Haemorrhoids (Piles)

What are piles?
Piles (also called haemorrhoids) are swollen veins located in the lower rectum and anus, which result from a variety of causes. They can be located either inside the rectum (internal haemorrhoids) or just under the skin around the anus (external hemorrhoids).
How do I know if I have piles?

The most common symptom is painless bleeding during bowel movement, which can range from a streak on the toilet paper to a splash in the pan.

Internal piles have delicate surfaces that bleed upon contact with the movement of stools, and especially so when stools are hard when one is constipated. When piles enlarge, straining on bowel movement can cause them to protrude beyond the anal opening, giving rise to prolapsed piles.

Prolapsed piles can be a source of discomfort, pain (when strangulated of its blood supply) or irritation/itch.

External piles can itch or bleed when irritated. Occasionally, they can form as a result of blood pooling under the skin, causing sudden pain and swelling (perianal haematoma).

Other symptoms include:

  • Lumps around the anus
  • Anal pain or discomfort
  • Anal itch or irritation
  • Leaking of faces
What causes piles?

Veins in the lower rectum and anus are a normal physiological feature, but these veins will swell in response to increased pressure in the lower rectum.

The causes for increased pressure include:

  • Straining during bowel movement
  • Prolonged sitting on a toilet
  • Chronic diarrhoea or constipation
  • Obesity
  • Pregnancy
  • Anal intercourse
When should I consult a doctor?

While rectal bleeding is the most common symptom of piles, not all rectal bleeding is caused by piles. Do not assume rectal bleeding is from piles until you get it checked out by a doctor. The symptoms of colon and rectal cancer are similar to those of piles, and only the appropriate investigations will be able to distinguish these two very different conditions.

If the bleeding is excessive, or if you experience shortness of breath or light-headnessness from it, it might just mean that your blood reserves are low. You will certainly be advised to seek urgent medical attention then.

If the bleeding is not a fresh red, but a dark maroon or black, or is accompanied with other symptoms like difficulty passing motion or a change in bowel habits, you should also get it checked out by your doctor.

Your doctor will be able to do a thorough medical examination after finding out more about the circumstances around the piles, before suggesting the appropriate treatment.

What are the potential complications of piles?

In addition to excessive bleeding which can lead to anaemia and consequent weakness and faintness, piles that have prolapsed can also be complicated with strangury.

Strangulation of piles occurs when the blood supply is cut off, often after it has prolapsed. Upon strangulation, it swells further and can lead to gangrene.

What should I expect from a consultation with the doctor?

The doctor will start with a detailed interview on your medical background before asking about the circumstances around the current problem of piles. A physical examination will then be performed, which includes a rectal examination. The rectal examination is not painful, and is required to visualise the lower rectum and anal canal for the presence of internal piles.

Based on the history and physical examination, your doctor will then proceed to propose a management plan, which may include a thorough examination of the colon with a colonoscopy. This might be required if you are at risk of having colorectal cancer, or if your symptoms are suggestive that you might have another digestive problem.

What are my treatment options?

Depending on the severity, your doctor may propose one of three available options:

Medication and lifestyle changes

  • Medication can help to smoothen bowel movement (lactulose, fybogel), as can dietary fibre by increasing the consumption of fruits, vegetables and unprocessed cereal
  • Medication may also be given to normalise the venous circulation (Daflon; micronised purified flavonoid fraction), to alleviate the symptoms of bleeding and discomfort caused by piles
  • Creams and suppositories can occasionally be given to alleviate mild itch and discomfort on a temporary basis
  • Increasing dietary fibre to improve bowel movement should be taken, to decrease the need to strain. Prolonged toileting sessions should be avoided by discouraging unnecessary concomitant habits of reading while on the toilet seat

Rubber band ligation

  • Tiny rubber bands can be placed over the base of the swollen veins (piles), causing them to wither and fall off. Ligation is simple and effective, but is limited by the size of the piles. There is some mild discomfort and tenesmus (feeling of wanting to open bowels) for about 2-4 days after the procedure, before the ligated piles fall off. There can occasionally be some bleeding when the piles fall off, but this is normally mild and stops spontaneously.


