Piles aka haemorrhoids

July 21, 2023

Haemorrhoids, commonly known as piles, are swellings containing enlarged blood vessels that are present inside or around the lower part of rectum and anus. Internal haemorrhoids are present along the inner lining of rectum and are mostly painless. External haemorrhoids are located under the skin around the anus. Globally the prevalence of symptomatic haemorrhoids is estimated at 4.4% in the general population.

Causes of Haemorrhoids:

  • Prolonged constipation - due to lack of fibre in diet, inadequate fluid intake
  • Having a family history of haemorrhoids
  • Age - as one gets older the risk of developing haemorrhoids increases

Haemorrhoids are associated with increased pressure in the blood vessels in and around the anus. The repeated passage of hard stools, straining and degenerative effects of ageing produces a shearing force on the fibrovascular cushions of the anal canal, leading to prolapse. These prolapsed cushions have impaired venous return resulting in bulge or swelling, which may be further aggravated by inadequate fibre intake, straining and conditions that increase the intra-abdominal pressure. This rise in pressure can cause the blood vessels to become swollen or inflamed.

Below are the factors that increase the pressure on your pelvic blood vessels:

  • Being obese or overweight, pregnancy, chronic diarrhea
  • Lifting heavy objects
  • Straining during physical activity such as coughing, sneezing & vomiting
  • People who sit or stand for long periods

Haemorrhoids are classified based on their relation to the dentate (pectinate) line, Internal haemorrhoids originate above the dentate line, whereas external haemorrhoids originate below the line. This line demarcates the transition of squamous epithelium and columnar epithelium.

In simple terms, there is a change in the inner lining of our anus which is called the dentate line. Piles that lie above this line are called internal haemorrhoids, the ones below the dentate line are called external haemorrhoids. The main difference from a patient's perspective is that internal haemorrhoids are typically painless, while external haemorrhoids may cause pain.
Internal vs external haemorrhoids- dentate line separates the 2

Symptoms of External haemorrhoids:

  • Lumps or swelling around your anus
  • Pain or tenderness in the anus, aggravated by sitting
  • Rectal bleeding
  • Itching, burning sensation
  • Thrombosed haemorrhoids - if blood pools in an external haemorrhoid and forms a thrombus, it causes severe pain, hard lump near your anus & swelling.

Symptoms of Internal haemorrhoids:

  • As internal haemorrhoids are present inside the rectum, you cannot feel them and they rarely cause discomfort.
  • Presence of small amounts of blood during straining or irritation of passing stool.
  • Pain and Irritation due to prolapsed or protruding haemorrhoids.
Other perianal conditions like anal fissure, fistula, abscess, pruritis ani, skin infections also have similar perianal symptoms. Detailed history taking and confirmatory examination has to be done in these patients.

Diagnosis & Management of haemorrhoids:

  • To diagnose haemorrhoids, your doctor will ask about medical history and symptoms followed by physical examination.
  • Digital rectal examination to check the muscle tone, feel for lump or tenderness.
  • Examination with anoscopy to look into the anal canal.
  • If rectal bleeding is present, to rule out other conditions and to evaluate internal haemorrhoids, colonoscopy, sigmoidoscopy are done.

To decide optimal treatment, haemorrhoids are classified into 4 grades.

Treatment depends on the severity of symptoms and examination findings. Often haemorrhoids go away on their own after a few days, without needing treatment. Those occurring during pregnancy also get better after child birth.

Non-medical management:

At an early stage, lifestyle modifications such as fibre supplements, increasing fluid intake, relieving constipation, avoiding straining, sitz bath, topical preparations and improving anal hygiene can alleviate symptoms of haemorrhoid.

Many patients see their symptoms improve or get cured with these conservative methods.

Surgical & Nonsurgical management:

Surgery is done for patients who do not respond well to the outpatient treatment of haemorrhoids. Only a small fraction of the patients undergoing treatment for haemorrhoids require surgical management. Surgery includes excision of the vascular cushions, stapled haemorrhoidopexy and ligation of haemorrhoidal artery.

Nonsurgical management like rubber band ligation of the haemorrhoids, submucosal injection called as injection sclerotherapy and Infrared coagulation are used.

Several day care procedures are available for the management of haemorrhoids,

  • Open & Closed Hemorrhoidectomy
  • Stapled haemorrhoidopexy
  • Rubber band ligation
  • Injection sclerotherapy
  • Electrocoagulation
  • Infrared coagulation
  • Doppler guided haemorrhoidal artery ligation




  • Staying physically active - helps in bowel movement
  • Drinking plenty of fluids and increase in amount of fibre in diet (more fruits, vegetables and whole grains)
  • Not delaying the urge to empty your bowels
  • Avoid sitting for long periods, particularly in the toilet, straining when trying to pass stool.

What position helps easy passage of stools?

Before the advent of western closets squatting was the most natural way to empty bowels. The traditional Indian toilets are squat toilets. The bottom of our rectum has a muscle that wraps around it known as puborectalis. Contraction of this muscle narrows the rectum and prevents stool from coming down. Studies show that squatting allows your rectal muscles to relax in a straight line, reduces straining and constipation. In contrast, in sitting position the puborectalis muscle is not relaxed and the rectum maintains continence.

The simplest way to relax your rectal muscles while sitting on a toilet is to flex your hips. This can be achieved with the help of potty stools or squatty potty.

Placing this stool when sitting on a western closet will get your knees higher than your hips, helps in squatting, changes the anorectal angle, thus easy passage of stools.


Several other gastrointestinal diseases cause symptoms similar to haemorrhoids and rectal bleeding. These include anal fissure, anal fistulae, skin tags, perianal abscess, pruritis ani, inflammatory bowel disease, colorectal cancer etc., So it is important to consult a doctor if you’re having any of the above mentioned symptoms.