Hemorrhoids / Piles

Haemorrhoids, also known as piles, are swollen, engorged blood vessel cushions in and around the anal canal. Everyone is born with these cushions of tissue — they are a normal part of anal anatomy that helps maintain continence. Haemorrhoids become a medical condition, rather than a normal structure, when they become enlarged, engorged, or prolapsed, causing bleeding, discomfort, or a palpable lump.

Haemorrhoids are extremely common — by some estimates, around half of adults will experience symptomatic haemorrhoids by age 50 — and the great majority of cases are mild and highly treatable, often without surgery. The more important point for anyone researching this condition is that haemorrhoids share a key symptom, rectal bleeding, with more serious conditions including colorectal cancer, which is why self-diagnosis based on symptoms alone is not recommended, however classic the presentation seems.

How Haemorrhoids Develop

The anal canal contains cushions of blood vessels, connective tissue, and muscle that sit just beneath the lining, helping to create a seal that supports continence. These anal cushions become haemorrhoids when persistently increased pressure in the lower rectum — from straining, prolonged sitting, chronic constipation or diarrhoea, pregnancy, or age-related weakening of the supporting tissue — causes them to swell, stretch, and, in more advanced cases, prolapse downward or bulge outward.

Where a haemorrhoid sits relative to a landmark called the dentate line, roughly midway along the anal canal, determines both its type and how it behaves clinically:

Internal vs External Hemorrhoids

• Internal Hemorrhoids: Develop above the dentate line, in tissue supplied by the same nerves as internal organs. Because this tissue is not sensitive to typical pain stimuli, internal haemorrhoids are usually painless, most often presenting as painless bright red bleeding during bowel movements, or as a lump that prolapses (bulges out) during straining.
• External Hemorrhoids: Develop below the dentate line, covered by skin richly supplied with the same somatic nerves that make skin elsewhere painful to touch. External haemorrhoids are often felt as a lump and can cause itching, irritation, and swelling, and become intensely painful if a blood clot forms within them (a thrombosed external haemorrhoid).

The Four Grades of Internal Hemorrhoids

Internal haemorrhoids are graded using the Goligher classification, based on the degree of prolapse. This grading is central to treatment planning, since the most appropriate treatment differs considerably from one grade to the next.

• Grade I: Haemorrhoids are enlarged but do not prolapse out of the anal canal. May bleed, but are not visible or palpable externally.
• Grade II: Prolapse out of the anal canal with straining or bowel movements, but reduce (go back in) on their own afterward.
• Grade III: Prolapse with straining and require manual pushing back in; do not reduce spontaneously.
• Grade IV: Permanently prolapsed and cannot be pushed back in; the most advanced grade, often causing persistent discomfort and mucus discharge.

Thrombosed External Haemorrhoids: When Piles Become Acutely Painful

A thrombosed external haemorrhoid occurs when blood pools and clots within an external haemorrhoid, causing sudden, often severe pain, along with a firm, tender, blue-purple lump at the anal verge. Unlike the typically painless nature of internal haemorrhoid bleeding, this is often the most acutely painful presentation of haemorrhoidal disease, and it understandably prompts many people to seek urgent assessment.

Timing matters for treatment here. If seen within roughly the first two to three days of pain onset, surgical removal of the clot (excision or incision and evacuation) typically brings rapid relief and may reduce the chance of recurrence. Beyond this early window, the clot tends to gradually reabsorb on its own over one to two weeks, and treatment shifts toward conservative pain relief rather than a procedure, since the benefit of intervening surgically diminishes once the acute window has passed. This is why prompt assessment — rather than waiting out several days of severe pain at home — genuinely changes the treatment options available.

Haemorrhoids or Colorectal Cancer? Why Rectal Bleeding Should Never Be Self-Diagnosed

Rectal bleeding is the symptom most people associate with haemorrhoids, and it is also a symptom of colorectal cancer and other significant bowel conditions. This overlap is precisely why rectal bleeding, however “classic” it may seem for haemorrhoids, should always be properly assessed rather than assumed.

Certain features make haemorrhoids a less likely explanation and warrant a more thorough work-up, including a change in bowel habit, unintentional weight loss, iron-deficiency anaemia, a family history of colorectal cancer or polyps, blood mixed within the stool rather than simply coating it, or an age over 45 to 50 without a prior colonoscopy. None of these features prove that a more serious cause is present, but they are the reason a doctor may recommend a colonoscopy alongside, or instead of, a simple anal examination — not because haemorrhoids are unlikely, but because ruling out a more serious cause first is the only way to be confident that ongoing bleeding is safe to treat as haemorrhoidal.

Symptoms of Haemorrhoids

Internal haemorrhoids

• Painless, bright red bleeding during or after a bowel movement
• A sensation of a lump or fullness that appears with straining
• Mucus discharge, particularly with higher-grade prolapse
• A feeling of incomplete emptying

External haemorrhoids

• A lump felt at or around the anus
• Itching and irritation
• Swelling around the anus
• Sudden, severe pain and a firm, discoloured lump, if thrombosed

Risk Factors for Hemorrhoids

• Straining during bowel movements
• Prolonged sitting, particularly on the toilet
• Chronic constipation or diarrhoea
• A low-fibre diet
• Obesity
• Pregnancy — combines hormonal effects with increased pelvic pressure
• Age — the tissue supporting the anal cushions naturally weakens and stretches over time
• Heavy lifting or activities that repeatedly raise abdominal pressure

How Haemorrhoids Are Diagnosed

• Digital Rectal Examination: A gloved, lubricated finger examination of the lower rectum and anal canal, assessing for lumps, tenderness, and other abnormalities, and often the first step in assessment.
• Anoscopy: A short, rigid, illuminated instrument allows direct visualisation of the anal canal and lower rectum, the primary way internal haemorrhoids are formally identified and graded.
• Colonoscopy: Recommended when bleeding features are atypical for haemorrhoids, when there has been no prior colonoscopy at an appropriate screening age, or when other risk factors for colorectal disease are present — examining the full colon and rectum directly to exclude other causes of bleeding, including polyps and colorectal cancer.

Preventing Hemorrhoids

• Eat a high-fibre diet — fruit, vegetables, and whole grains soften stool and reduce the straining that contributes to haemorrhoids
• Drink plenty of fluids to help keep stool soft
• Avoid straining or holding your breath during bowel movements
• Respond to the urge to have a bowel movement promptly, rather than delaying
• Limit time spent sitting on the toilet, including avoiding reading or scrolling on your phone while seated
• Exercise regularly to support healthy bowel function and reduce constipation
• Maintain a healthy weight, since excess weight increases pressure on the pelvic veins