Definition and Overview

Haemorrhoids are pillow-like clusters of blood vessels that line the lowest part of the rectum and anus. Also called piles, they are thought to assist in closing the anal canal and maintaining continence. They can become swollen and enlarged when there is intense pressure inside the anal canal.

Piles can either be internal or external. External piles form under the skin around the anus. They tend to itch and can cause a great deal of discomfort. Internal piles, on the other hand, lie inside the rectum. They may or may not cause pain, but they can bleed. They can also protrude outside the anal canal. The severity of their protrusion is graded as follows:

  • Grade I - The piles are contained in the rectum. They do not protrude outside the anal canal.

  • Grade II - The piles begin to slide down the anal canal during bowel movements. But they can retract back inside on their own. Both grades I and II internal piles are not a cause for concern. They are often not painful or dangerous. But they can cause discomfort during bowel movements.

  • Grade III - The piles protrude outside the anus during bowel movements. They have to be manually pushed back. They can cause pain when they touch the anal nerve endings.

  • Grade IV - They slide out of the anal canal and cannot be reinserted manually. They can be very painful. Treatment is necessary in some cases.

Causes of Condition

Piles can swell because of intense pressure in the anal canal. Often, this pressure is caused by:

  • Straining too much during bowel movements

  • Chronic diarrhea or constipation

  • Pregnancy - The pressure of the foetus in the abdomen can cause piles to enlarge. Hormonal changes can also play a role. In addition, childbirth can also place severe pressure in the anal canal. Pregnancy-related piles often resolve on their own after childbirth.

  • Obesity or being overweight

  • Sitting on the toilet for too long

Factors that can increase the risk of piles are:

  • Drinking too much caffeine

  • Anal intercourse

  • A diet that is low in fibre and high in fat

  • Jobs that require a person to sit or stand for long periods

  • Loss of pelvic floor muscle tone (often due to old age)

  • A sedentary lifestyle

  • Severe liver or heart disease

  • Infection in the anal area

  • Genetics. A person with a close family member, such as a parent or siblings with piles, has a higher than average risk of the condition.

Key Symptoms

Prolapsed internal haemorrhoids can cause bleeding. Patients may see bright red blood in their stool, in the toilet bowl, or on toilet paper. They also have a hard lump and mucous discharge from the anus. Other symptoms include pain during bowel movements and itching around the anal area. These can be quite severe in some cases.

It is important to note that these symptoms are also signs of another condition called rectal prolapse. This also causes tissue from within the rectum to protrude outside of the anus. But unlike prolapsed piles, it also causes leakage of stool and a feeling of fullness in the bowels. Patients with rectal prolapse often need treatment.

Who to See and Types of Treatments Available

Piles are often not a cause for concern. Although they can cause discomfort or pain at times, they often resolve without treatment or with home remedies. Certain measures that can be taken to relieve their symptoms include:

  • Sitting in a bathtub with warm (not hot) water for at least 10 minutes. This can be done several times a day to relieve itching and swelling.

  • Applying over-the-counter haemorrhoid cream outside the anus to relieve itching.

  • Eating a diet that is high in fibre to prevent constipation. Good sources of fibre are vegetables, whole grains, and fruits. Over-the-counter fibre supplements can also be used. Drinking eight glasses of water everyday can also help.

  • Exercising. A sedentary lifestyle can increase one’s risk of piles. Exercising regularly or being active can reduce pressure on veins. It can also help a person lose weight. Being overweight is another risk factor for piles.

If symptoms persist, patients can consult their doctor. The condition is diagnosed through a physical exam.

Surgery can be recommended if all non-invasive therapies have not worked. The most effective are rubber band ligation and haemorrhoidectomy.

In a rubber band ligation, piles are tied off at their base using rubber bands. This cuts their blood supply, causing them to die. They will then fall off on their own after about a week. The resulting scar tissue will hold nearby nerves so they will not protrude in the anal canal.

Because the procedure can sometimes be painful, only one or two piles are removed at a time. But when performed under general anaesthesia, several piles can be removed at the same time.

Haemorrhoidectomy, on the other hand, is an outpatient procedure carried out under general anaesthesia. It involves making incisions around the piles so they can easily be cut off. Surgeons can use a scalpel, laser, or electricity to do this. The wound can be sewn closed or left open.

Another procedure is called haemorrhoidopexy. It is less painful than haemorrhoidectomy but is more expensive. It also has a high recurrence rate. The procedure does not require incisions. Surgeons use a stapling device to remove swollen veins and close the wound.


  • Lohsiriwat V. Hemorrhoids: From Basic Pathophysiology to Clinical Management. World Journal of Gastroenterology. 2012;18:2009–2017.

  • Sanchez C, Chinn B. Hemorrhoids. Clinics in Colon and Rectal Surgery. 2011;24:5–13.

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