Piles

Symptoms Of Piles

Many people do not initially realize that they have piles because of not experiencing any symptoms. When symptoms occur, patients may have:

• Bleeding during passing the stool (the blood is usually bright red)

• Prolapse (protrusion of skin during passing the stool)

• Pain during passing the stool

• Itching in the anal area

• Presence of lumps in the anal area, which may require pushing back after passing the stool

• Mucus discharge especially while passing a stool which may be seen in your underwear or on toilet paper after wiping

• Redness and swelling around the anus

• Fecal seepage (the inability to control bowel movements, causing stool to leak unexpectedly from the rectum)

• Feeling of incomplete defecation even after going to the toilet

• Sitting for long periods to pass stool

• Abdominal pain

• Bloating

These symptoms usually get worse by excessive straining (pushing too hard to pass the stool), rubbing, and cleaning around the anus. 

Piles are often mistaken as some other gastrointestinal disorders because various anal symptoms of piles such as abdominal pain, bloating, and bleeding resembles other medical conditions?

Causes Of Piles

Piles, also known as hemorrhoids and hemorrhoidal disease involves the disturbances in the naturally occuring cushions like structure in the anal canal. These cushions are naturally present in the anus and are known as hemorrhoids. It comprises loose connective tissue, smooth muscle and blood muscles. The main function of hemorrhoids is to hold stool. 

The main cause of piles is exerting excessive pressure in the lower rectum which leads to increase in the size of anal cushions and degeneration of supportive tissues. This can be due to some disease conditions such as chronic obstructive pulmonary disease (COPD), enlarged prostate, constipation, ovarian tumor, etc. The anal cushions can also be affected by other conditions such as low fiber diet, pregnancy, advancing age etc.  

Some studies also suggest that abnormalities in the quality and quantity of collagen present in anal cushion can also cause piles.

Types Of Piles

Piles can be classified into four main categories:

1. Internal hemorrhoids

These types of piles develop deep within the rectum in the lining of anus and lower rectum. Due to their location, they are not visible and often remain asymptomatic. In most cases, they go away on their own.

However, larger hemorrhoids can cause several symptoms such as pain, itching, burning sensation, rectal bleeding, etc. 

2. Prolapsed hemorrhoids

Internal hemorrhoids are pushed into anal opening by passing stool or putting pressure on the anus leading to the formation of prolpased hemorrhoids. They can be graded according to the extent of protrusion:

• Grade 1: In this stage, internal hemorrhoids bulge into anal canal but do not prolapse .

• Grade 2: This grade is characterized by prolapse of the swollen veins in the presence of increased pressure in the rectal or anal area such as during defecation or straining. The protruded hemorrhoids reduce spontaneously on their own after passing stool.

• Grade 3: This grade is similar to grade 2 except that in this case, hemorrhoids do not go inside on their own. Instead, they require manual reduction. 

• Grade 4: The prolapse hemorrhoids cannot be pushed back into their normal position and can lead to intense and sudden pain. 

3. External hemorrhoids

Most people think of external hemorrhoids when they hear the word piles. These are the visible lumps that are formed under the skin around the anus. They cause more severe pain due to their external appearance which can disrupt daily activities such as sitting etc. 

4. Thrombosed hemorrhoids

As the name suggests, it refers to the internal or external hemorrhoids with a blood clot called thrombus. It is usually a complication of an untreated hemorrhoid and causes more severe symptoms such as intense pain, burning, itching, redness and swelling.

Risk Factors For Piles

Anything that can increase the pressure in the lower rectum for a long period of time increases the risk of piles. Various risk factors are discussed below:

1. Long term constipation

Constipation in the long run increases the chances of straining which can cause swelling of the veins of anus and lower rectum. This can lead to piles. 

Watch this video by our expert to know the simple ayurvedic remedies to relieve constipation.

2. Age

As we age, the fibers of the muscles that support normally existing hemorrhoids become weaker. This makes them less supportive and can lead to prolapse of piles. 

