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Piles (haemorrhoids)

Piles, or haemorrhoids, affect millions of people around the world.

According to some estimates, approximately 50%  of all people over the age of 50 will have haemorrhoids at some point in their lives.

At Circle Health Group hospitals, we help lots of people seeking advice and treatment for piles every year.

Piles, also known as haemorrhoids, are a condition in which the normal veins or blood vessels in and around the back passage (anus) become swollen. Sometimes they also pop out of place.

Dr Said Mohamed, Consultant Colorectal and General Surgeon at Circle Health Group hospitals, emphasises the fact that everyone “has haemorrhoids to some extent.”

Haemorrhoids are “normal vascular cushions within the anal canal,” Dr Mohamed explains. When excessive pressure is applied to these “anal cushions,” they become enlarged and irritated, starting to look and feel like lumps.

This is when haemorrhoids become symptomatic, leading to the condition called “piles,” or “haemorrhoids”.

So, haemorrhoids, per se, “are not a disease,” Dr Mohamed clarifies, but they can become symptomatic under certain conditions.

Typically, piles are not serious, and they tend to go away on their own. However, there are things you can do to relieve the discomfort and speed up the healing process. 

Piles can be internal, external, or a combination of the two.

  • Internal piles are inside the anal canal
  • External piles are under the skin surrounding your anus
  • Mixed interno-external piles are found both inside and around the anus

Medical professionals also divide internal piles into four groups or degrees, according to their appearance and severity:

  • Grade I, or first-degree piles: the vascular cushions (or anal cushions) are bleeding but have not prolapsed
  • Grade II, or second-degree piles: the piles have prolapsed, or fallen out through the anus when straining (for example when going to the toilet) but they can go back inside on their own
  • Grade III, or third-degree piles: the piles have prolapsed, but they can be gently pushed back in
  • Grade IV, or fourth-degree piles: the piles have prolapsed, they stay prolapsed at all times, and they cannot be manually pushed back in

It is possible to have a mix of different types of piles at the same time.

Internal piles look like the varicose veins that someone will have in their lower leg, Dr Mohamed explains.

This is because piles and varicose veins are biologically very similar — although haemorrhoids are not just blood vessels, they also have tissue in them, which gives them their cushion-like aspect.

External piles, Dr Mohamed explains, “look like a bunch of small grapes — sometimes two, three, or four of them.”

If you take a selfie with a mobile phone, he says, you can see that they are usually purple in colour.

The most common symptom of piles is bleeding from your bottom, or anus, when pooing. You may find bright red blood in the toilet bowl, in your stool, or on the toilet paper after you wipe.

Other symptoms of piles depend on the degree of severity and include:

  • Pain
  • Irritation or itching around the anus
  • Discharge of mucus from your bottom, which you may notice on your underwear or when you wipe
  • Swelling or lumps around your anus, which are usually the size of small grapes
  • Prolapse of these lumps, meaning that they are sticking out of the anus

Haemorrhoids cause pain when they become swollen and very enlarged, explains Dr Mohamed. The pain can range from mild to severe.

Rarely, the pain is severe due to a complication called “thrombosed haemorrhoid” — that is, a haemorrhoid that bleeds into itself, similar to a bruise.

Discharge is a common symptom in people with large haemorrhoids. When the haemorrhoid is prolapsed, people may have the sensation that a lump is coming out of their anus when they go to the toilet. Many patients report having to manually push the haemorrhoid back in.

“The primary reason for [piles] is increased pressure in the pelvis,” says Dr Mohamed. Pressure due to giving birth, constipation, or over-wiping the bottom are all common causes of piles.

Common risk factors for piles include:

  • Being pregnant
  • Sitting on the toilet for too long
  • Having obesity
  • Having a family history of piles
  • Having long-term constipation

Other potential risk factors include:

  • Eating a diet low in fibre
  • Eating spicy foods
  • Drinking too much alcohol

Piles may develop for a number of different reasons, and it isn’t always clear why or what is causing them.

Piles usually go away on their own, and they are nothing to worry about. However, sometimes they may cause complications, such as:

  • Excessive bleeding
  • Blood clots that may form into an external haemorrhoid (thrombosed haemorrhoid)
  • Anal skin tags
  • Prolapsed and strangulated haemorrhoid — this occurs when an internal haemorrhoid falls through the anal opening and the anal muscles cut off its blood supply. This may cause severe pain and bleeding.
  • Excessive or long-term bleeding from a haemorrhoid can cause anaemia or a low blood count

Piles are common in pregnancy. Some studies estimate that between 25% and 35% of pregnant women develop piles. In some populations, as many as 85% of pregnant women have piles.

This is due to the increased pressure in the pelvis, Dr Mohamed explains, especially “in the latter part of pregnancy, when women tend to develop quite large haemorrhoids.”

Treatments for piles in pregnancy

Treatments for piles in pregnancy include:

  • Eating more fibre
  • Taking stool softeners
  • Drinking more liquids
  • Changing toilet habits
  • Taking painkillers and anti-inflammatory medication

Some ointments may also help relieve symptoms of haemorrhoids. These contain a mix of anaesthetics, corticosteroids, and anti-inflammatories. However, there is not enough evidence to show that these ointments can prevent bleeding or prolapse in pregnancy.

