Haemorrhoids (Piles)

Haemorrhoids are cushions of blood vessels and connective tissue that are normally present in the anal canal and help with bowel control. When these structures enlarge, slip downwards or develop a clot inside them, and this leads to complaints such as bleeding, swelling, itching or pain, the condition is called “haemorrhoidal disease”.

Haemorrhoids are considered in two main groups:

• Internal haemorrhoids: These develop inside the anal canal. They most often show themselves through painless, bright red bleeding and prolapse (slipping outwards).
• External haemorrhoids: These lie under the skin of the outer part of the anus. When a clot forms inside them, they can cause a painful, hard swelling that starts suddenly.

Haemorrhoids are a common health problem in the population, nothing to be embarrassed about, and in most patients they can be brought under control without the need for surgery [1,2].

What symptoms can haemorrhoids cause?

The most common symptoms are:

• Bright red bleeding during or after a bowel movement
• Blood on the toilet paper, on the stool or in the toilet bowl
• A swelling that comes out during a bowel movement or that can be felt by hand
• Itching, irritation, burning or a feeling of wetness around the anus
• A feeling of not having emptied the bowel completely
• A painful, hard swelling that starts suddenly when a clot forms inside an external haemorrhoid

Internal haemorrhoids mostly cause painless bleeding. If there is severe pain, other conditions such as an anal fissure, an abscess or a thrombosed (clotted) external haemorrhoid should also be considered.

Why do haemorrhoids develop?

The main factors that can make haemorrhoids more likely to develop are:

• Constipation and hard stools
• Straining for a long time during bowel movements
• Sitting on the toilet longer than necessary
• A diet low in fibre
• Frequent diarrhoea or very frequent bowel movements
• Pregnancy
• Excess weight
• Weakening of the supporting tissues with age
• Conditions that increase pressure inside the abdomen

Spicy foods on their own do not cause haemorrhoids. However, in some patients they can make complaints worse, especially burning and itching.

Is all bleeding from the back passage due to haemorrhoids?

No. Although haemorrhoids are one of the common causes of bleeding from the back passage, anal fissures, inflammatory bowel conditions, polyps and cancers of the large bowel can also cause bleeding.

For this reason, bleeding that appears for the first time, keeps coming back or is getting worse should not be dismissed with the thought “it is probably just piles”. If there is a change in bowel habits, unexplained weight loss, abdominal pain, anaemia or a family history of bowel cancer, assessment should not be delayed [1].

The diagnosis is usually made by listening to the patient’s complaints and examining the anal area. During the examination, external haemorrhoids, clotted swellings, anal fissures and other possible conditions are assessed.

Where necessary, the following may be carried out:

• A digital rectal examination (examination with a finger)
• Anoscopy, in which the anal canal is examined with a short, thin instrument
• Colonoscopic examinations, in which the rectum or the large bowel is assessed.

Colonoscopy is not mandatory for every patient with haemorrhoids. It may be recommended if the source of the bleeding cannot be explained, or if there is a change in bowel habits, anaemia, weight loss, a family history of colorectal cancer or a need for colorectal cancer screening. The decision on colonoscopy is made by considering the patient’s age, complaints and personal risks together [1].

Treatment for haemorrhoids is not the same for everyone. Treatment is decided according to the main complaint, such as bleeding, pain or prolapse, whether the haemorrhoids are internal or external, and the grade of the disease.

Lifestyle changes

For haemorrhoids that cause symptoms, the first step of treatment is to soften the stool and reduce straining.

Measures that may be recommended include:

• Eating more fibre-rich foods such as vegetables, fruit, pulses and whole grains
• Taking a fibre supplement when needed, on your doctor’s advice
• Drinking an amount of water appropriate to your state of health
• Not putting off going to the toilet
• Not straining too much during bowel movements
• Not sitting on the toilet for long periods and not using your phone there
• Staying physically active on a regular basis
• If there is constipation or diarrhoea, looking for its cause and treating it

Scientific studies show that increasing fibre intake reduces the general complaints associated with haemorrhoids and, in particular, bleeding [1,3].

The amount of fibre should be increased gradually, not all at once, to prevent wind and bloating. People who have to restrict their fluid intake because of heart or kidney disease should discuss the amount of fluid they drink with their doctor.

Are creams, suppositories and sitz baths helpful?

Creams and suppositories can relieve complaints such as itching, burning and swelling for a short time; however, they do not get rid of haemorrhoids permanently. Using products that contain cortisone or a numbing agent for long periods without supervision, in particular, can cause thinning of the skin, irritation or sensitivity.

A sitz bath in warm water may bring relief for some patients. Care should be taken that the water is not too hot and that no irritating soaps or chemical products are used.

It is advisable to consult a doctor about the choice of medicines and how long to use them. Current guidelines do not contain strong scientific evidence supporting the long-term use of these products [1].

