Haemorrhoids (piles)

Haemorrhoids, also known as piles, are swellings containing enlarged blood vessels that are found inside or around the bottom (the rectum and anus).

In many cases, haemorrhoids don't cause symptoms, and some people don't even realise they have them. However, when symptoms do occur, they may include:

• bleeding after passing a stool (the blood is usually bright red)
• itchy bottom
• a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool
• a mucus discharge after passing a stool
• soreness, redness and swelling around your anus

Haemorrhoids aren't usually painful, unless their blood supply slows down or is interrupted.

When to seek medical advice

See your GP if you have persistent or severe symptoms of haemorrhoids. You should always get any rectal bleeding checked out, so your doctor can rule out more potentially serious causes.

The symptoms of haemorrhoids often clear up on their own or with simple treatments that can be bought from a pharmacy without a prescription (see below). However, speak to your GP if your symptoms don't get better or if you experience pain or bleeding.

Your GP can often diagnose haemorrhoids using a simple internal examination of your back passage, although they may need to refer you to a colorectal specialist for diagnosis and treatment.

Some people with haemorrhoids are reluctant to see their GP. However, there’s no need to be embarrassed, because GPs are very used to diagnosing and treating haemorrhoids.

Read more about diagnosing haemorrhoids.

What causes haemorrhoids?

The exact cause of haemorrhoids is unclear, but they're associated with increased pressure in the blood vessels in and around your anus. This pressure can cause the blood vessels in your back passage to become swollen and inflamed.

Many cases are thought to be caused by too much straining on the toilet, due to prolonged constipation – this is often due to a lack of fibre in a person's diet. Chronic (long-term) diarrhoea can also make you more vulnerable to getting haemorrhoids.

Other factors that might increase your risk of developing haemorrhoids include:

• being overweight or obese
• age – as you get older, your body's supporting tissues get weaker, increasing your risk of haemorrhoids
• being pregnant – which can place increased pressure on your pelvic blood vessels, causing them to enlarge (read more about common pregnancy problems)
• having a family history of haemorrhoids
• regularly lifting heavy objects
• a persistent cough or repeated vomiting
• sitting down for long periods of time

Preventing and treating haemorrhoids 

Haemorrhoid symptoms often settle down after a few days, without needing treatment. Haemorrhoids that occur during pregnancy often get better after giving birth.

However, making lifestyle changes to reduce the strain on the blood vessels in and around your anus is often recommended. These can include:

• gradually increasing the amount of fibre in your diet – good sources of fibre include fruit, vegetables, wholegrain rice, wholewheat pasta and bread, pulses and beans, seeds, nuts and oats
• drinking plenty of fluid – particularly water, but avoiding or cutting down on caffeine and alcohol
• not delaying going to the toilet – ignoring the urge to empty your bowels can make your stools harder and drier, which can lead to straining when you do go to the toilet
• avoiding medication that causes constipation – such as painkillers that contain codeine
• losing weight (if you're overweight)
• exercising regularly – can help prevent constipation, reduce your blood pressure and help you lose weight

These measures can also reduce the risk of haemorrhoids returning, or even developing in the first place.

Medication that you apply directly to your back passage (known as topical treatments) or tablets bought from a pharmacy or prescribed by your GP may ease your symptoms and make it easier for you to pass stools.

There are various treatment options for more severe haemorrhoids. One of these options is banding, which is a non-surgical procedure where a very tight elastic band is put around the base of the haemorrhoid to cut off its blood supply. The haemorrhoid should fall off after about a week.

Surgery carried out under general anaesthetic (where you're unconscious) is sometimes used to remove or shrink large or external haemorrhoids.

Read more about treating haemorrhoids and surgery for haemorrhoids.

Your GP can diagnose haemorrhoids (piles) by examining your back passage to check for swollen blood vessels.

Some people with haemorrhoids are reluctant to see their GP. However, there’s no need to be embarrassed – all GPs are used to diagnosing and treating piles.

