Types of Piles
  • Internal
  • External
Symptoms of Piles
  • Sometimes asymptomatic
  • Bleeding
  • Prolapse
  • Pain
Treatments of Piles
  • Non-Surgical:
    • Change of lifestyle
    • Ointments and creams
    • Banding of Haemorrhoids
  • Surgical Options:
    • Haemorrhoidectomy
    • Haemorrhoidal Artery Ligation

Piles (haemorrhoids) are swellings that develop inside and around the back passage (anal canal). 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 due to lack of supporting connective tissue. The engorged veins and the overlying tissue may then form into one or more swellings (piles).

What are the different types?

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.
  • 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 piles can enlarge and drop-down (prolapse), so that they hang outside of the anus.

They are graded according to their size:

  • 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 2 are larger. They may be partly pushed out from the anus when you go to the toilet, but quickly spring back inside again.
  • Grade 3 hang out from the anus 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, and you cannot push them back inside. They sometimes become quite large.
What are the symptoms?
  • Asymptomatic: Sometimes they do not cause any symptoms and you do not realise you have them.
  • Bleeding – The bleeding is usually fresh blood and painless and occurs at the end of opening your bowels.
  • Prolapse – As they get larger (Grade3/4) they can protrude out of the anal canal and give a sensation of a lump at the back passage which may cause discomfort, mucous discharge, anal irritation and itching.
  • Pain – If the piles get thrombosed (blood clot), they can be extremely painful. The pain usually reaches a peak after 48-72 hours and then gradually goes away over 7-10 days.
Do I need any Tests?

Any bleeding from the back passage needs investigating and your GP will assess the need for further tests.

  • Rectal examination – This a finger examination by a lubricated gloved finger to examine the back passage for lumps and bumps.
  • Proctoscopy – Is a visual examination with a small instrument with a light to examine and grade the piles.
  • Sigmoidoscopy/Colonoscopy – These are specialist tests to ensure that there is no other cause of bleeding from further up inside of the bowel (further info in relevant sections).
What treatments are available?
  • Lifestyle
    Most of the mild symptoms can be treated by simple changes to your lifestyle.

    • Avoid constipation by increasing fibre content in the diet or fibre supplements.
    • Ensure adequate hydration to keep stools soft and easy to evacuate.
    • Establish a regular toilet routine and avoid staring.
    • Keep good anal hygiene by avoiding repeated wiping by harsh toilet paper which can cause micro-abrasions and make the itching worse. Gentle dabbing with most baby wipes or using a douche or showerhead and wiping with a cotton cloth.
    • Avoid constipating pain killers if possible.
  • Ointments and creams
    Haemorrhoid creams or suppositories (dissolvable soft pellets that are placed inside the anus) are available over the counter and normally contain a local anaesthetic and a mild steroid to reduce irritation and inflammation. They should be used for only a few days, as they may cause, skin atrophy, contact dermatitis and sensitisation of the anal skin.
  • Banding of Haemorrhoids
    Internal haemorrhoids Grade 2 can be treated by placing a tight rubber band at the base of the piles to cut off its blood supply causing it to shrink and eventually drop off. This is generally a painless procedure that can be performed in the clinic.
Surgical Options

If symptoms are not controlled by simple lifestyle changes or the piles are large you may need surgical treatment and need a General or regional anaesthesia.

  • Haemorrhoidectomy
    This is a surgical excision of haemorrhoids performed for large and prolapsing haemorrhoids. This is a painful procedure, however, there is a less chance of recurrence and may sometimes be the ideal procedure for a prolapsing painful haemorrhoid. Complications can include infection, secondary haemorrhage, urinary retention, abscess formation, faecal incontinence, fistula and anal stenosis.
  • Haemorrhoidal Artery Ligation
    The procedure involves identifying the feeding haemorrhoidal vessels with a Doppler probe and cutting off the blood supply to the haemorrhoids by suture so shrinking them. The prolapsing haemorrhoid can then be hitched up back inside the anal passage.

More information on NICE and ACPGBI website