What non-surgical procedures are there?

For internal haemorrhoids where bleeding or prolapse continues despite lifestyle changes, a number of procedures that do not require a hospital stay can be carried out. Each of these treatment options is described separately below.

Rubber band ligation

A small rubber band is placed at the base of the internal haemorrhoid. With its blood supply reduced, the haemorrhoid tissue shrinks and falls off on its own within a few days.

According to the current ASCRS guideline, rubber band ligation is one of the most effective office procedures for first- and second-degree internal haemorrhoids and in selected third-degree cases [1].

For a few days after the procedure there may be a feeling of fullness or pressure, or slight bleeding. If severe pain, fever, inability to pass urine or heavy bleeding develops, you should go to a healthcare facility immediately.

Patients taking blood-thinning medicines must tell their doctor about this before the procedure. These medicines should not be stopped without a doctor’s advice.

Sclerotherapy

A special medicine that makes the haemorrhoid tissue shrink is injected into it. It may be preferred particularly for some internal haemorrhoids in which bleeding is the main problem.

Infrared coagulation

Heat energy is used to reduce the blood supply to the haemorrhoid tissue and make it shrink. It is usually used for small, early-stage internal haemorrhoids.

These procedures can be short, and most patients can go home on the same day. However, depending on the size of the haemorrhoid and how it responds to treatment, the procedure may need to be repeated.

How is a thrombosed external haemorrhoid treated?

When a clot forms inside an external haemorrhoid, a hard, painful swelling that starts suddenly may develop at the edge of the anus.

Not every thrombosed external haemorrhoid has to be operated on. When the pain is easing or a few days have already passed, painkillers, measures to soften the stool and warm sitz baths may be enough.

In selected patients with severe pain whose symptoms have only recently started, surgical removal of the clotted haemorrhoid may provide faster relief and a lower chance of recurrence. The treatment decision should be made together with the doctor, according to how long the complaints have lasted and how severe they are [1].

When is surgery needed?

Surgical treatment may be considered in the following situations:

• Large external haemorrhoids
• Advanced internal and external haemorrhoids occurring together
• Haemorrhoids that stay outside all the time or cannot be pushed back in by hand
• Recurrent bleeding that affects daily life
• Complaints that continue despite non-surgical procedures
• Selected thrombosed external haemorrhoids with severe pain

What are the surgical treatment options?

Haemorrhoidectomy

This is the surgical removal of the haemorrhoid tissue. It is one of the most effective and lasting methods for advanced internal and external haemorrhoids. The recovery period may be more painful than after non-surgical procedures; however, the chance of recurrence is generally lower [1,2].

Haemorrhoidal artery ligation

This is based on locating and tying off the blood vessels that carry blood to the haemorrhoids. In some patients there may be less pain after the operation. However, compared with conventional haemorrhoidectomy, the chance of the haemorrhoids coming back or prolapsing again may be higher [1].

Stapled haemorrhoidopexy

This aims to lift the prolapsing internal haemorrhoid tissue back up using a special instrument. It does not treat external haemorrhoids directly. Although it may cause less pain in the early period in some patients, because of its chance of recurrence and the risks specific to the method, the current ASCRS guideline does not recommend it routinely as the first surgical option [1].

After rubber band ligation, sclerotherapy or infrared coagulation, most patients can go home on the same day and return to their daily lives within a short time. For a few days there may be slight fullness, discomfort or a small amount of bleeding.

In the first days after haemorrhoid surgery, pain and tenderness during bowel movements can be expected. Pain control, keeping the stool soft and preventing constipation are the most important parts of the recovery process.

The time it takes to return to work varies according to the method used and how physically demanding the work is. Some patients who work at a desk can return to work within about 1–2 weeks. For those in physically demanding jobs, or after haemorrhoidectomy, this period may extend to 2–4 weeks. Full recovery may take several weeks.

You should contact your healthcare team if any of the following develops:

• Bleeding that does not stop or is heavy
• Pain that keeps getting worse or cannot be controlled with medicines
• Fever or shivering
• Inability to pass urine
• Foul-smelling discharge
• Marked weakness, dizziness or fainting

1. Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Diseases of the Colon & Rectum. 2024;67(5):614–623. https://pubmed.ncbi.nlm.nih.gov/38294832/
2. van Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: Guideline for Haemorrhoidal Disease. Colorectal Disease. 2020;22(6):650–662. https://pubmed.ncbi.nlm.nih.gov/32067353/
3. Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the Treatment of Hemorrhoids Complications: A Systematic Review and Meta-analysis. American Journal of Gastroenterology. 2006;101(1):181–188. https://pubmed.ncbi.nlm.nih.gov/16405552/
4. National Institute for Health and Care Excellence. Haemorrhoids: Management. NICE Clinical Knowledge Summaries. https://cks.nice.org.uk/topics/haemorrhoids/management/management/