It's important to tell your GP about all of your symptoms – for example, tell them if you've recently lost a lot of weight, if your bowel movements have changed, or if your stools have become dark or sticky.

Rectal examination

Your GP may examine the outside of your anus to see if you have visible haemorrhoids, and they may also carry out an internal examination called a digital rectal examination (DRE).

During a DRE, your GP will wear gloves and use lubricant. Using their finger, they'll feel for any abnormalities in your back passage. A DRE shouldn't be painful, but you may feel some slight discomfort.

Proctoscopy

In some cases, further internal examination using a proctoscope may be needed. A proctoscope is a thin hollow tube with a light on the end that's inserted into your anus.

This allows your doctor to see your entire anal canal (the last section of the large intestine).

GPs are sometimes able to carry out a proctoscopy. However, not all GPs have the correct training or access to the right equipment, so you may need to go to a hospital clinic to have the procedure.

Types of haemorrhoids

After you've had a rectal examination or proctoscopy, your doctor will be able to determine what type of haemorrhoids you have.

Haemorrhoids can develop internally or externally. Internal haemorrhoids develop in the upper two-thirds of your anal canal and external haemorrhoids in the lower third (closest to your anus). The nerves in the lower part can transmit pain messages, while the nerves in the upper part can't.

Haemorrhoids can be further classified, depending on their size and severity. They can be:

• first degree – small swellings that develop on the inside lining of the anus and aren't visible from outside the anus
• second degree – larger swellings that may come out of your anus when you go to the toilet, before disappearing inside again
• third degree – one or more small soft lumps that hang down from the anus and can be pushed back inside (prolapsing and reducible)
• fourth degree – larger lumps that hang down from the anus and can't be pushed back inside (irreducible)

It's useful for doctors to know what type and size of haemorrhoid you have, as they can then decide on the best treatment.

Read more about treating haemorrhoids.

Haemorrhoids (piles) often clear up by themselves after a few days. However, there are many treatments that can reduce itching and discomfort.

Making simple dietary changes and not straining on the toilet are often recommended first.

Creams, ointments and suppositories (which you insert into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.

If more intensive treatment is needed, the type will depend on where your haemorrhoids are in your anal canal – the lower third (closest to your anus) or the upper two-thirds. The lower third contain nerves which can transmit pain, while the upper two-thirds do not.

Non-surgical treatments for haemorrhoids in the lower part of the canal are likely to be very painful, because the nerves in this area can detect pain. In these cases, haemorrhoid surgery will usually be recommended.

The various treatments for haemorrhoids are outlined below. 

Dietary changes and self care

If constipation is thought to be the cause of your haemorrhoids, you need to keep your stools soft and regular, so that you don't strain when passing stools.

You can do this by increasing the amount of fibre in your diet. Good sources of fibre include wholegrain bread, cereal, fruit and vegetables.

You should also drink plenty of water and avoid caffeine (found in tea, coffee and cola).

When going to the toilet, you should:

• avoid straining to pass stools, because it may make your haemorrhoids worse
• use moist toilet paper, rather than dry toilet paper, or baby wipes to clean your bottom after passing a stool
• pat the area around your bottom, rather than rubbing it

Read more about preventing constipation.

Medication

Over-the-counter topical treatments

Various creams, ointments and suppositories (which are inserted into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.

These medicines should only be used for five to seven days at a time. If you use them for longer, they may irritate the sensitive skin around your anus. Any medication should be combined with the diet and self-care advice discussed above.

There's no evidence to suggest that one method is more effective than another. Ask your pharmacist for advice about which product is most suitable for you, and always read the patient information leaflet that comes with your medicine before using it.

Don't use more than one product at once.

Corticosteroid cream

If you have severe inflammation in and around your back passage, your GP may prescribe corticosteroid cream, which contains steroids.

You shouldn't use corticosteroid cream for more than a week at a time, because it can make the skin around your anus thinner and the irritation worse.

