Piles (haemorrhoids): what actually helps, and when it isn't piles at all

Most people who decide they have piles have never had anyone look. A fair number have an anal fissure, which is treated differently and won't respond to the cream they've been using for a fortnight. Here's how to tell them apart, and what the evidence actually supports once you know.

Everyone has haemorrhoids; they're cushions of blood vessels and connective tissue sitting just inside the anal canal, and they help with continence by sealing the canal closed. The problem isn't that they exist; it's when they enlarge, become congested, or slip down out of position. That's when they start bleeding, itching, or getting in the way.

Where they sit determines how they feel. Internal piles form above the dentate line, in tissue with almost no pain nerve supply, which is why they can bleed steadily without hurting. External piles form below it, in skin with a full nerve supply, which is why those ones hurt. These two are the same condition, but with a different presentation; it's the reason people talk about piles in contradictory terms.

Internal piles are graded one to four:

1. Grade 1: they bleed but stay inside.
2. Grade 2: they come down when you strain and go back on their own.
3. Grade 3: they come down and need pushing back.
4. Grade 4: they stay down permanently and can't be pushed back.

What grade your piles fall into determines how you should treat them and the next steps to take. A grade 1 or 2 will usually settle with fibre, fluid and time, with a topical product taking the edge off while that happens. A grade 3 or 4 won't; no cream will pull prolapsed tissue back into the anal canal and hold it there. If you're pushing something back after every bowel movement, you need to book an appointment with your GP to discuss other options. 

The first distinctive symptom is whether it hurts when you go.

An anal fissure is a tear in the lining of the anal canal, usually caused by passing a hard stool. It produces sharp pain during a bowel movement, often described as passing glass or razor blades, followed by a burning ache that can last anywhere from a few minutes to a couple of hours afterwards. There's often bright red blood on the paper. People find themselves putting off going to the toilet because it's so painful, which hardens the stool further and tears it again.

Internal piles bleed without pain, so the typical description is blood on the paper or in the bowl with nothing to feel. Alongside that you might get itching, mucus discharge, or a sense that you haven't finished. If there's a lump, it usually appears with straining.

Painless bleeding points to piles, painful bleeding points to a fissure; don't use this as definite, and they're meant to be diagnostics on their own, but they can give you a good idea of what you might be dealing with and which direction to lean in. A thrombosed external pile is extremely painful, but it comes on suddenly as a hard, tender lump rather than as pain tied to the timing of a bowel movement.

Two other things get mistaken for piles regularly. Skin tags left behind after a pile or a thrombosis has resolved are common, harmless, and not active piles; though people treat them as though they are. And persistent perianal itching without piles is often caused by over-washing or by prolonged use of a steroid cream; which means the treatment ends up causing the problem it was bought for. 

Both problems need the stool softened, but a fissure that doesn't settle needs something that relaxes the anal sphincter to let it heal. Treating a fissure with pile cream for a month doesn't do anything for it other than waste your time and money. Working out which one you're dealing with can be quite difficult and is what an examination is for, so if you find creams aren't doing anything, or you are struggling to determine what you are suffering with, booking in with a GP despite how uncomfortable and awkward you may find it will be the best course of action.

Piles are a pressure problem; anything that repeatedly raises pressure inside the abdomen and the anal canal, or that weakens the tissue holding those cushions in place, makes them more likely.

Straining is the main one, and it usually comes from constipation. Hard stool means pushing; pushing raises pressure, and over time the supporting tissue stretches and the cushions slip. Chronic diarrhoea does damage too, through frequency, urgency and repeated irritation rather than through straining.

Time on the toilet is underrated and rarely mentioned. Sitting on a toilet leaves the perianal area unsupported, and the longer you sit the more the cushions engorge. Ten minutes doom scrolling on your phone is ten minutes of sustained pressure. In practice this is now one of the more common contributors, and it's also one of the easiest to change: go when you need to, and leave when you're done. If nothing's happening after a few minutes, get up and come back later rather than sitting it out.

Pregnancy and childbirth raise abdominal pressure, slow the bowel, and add the strain of delivery. Very common.

Age matters because the connective tissue supporting the cushions weakens over time, which is why prolapse becomes more likely with age even without much straining.

Heavy lifting, whether occupational or in the gym, raises intra-abdominal pressure repeatedly. Breath-holding under load makes it worse.

Being significantly overweight raises baseline abdominal pressure and is often accompanied by a lower fibre intake, so the two effects compound.

Fibre and fluid

A Cochrane review pooled seven randomised trials covering 378 people with symptomatic piles, comparing fibre against placebo or no treatment. The risk of symptoms persisting rather than improving fell by 53% in the fibre group (RR 0.47, 95% CI 0.32 to 0.68), and bleeding specifically was roughly halved (RR 0.50, 95% CI 0.28 to 0.89). Trials that followed people up at six weeks and three months found the benefit held over time. ^[1]

It's important to note the review authors flagged the risk of publication bias and only moderate study quality, and the trials were small. More importantly, the benefit was specific. Pooled results for prolapse, pain and itching drifted toward no effect, so fibre reduces bleeding and overall symptom persistence but shouldn't be expected to stop the itch.