For many pregnant people, most symptoms will go away on their own after giving birth. In some rare cases, however, surgery will be necessary during pregnancy or after delivery.

Because the fundamental cause of piles is pressure, Dr Mohamed explains, the first thing you should do to relieve the symptoms is to reduce pressure by softening your stool. You can achieve this by:

  • Eating more fibre and drinking more fluids
  • Eating less fatty foods
  • Exercising regularly
  • Avoiding medication that may cause constipation or diarrhoea

Generally, piles can be successfully managed with a series of lifestyle and behaviour changes, such as:

  • Practising better anal hygiene
  • Not straining while on the toilet
  • Not wiping excessively
  • Avoiding activities that make you sit on the toilet for longer, such as reading or using devices such as iPads or phones
  • Limiting time spent on the toilet to 3-5 minutes

Piles treatment at home

Other things you can do to treat piles and relieve your symptoms at home include:

  • Taking a warm bath of plain water a few times a day
  • Taking sitz baths, which are warm, plain water baths that cover only the buttocks and hips. By soaking your perineum, which is the region between your genitalia and your anus, a sitz bath can relieve the itching and pain associated with piles
  • Taking painkillers
  • Applying local ointments or suppositories
  • Taking stool softeners such as mild laxatives or bulk-forming agents

Should you use cream for piles?

Dr Mohamed recommends suppositories in the first place, because they can treat piles internally, and most haemorrhoids are developed internally. But, if the inside area is too painful, he recommends ointments.

“Ointments are always better than creams,” Dr Mohamed notes. “The simple reason is that creams have far too many chemicals and a lot of these chemicals can cause irritation to the skin,” he warns.

These treatments may contain local anaesthetics, corticosteroids, antibiotics, and anti-inflammatory drugs.

“Generally speaking, the common theme of all of these hemorrhoidal preparations is that they have a combination of topical steroids and a local anaesthetic,” Dr Mohamed explains.

Preparation H is an ointment that can be applied locally. It is made of 0.25% phenylephrine, petrolatum, light mineral oil, and shark liver oil. Phenylephrine is a vasoconstrictor, which means it helps the narrowing of blood vessels, slowing or blocking the blood flow to the haemorrhoids. It provides short-term relief from bleeding and pain.

Preparation-H comes in the form of an ointment, cream, gel, suppositories and medicated wipes.

Other piles medicine and ointments

An ointment with nifedipine has also shown benefit in treating thrombosed external haemorrhoids — that is, external haemorrhoids that are filled with blood clots.

Nitrite and calcium channel blockers have also shown benefits in relieving symptoms of haemorrhoids.

Finally, glyceryl trinitrate 0.2% ointment can relieve haemorrhoid symptoms in people with low-grade haemorrhoids. However, studies have shown that over 40% of people who take this treatment have had headaches as a side effect.

Oral treatments include flavonoids or calcium dobesilate.

Good toilet practice/wiping

In addition to a high-fibre diet to soften the stool, Dr Mohamed stresses the importance of good toilet habits for the management and prevention of piles.

“We tend to over-wipe the bottom excessively and my recommendation is to dab the bottom gently with a toilet paper rather than wiping and if possible, to wash the area with water. This minimises abrasion or friction and [lowers the] risk of itching and irritation or bleeding.”

Not spending too much time sitting on the toilet is also critical. “The longer one sits on the bottom, the bottom becomes relaxed, the haemorrhoids become engorged and swollen and they will cause symptoms.”

Dr Mohamed tells his patients to “not sit on the toilet for more than 10 minutes. This is absolutely critical,” he says. Even when a person has constipation, sitting on the toilet for longer than that will only make the piles worse. He also recommends not to take any devices or reading material in the bathroom.

Dr Mohamed urges people not to panic if they see bright red blood in their stool as a result of haemorrhoids.

He stresses the importance of self-management in piles, with the lifestyle changes mentioned above.

“However, if these changes are not making a difference within a week, you should go and consult with a doctor,” he says.

To check for piles, your doctor will ask questions about your medical history and perform a careful clinical examination. They may manually check the area around your anus for external haemorrhoids, and/or your rectum for internal haemorrhoids. In the case of an internal rectum check, your consultant will insert a gloved, lubricated finger into your rectum to examine it.

Your healthcare provider may also use a small tube with a light called an anoscope. They may also use a lighted tube and perform a proctoscopy, which gives your consultant a view of the entire rectum.

Piles tests

Some additional tests that your consultant may perform include:

  • A sigmoidoscopy: this involves a lighted tube that is inserted through the anus. It blows air inside your intestine, swelling it up, and provides a view of part of your large intestine.
  • Colonoscopy: this uses a lighted tube that offers a view of the entire large intestine. In this procedure, your consultant can see the full length of your large intestine and the lining of your colon.