Painkillers

Common painkilling medication, such as paracetamol, can help relieve the pain of haemorrhoids.

However, if you have excessive bleeding, avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, because it can make rectal bleeding worse. You should also avoid using codeine painkillers, because they can cause constipation.

Your GP may prescribe products that contain local anaesthetic to treat painful haemorrhoids. Like over-the-counter topical treatments, these should only be used for a few days, because they can make the skin around your back passage more sensitive.

Laxatives

If you're constipated, your GP may prescribe a laxative. Laxatives are a type of medicine that can help you empty your bowels.

Non-surgical treatments

If dietary changes and medication don't improve your symptoms, your GP may refer you to a specialist. They can confirm whether you have haemorrhoids and recommend appropriate treatment.

If you have haemorrhoids in the upper part of your anal canal, non-surgical procedures such as banding and sclerotherapy may be recommended.

Banding

Banding involves placing a very tight elastic band around the base of your haemorrhoids to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment.

Banding is usually a day procedure that doesn't need an anaesthetic, and most people can get back to their normal activities the next day. You may feel some pain or discomfort for a day or so afterwards. Normal painkillers are usually adequate, but your GP can prescribe something stronger, if needed.

You may not realise that your haemorrhoids have fallen off, as they should pass out of your body when you go to the toilet. If you notice some mucus discharge within a week of the procedure, it usually means that the haemorrhoids have fallen off.

Directly after the procedure, you may notice blood on the toilet paper after going to the toilet. This is normal, but there shouldn't be a lot of bleeding. If you pass a lot of bright red blood or blood clots (solid lumps of blood), go to your nearest accident and emergency (A&E) department immediately.

Ulcers (open sores) can occur at the site of the banding, although these usually heal without needing further treatment.

Injections (sclerotherapy)

A treatment called sclerotherapy may be used as an alternative to banding.

During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so that a scar is formed. After about 4 to 6 weeks, the haemorrhoid should decrease in size or shrivel up.

After the injection, you should avoid strenuous exercise for the rest of the day. You may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.

Electrotherapy

Electrotherapy, also known as electrocoagulation, is another alternative to banding for people with smaller haemorrhoids.

During the procedure, a device called a proctoscope is inserted into the anus to locate the haemorrhoid. An electric current is then passed through a small metal probe that's placed at the base of the haemorrhoid, above the dentate line. The specialist can control the electric current using controls attached to the probe.

The aim of electrotherapy is to cause the blood supplying the haemorrhoid to coagulate (thicken), which causes the haemorrhoid to shrink. If necessary, more than one haemorrhoid can be treated during each session.

Electrotherapy can either be carried out on outpatient basis using a low electric current, or a higher dose can be given while the person is under a general anaesthetic or spinal anaesthetic.

You may experience some mild pain during or after electrotherapy, but in most cases this doesn't last long. Rectal bleeding is another possible side effect of the procedure, but this is usually short-lived.  

Electrotherapy is recommended by the National Institute for Health and Care Excellence (NICE), and has been shown to be an effective method of treating smaller haemorrhoids. It can also be used as an alternative to surgery for treating larger haemorrhoids, but there's less evidence of its effectiveness.

Surgery

Although most haemorrhoids can be treated using the methods described above, around 1 in every 10 people will eventually need surgery.

Surgery is particularly useful for haemorrhoids that have developed below the dentate line because, unlike non-surgical treatments, anaesthetic is used to ensure you don’t feel any pain.

There are many different types of surgery that can be used to treat haemorrhoids, but they all usually involve either removing the haemorrhoids or reducing their blood supply, causing them to shrink.

Read more about surgery for haemorrhoids.

Surgery may be recommended if other treatments for haemorrhoids (piles) haven't worked, or if you have haemorrhoids that aren't suitable for non-surgical treatment.

There are many different surgical procedures for piles. The main types of operation are described below.

Haemorrhoidectomy

A haemorrhoidectomy is an operation to remove haemorrhoids. It's usually carried out under general anaesthetic, which means you'll be unconscious during the procedure and won't feel any pain while it's carried out.