  • Surgery is required if the piles are complicated (prolapsed, strangulated or gangrenous) or too large to be ligated by the rubber bands
What are the surgical options for piles?

Surgery is performed under general or regional anaesthesia, and a same-day discharge is normally expected. There are a few surgical options available, the choice of which will depend on your circumstances and choice, after knowing the advantages and relative limitations of each method. Your surgeon will explain all these in detail before you make your choice.

  • Conventional piles removal (conventional haemorrhoidectomy): Piles are removed together with the adjoining external tag of skin, creating in an open wound at the anus that might take 6-8 weeks to completely heal. There is a little more post-operative pain as compared to the other methods, and the post-operative care of the wound is simple, requiring a regular shower hosing after bowel movement.
  • Stapler procedure (stapled haemorrhoidectomy): Piles are removed on the inside of the anal canal with a special stapler device, without the need for an external wound. By the stapling of the anal canal with a row of tiny titanium staples, the blood supply to any possibly remaining piles is reduced, causing their eventual shrinkage. Post-operative pain, as a result, is expected to be less and a faster return to work is expected.
  • THD (transanal haemorrhoidal dearterialisation): A thin viewing device is used to locate the blood vessels that supply the piles in the anal canal, and these vessels are tied off using sutures. Once the blood supply is cut off, the piles are expected to shrink over several weeks. While there is less pain associated with this procedure (as there is no external wound), there can be some anal discomfort and tenesmus (feeling of wanting to open bowels) as a result of the swelling caused by the stitching, which will resolve once the piles shrink.
What are the possible complications of piles surgery?

After the effects of the anaesthesia wear off, there will be some discomfort and tenesmus in the anus. The discomfort or pain can be controlled with medication, and will resolve eventually when the wounds heal.

Some patients might have difficulty passing urine after the operation, and will need a temporary tube to help with urinary passage.

During the recovery period the following uncommon complications can possibly occur:
  • Bleeding: Usually mild, but rarely excessive, occurring 7-10 days after surgery
  • Constipation: Which can lead to a painful anal tear (anal fissure)
  • Infection: Scar tissue causing a tightening of the anal canal (anal stenosis)

The following are rare complications of piles surgery:

  • Faecal incontinence
  • Tear in the rectum (rectal perforation)
  • Tear of the rectum leading into the vagina if you are a woman (anovaginal fistula)
What kind of care should I have after surgery for piles?

Most patients are able to return home on the same day as surgery, and can expect to have a combination of medications to relieve pain, smoothen bowel movement and normalise anal blood circulation.

If you have undergone conventional piles removal, you should use a gentle shower spray with lukewarm water for clean yourself after bowel movement. Dap (not rub) the area dry gently with a soft cotton towel. Alternatively, use a hair dryer. No dressing is required, but most patients find it convenient to use a panty liner to prevent staining of undergarments from the expected wound discharge.

If there is significant swelling in the anal area, most patient find relief in soaking the area with plain warm water 10-15 minutes 2-3 times a day in a sitz bath.

How can I prevent piles?

Piles can be managed or possibly prevented with the following measures

  • Adopting a high fibre diet: More fibre increases the bulk of the stools, and with plenty of fluids, keeps it soft and smooth. It will help avoid the straining which can cause piles. If fruits and vegetables are not readily accessible, consider taking dietary fibre supplements, which can be conveniently packaged as in Fybogel satchets
  • Drinking plenty of fluids: To keep the stools soft, keep adequately hydrated especially in hot weather and after exercise
  • Do not strain during bowel movement: This increases the pressure in the lower rectal and anal veins
  • Do not read or surf the Internet while on the toilet: Minimising the time spent toileting can help prevent high pressures in the lower rectum and anal veins
  • Exercise: Stay active to prevent prolonged sitting or standing, and to lose weight