These examinations will check for:

  • Anal skin tags
  • Bleeding
  • Skin irritation
  • Fistulas, which are holes or connections that form between two organs
  • Small tears in the anus, called anal fissures
  • How large, swollen, or severely inflamed the haemorrhoids are
  • Prolapsed haemorrhoids
  • Any abnormal masses in your anus and rectum
  • Narrowing of the anal canal, also called anal stenosis

There are several treatment options for piles. Therapies are generally divided into treatments that do not require surgery (non-operative) and treatments that do require surgery (operative).

The following treatment options are available at Circle Health Group.

Non-operative treatments

Below are some options for non-operative piles treatment at Circle Health Group hospitals.

Rubber band ligation

Rubber band ligation, also called haemorrhoid banding, is a simple, quick and effective technique to get rid of internal piles. In the procedure, your consultant will apply a tight rubber band to the internal haemorrhoids, just above the anal canal.

By applying this band, the blood supply to the haemorrhoid is cut off, which makes the haemorrhoid shrink. This treatment can be performed in the consultant’s office, and no anaesthesia is necessary.

“Patients often tolerate this procedure very well,” explains Dr Mohamed. “They have a little bit of discomfort, they will feel as though they need to go to the toilet or as though something is stuck there [...], for a day or two. And they might get a little bit of bleeding, but essentially, it doesn't disrupt their lives too much and they make a very quick recovery in the vast majority of cases.”

However, as with any procedure, there are risks, explains Dr Mohamed. Severe pain shouldn't occur if the procedure is done correctly. Severe bleeding may occur very rarely.

Mild pain or discomfort around the rectum is the most common complication of rubber band ligation. This is usually relieved with warm baths or sitz baths, mild painkillers, and by taking stool softeners to avoid a hard stool.


Sclerotherapy, or injections for piles, are sometimes recommended for first- and second-degree haemorrhoids. The procedure involves injecting a chemical substance around the blood vessels to fixate and shrink the haemorrhoids.

Dr Mohamed notes, however, that many consultants do not use this technique anymore, as it is quite old and not very effective.

The only advantage of this technique is that it can be done in the consultation room, he says.

Surgical procedures

Operative or surgical procedures range from less invasive procedures to more highly invasive procedures, explains Dr Mohamed. As we move through this range, the amount of discomfort, inconvenience and difficulty of the recovery process increases, but so does the effectiveness of the procedure.

The HALO technique

The Circle Health Group hospitals offer the Hemorrhoidal Artery Ligation Operations (HALO) technique, also called the Transanal Haemorrhoidal Dearterialisation (THD) technique.

These procedures are essentially the same, says Dr Mohamed. Both are highly effective and minimally invasive surgical treatments for haemorrhoids. The only slight difference is in the instrument that is being used.

Both HALO and THD  require general anaesthetic and 5–6 stitches just above the anal canal, explains Dr Mohamed. He adds that the main advantage of the HALO and THD techniques ”is that they don’t involve any cutting, [and while] it is painful or uncomfortable for the first week, the recovery is usually quite rapid.”

The procedure is the ligation, or tying of a blood vessel — in this case, tying the internal haemorrhoid’s artery. Similar to banding, the end goal is to stop the blood supply to the haemorrhoid and therefore shrink it. However, in the case of the HALO technique, this is done with an ultrasound probe.

The HALO technique is less invasive than a haemorrhoidectomy — that is, surgery to remove or cut off haemorrhoids — and has a 90% patient satisfaction rate. Piles may reoccur after the HALO procedure in less than 10% of cases. 

Rafaelo technique

In the Rafaelo technique, the consultant is “inserting a probe into the internal haemorrhoid and essentially heating it up by doing what's called a radiofrequency ablation,” explains Dr Mohamed.

The Rafaelo technique can be performed as an outpatient procedure, and it usually lasts about 20 minutes. It can be done under general anaesthesia or other forms of anaesthesia.

“A lot of these techniques do not really add any extra advantage [compared] to either the banding or the femoral artery ligation,” says Dr Mohamed. However, people may come across them online, especially because the companies that supply the kits promote them, so they will often come up in the Google searches for treatments, he explains.


Haemorrhoidectomy is the removal or cutting out of haemorrhoids through surgery.

It is the most effective treatment for piles. The chances of the haemorrhoids returning are the lowest with this procedure. However, recovery is “exceptionally painful” and the procedure is “majorly disruptive” to the patient’s life, according to Dr Mohamed.

“I tell patients that it's very painful for the first two weeks, especially the first time they go to the toilet, and the wound in that area will take six to eight weeks to heal,” during which time the patient will experience some discomfort.

The procedure is very inconvenient, as no social activities are recommended during the first 1–3 weeks of recovery. Time off work during this period is also necessary, and people with childcare responsibilities will need to arrange for help, he advises.

The procedure is very helpful for people with large external haemorrhoids, haemorrhoid skin tags, and large prolapsing haemorrhoids, adds Dr Mohamed. The treatment is too excessive and not suitable for minor internal haemorrhoids.

Some of the complications that may occur with this procedure include:

  • An inability to fully empty the bladder, which can affect 30–50% of people
  • Bleeding
  • Sepsis
  • Unhealed wounds
  • Loss of sensation in the anus 

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Content reviewed by Mr Said Mohamed in May 2022. Next review due May 2025.

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