• Pain Relievers: Managing pain and inflammation may be helped by NSAIDs such as ibuprofen or naproxen.

Note: These medications provide symptomatic relief for mild-to-moderate haemorrhoids but should be used as directed and discontinued if symptoms persist beyond the recommended duration or worsen, requiring medical evaluation.

Office-Based Procedures: 

For internal haemorrhoids grade I to III, minimally invasive treatments may be advised if home remedies fail:

• Rubber Band Ligation: A tiny rubber band encircles the base of the haemorrhoid to cut off its blood supply; it will shrink and fall off. First-line option for Grade II-III.
• Infrared Coagulation: Typically painless and quick, infrared radiation is used to cause coagulative necrosis. Heat is delivered through a probe to coagulate the blood vessels of the haemorrhoid, therefore reducing it.
• Sclerotherapy: It is the injection of a chemical solution, such as phenol, into the haemorrhoid to induce its collapse. 
• Electrocoagulation: An electrical current closes off the blood vessels and kills haemorrhoid tissue. Surgery may be needed for persistent, prolapsed, or large haemorrhoids. 

Surgical Treatments: 

• Haemorrhoidectomy: It is the surgical removal of big outside or prolapsed internal haemorrhoids with a scalpel. Though it entails more post-operative pain and a longer recovery, this is sometimes used for advanced diseases.
• Stapled Haemorrhoidopexy: It is a stapling instrument that either cuts or repositions sagging internal haemorrhoids and lowers blood flow to the region. Though it may have particular postoperative hazards, it can be less painful than conventional surgery.
• Transanal Haemorrhoidal Dearterialisation (THD): Internal haemorrhoids are stitched and repositioned, which could lead to less discomfort and hasten recovery.
• Haemorrhoidal Artery Ligation: Obstructs the blood arteries feeding the haemorrhoid. Grade II and III haemorrhoids benefit particularly from this approach.
• Excision of Thrombosed External Haemorrhoids: Surgical resection of a thrombosed haemorrhoid can drastically lessen discomfort and swelling if done within 48-72 hours of symptom onset.

Alternative and Complementary Choices: 

• Witch Hazel: Some people look at other ways to relieve symptoms. Often applied topically in liquid form or in creams and pads to relieve itching and irritation, witch hazel helps to alleviate the discomfort. Evidence for efficacy is limited; consult your doctor before using.
• Herbal Remedies: Sometimes employed are herbal treatments like gotu kola, goldenrod, and yarrow. These herbs are used in traditional medicine, but robust scientific evidence is lacking. Discuss with your healthcare provider before use.
• Probiotic Supplements: These could promote regularity and general gut health.

Home Remedies: 

By concentrating on reducing piles' symptoms and encouraging simpler bowel motions, home treatments help to control them (NHS Nottingham, 2021).

• Adding more fibre via whole grains, fruits, vegetables, or fibre supplements like psyllium husk helps soften stools and lessen straining during defecation
   
• Drinking plenty of water daily helps to preserve hydration and promote regular bowel movements
   
• Ten to fifteen minute warm sitz baths taken many times each day can help to calm redness, itching, and inflammation close to the anus (NHS, 2025).
   
• Additionally helpful in lowering inflammation and pain is the use of cold compresses or ice packs for brief periods
   
• By gently cleaning with odourless wipes or lukewarm water, avoiding perfumed soaps, and not sitting on the toilet for long periods, good anal hygiene helps to reduce further irritation

Living with piles, also known as haemorrhoids, calls for more than only transient comfort. Good management entails lowering pain, encouraging healing, and avoiding relapse using consistent lifestyle choices and appropriate medical follow-up. 

• Measures of Daily Lifestyle: Patients should minimise prolonged sitting on the toilet and avoid straining during bowel movements. Straining exacerbates symptoms by raising rectal venous pressure. A fibre-rich diet (fruits, vegetables, whole grains) and at least two litres of water daily help patients to prevent constipation, a serious trigger. These practices assist with regular bowel movements and soften stools. Scented wipes or abrasive toilet paper should also be avoided since they might irritate the anal skin. Rather, gentle cleaning with just plain water and dabbing dry with soft tissue or fabric would be best. Pressure on external haemorrhoids might be relieved by sitting on soft surfaces. 
• Postoperative Care: Following operations like rubber band ligation or haemorrhoidectomy, patients may have discomfort, anal fullness, or light bleeding. Pain is typically controlled with NSAIDs or recommended painkillers; sitz baths and stool softeners are advised to lessen suffering. Adequate rest should be taken for better recovery. Patients should avoid codeine-based medicines since these often cause constipation. If pain worsens after surgery, it may signify infection and should be quickly assessed. 
• Patient Education: Healthcare experts, including doctors, nurses, and dietitians, should advise patients to maintain appropriate fluid consumption, avoid extended sitting, reduce extra weight, and consume a diet high in fibre. These easy, environmentally friendly adjustments lower stress in the anorectal area, therefore lowering the likelihood of future flare-ups and needless surgical operations. Managing Recurrence

• The patients suffering from haemorrhoids should visit a doctor when the symptoms don’t resolve within a week or worsen, and there is a persistent/heavy amount of blood loss. 
• Even if there is fainting, dizziness, lightheadedness, feeling unwell, or pus leakage from piles, rush to the doctor for the management and diagnosis of the condition. 

• Piles affect around 50 to 66% of the population's lifetime prevalence.
• Usually asymptomatic; if symptomatic, therapy choices range from surgical to medical.
• Prevention and relapse depend critically on lifestyle choices.
• Physical examinations, anoscopy, and colonoscopy all count among diagnostic tools.
• For more serious instances, treatments include RBL, sclerotherapy, coagulation, and surgery.
• Look for vivid red bleeding, tumours, itching, or mucus by staying attentive. 
• Eating high-fibre foods, staying hydrated, avoiding straining, and exercising routinely should all be given priority.
• Treat minor symptoms using over-the-counter drugs and behavioural modifications.
• Consult a doctor if your symptoms linger or worsen.
• Follow the doctor’s advice, use medications correctly, and sustain lifestyle changes even after recovery.

Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with qualified healthcare providers for diagnosis, treatment, and medical decisions related to piles or haemorrhoids.