What you should take from this is increase your fibre intake gradually, from food where you can, and drinking enough that it works with you rather than against you. If diet alone isn't getting you there, a bulk-forming agent like ispaghula husk does the same job. Raising fibre abruptly causes bloating and wind, which is why many people abandon it in week one, so increase it over a fortnight rather than overnight.

Creams, ointments and suppositories

These fall into a few groups. Local anaesthetics numb the area for a short period. Astringents such as zinc oxide and bismuth are soothing and mildly protective. Corticosteroid-containing products reduce local inflammation and are the strongest option. 

These all treat the symptoms, none of them have been shown to shrink a pile, pull prolapsed tissue back, or shorten how long the underlying problem lasts. That isn't to say they don't have their use, itching and soreness are the symptoms people actually want gone, and they're the symptoms that fibre doesn't treat. The best advice is to use a topical product for comfort while increasing your fibre to get rid of the piles.

Steroid-containing products for piles are only licensed for short courses, which is defined as five to seven days. The reason they are limited to this, is due to what topical steroids do to skin over time. Thinning of the skin can follow extensive use, the area shouldn't be covered over with dressings (occluded) or anything that traps the product against it, as it can increase the amount of product absorbed, enough steroid can be absorbed into the bloodstream to affect the body's own hormone production, even without anything covering it. Perianal skin is thin, it's naturally occluded by anatomy, and it's one of the easier places on the body to thin with repeated steroid use. Thinner skin tears more readily and itches more, carrying on with the cream past the seven days can cause the problem to get worse rather than better. 

This is the most common mistake made with piles creams. They get a cream, it helps, symptoms come back when they stop, so they use it again or after 7 days the problem hasn't fully gone away so they carry on for a few days more, causing the problem to re-occur over and over and get caught in a cycle.

Piles are common in pregnancy and very common in the weeks after birth. Progesterone relaxes the bowel and slows things down, the growing uterus raises pressure in the pelvis, and the pushing stage of labour adds a short burst of very high pressure. Plenty of women get their first piles in the days after delivering.

The good news is that pregnancy-related piles often settle on their own once the pressure comes off, so the aim is usually to keep you comfortable rather than to treat them aggressively.

Conservative like keeping stool soft with fibre and fluid, not delaying when you need to go, not sitting on the toilet longer than necessary, and lying on your side rather than sitting for long stretches where you can, should provide enough relief.

Steroid-containing products need more thought in pregnancy and should generally be avoided during the first trimester, due to a possible increased risk of oral clefts with first-trimester glucocorticoid exposure, and prolonged use in particular must be avoided. They should only be initiated by a GP after the benefits have been weighed against the risks in pregnant and breastfeeding women.

Simpler soothing preparations are generally more appropriate, but always check with a pharmacist, doctor or midwife before using any piles treatment.

Sometimes a clot forms in an external pile. It comes on suddenly, over hours rather than days, as a firm purple or blue lump at the anal margin, and it hurts considerably more than piles usually do. People often describe it as the worst pain they've had down there and are convinced something serious has happened.

It's self-limiting. Pain typically peaks somewhere around 48 to 72 hours and then eases over the following week or so as the clot breaks down and reabsorbs. Left alone they will usually resolve. 

Timing does affect your options, though. If you're seen early, while it's still acutely painful, removing the clot surgically under local anaesthetic is one route, and it can shorten how long you're uncomfortable. Later on, once the pain is already improving, there's little to gain and conservative treatment is the sensible course.

Several coloproctology societies favour conservative management as first-line regardless of timing, and there aren't formal guidelines specific to this. So if it's severe, get seen promptly so the option is on the table, rather than deciding on your own that nothing can be done.

In the meantime, pain relief, keeping stool soft, and cold compresses are some good options while it takes care of itself.

If fibre, fluid and topical treatment haven't sorted things, or if the piles are prolapsing, there are procedures that can be done to solve your piles. Most are done as outpatient appointments rather than proper operations, and you'd be referred by your GP.

Rubber band ligation is the most common. A small band is placed at the base of an internal pile, cutting off its blood supply so it shrinks and drops off over about a week. It's quick, doesn't usually need anaesthetic because it's placed above the pain-sensitive zone, and it's the usual first choice for grade 2 and grade 3 piles.

Sclerotherapy involves injecting a solution that scars and shrinks the pile. Sometimes preferred for people on blood thinners, where banding carries more bleeding risk.

Infrared coagulation uses heat to achieve much the same effect, generally for smaller grade 1 and 2 piles.

Haemorrhoidal artery ligation and stapled haemorrhoidopexy are day-case procedures that either cut the blood supply or lift prolapsed tissue back into position.

Haemorrhoidectomy, actual surgical removal, is reserved for grade 4 piles or cases where everything else has failed. It's effective and it's the most uncomfortable to recover from, which is why it isn't the starting point.

None of this happens quickly, and do not keep them as a reason to avoid getting seen. The far more common outcome of a referral is being told it's grade 1 or 2, that banding isn't needed, and to sort your fibre out.