A conventional haemorrhoidectomy involves gently opening the anus so the haemorrhoids can be cut out. You'll need to take a week or so off work to recover.

You'll probably experience significant pain after the operation, but you will be given painkillers. You may still have pain a few weeks after the procedure, which can also be controlled with painkillers. Seek medical advice if you have pain that continues for longer.

After having a haemorrhoidectomy, there's around a 1 in 20 chance of the haemorrhoids returning, which is lower than with non-surgical treatments. Adopting or continuing a high-fibre diet after surgery is recommended to reduce this risk.

Haemorrhoidal artery ligation

Haemorrhoidal artery ligation is an operation to reduce the blood flow to your haemorrhoids.

It's usually carried out under general anaesthetic and involves inserting a small ultrasound probe into your anus. The probe produces high-frequency sound waves that allow the surgeon to locate the vessels supplying blood to the haemorrhoid.

Each blood vessel is stitched closed to block the blood supply to the haemorrhoid, which causes the haemorrhoid to shrink over the following days and weeks. The stitches can also be used to reduce prolapsing haemorrhoids (haemorrhoids that hang down from the anus).

The National Institute for Health and Care Excellence (NICE) recommends haemorrhoidal artery ligation as a safe and effective alternative to a haemorrhoidectomy or stapled haemorrhoidopexy (see below). It causes less pain and, in terms of results, a high level of satisfaction has been reported.

The recovery time after having haemorrhoidal artery ligation is also quicker compared with other surgical procedures. There's a low risk of bleeding, pain when passing stools, or the haemorrhoid becoming prolapsed after this procedure, but these usually improve within a few weeks.

Stapling

Stapling, also known as stapled haemorrhoidopexy, is an alternative to a conventional haemorrhoidectomy. It's sometimes used to treat prolapsed haemorrhoids and is carried out under general anaesthetic.

The procedure isn't carried out as often as it used to be, because it has a slightly higher risk of serious complications than the alternative treatments available.

During the operation, part of the anorectum (the last section of the large intestine), is stapled. This means the haemorrhoids are less likely to prolapse and it reduces the supply of blood to the haemorrhoids, which causes them to gradually shrink.

Stapling has a shorter recovery time than a traditional haemorrhoidectomy, and you can probably return to work about a week afterwards. It also tends to be a less painful procedure.

However, after stapling, more people experience another prolapsed haemorrhoid compared with having a haemorrhoidectomy. There have also been a very small number of serious complications following the stapling procedure, such as fistula to vagina in women (where a small channel develops between the anal canal and the vagina) or rectal perforation (where a hole develops in the rectum).

Other treatments

Other treatment options are available, including freezing and laser treatment. However, the number of NHS or private surgeons who perform these treatments is limited.

General risks of haemorrhoid surgery

Although the risk of serious problems is small, complications can occasionally occur after haemorrhoid surgery. These can include:

• bleeding or passing blood clots, which may happen a week or so after the operation
• infection, which may lead to a build-up of pus (known as an abscess) – you may be given a short course of antibiotics after surgery to reduce this risk
• urinary retention (difficulty emptying your bladder)
• faecal incontinence (the involuntarily passing of stools) 
• anal fistula (a small channel that develops between the anal canal and surface of the skin, near the anus)
• stenosis (narrowing of the anal canal) – this risk is highest if you have treatment on haemorrhoids that have developed in a ring around the lining of the anal canal

These problems can often be treated with medication or more surgery. Ask your surgeon to explain the risks in more detail before deciding to have surgery.

When to seek medical advice

Seek medical advice from the hospital unit where the surgery was carried out, or from your GP, if you experience:

• excessive bleeding
• a high temperature (fever)
• problems urinating
• worsening pain or swelling around your anus

If you're unable to contact the hospital or your GP, call NHS 24 111 service for advice or visit your nearest accident and emergency (A&E) department.