3. Diet

Low fiber diet leads to hardening of stools and increases the chances of straining. The constant straining can cause piles by injuring the local tissues. 

4. Chronic diarrhea

Chronic diarrhea is also associated with an increased risk of piles. In a study, patients suffering from diarrheal conditions such as colitis, malabsorption, intestinal bypass, and chronic pancreatitis were more prone to piles.

5. Overweight/obesity

The excess weight especially in the abdominal or middle region puts an extra pressure on anal veins which can lead to piles.

Obesity is one of the most complex and largely preventable diseases that affects around one-third of the world’s population. Here are some of the common health complications due to obesity in women.
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6. Pregnancy

It is the most common risk factor for piles as increased baby’s weight puts pressure on the pelvic blood vessels and anal region. 

Constipation is a common symptom during pregnancy which also increases the chances of piles. Here’s a quick guide with tips that can help to manage constipation in pregnancy.
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7. Family history

The chances of piles also increases, if someone in the family had piles in the past.   

Other factors that might increase the risk of piles include:

• Lifting heavy objects

• Persistent cough

• Repeated vomiting

• Sitting down for longer periods 

• Sitting on the toilet for long periods

• Living in developed countries

• Straining during bowel movements

• Faulty bowel function due to overuse of laxatives or enemas

• Spending long periods of time on the toilet 

• Sedentary lifestyle

• Higher socioeconomic status

• Injury to the spinal cord

• Rectal surgery

• Anal sex

• Inflammatory bowel disease

Diagnosis Of Piles

Piles is often confused with other anorectal disease such as fissures, fistulas, and abscesses. The complete diagnosis is important to confirm piles before initiating the treatment. The external hemorrhoids are usually diagnosed by physically analyzing the area around the anus whereas procedures such as digital rectal exam are performed to confirm internal hemorrhoids. 

1. Medical history 

The first step in diagnosing piles includes enquiry about the symptoms and medical history. The doctor also asks about the patient’s eating habits, toilet habits, laxative use, and current medical condition. 

2. Physical examination

Rectal examination involves the inspection of a person's lower rectum, pelvis, and lower belly. The test is performed by inserting the gloved finger into the rectum. This test checks external hemorrhoids, skin tags, prolapsing internal hemorrhoids, fissures, fistulas, and abscesses. The examination is also done by pressing the surface of the rectum to assess abnormal masses and tenderness. The technique is not usually painful, but you may feel some slight discomfort.

3. Anoscopy

It involves examination of the anus and lower rectum with the help of a device called anoscope. It is used to rule out other possible causes of rectal bleeding. The procedure requires the insertion of a tube into the rectum through the anus. The anal region is then inspected using a light. Patients are instructed to sit on a commode and strain during the exam to give an accurate idea about the degree of prolapse. 

4. Proctoscopy

This test is used to examine the internal organs of the rectum and anus using an instrument, known as protoscope. A protoscope is a straight, hollow metal or plastic tube, sometimes with light at the end. The instrument is a little larger than anoscope and helps in examining the entire anal canal. It is usually performed in case of red flag symptoms which includes bleeding, weight loss, change in bowel habits, or anemia.

5. Colonscopy

Colonoscopy is a procedure in which a doctor uses a colonoscope to look inside your rectum and colon. It is considered in patients with red flag symptoms.

6. Barium enema

The test includes the injection of barium enema (radio contrast fluid, barium sulfate) into the rectum from the anus. 

7. Other tests

In some cases, other tests such as hemoglobin, complete blood count (CBC), blood coagulation studies, liver function tests (LFT) are also performed.

Specialist To Visit

Piles is very common due to dietary habits and sedentary lifestyle. Various people experience symptoms but do not visit the doctor due to embarrassment. This worsens the condition of the patient and significantly impacts quality of life.

You should immediately consult the doctor if:

• Are constantly losing weight

• Your bowel habits have changed

• Your stool become dark or sticky 

• You are experiencing rectal bleeding

• You have a feeling of sitting on a foreign object

The symptoms of piles often resolve on their own or with simple treatments. However, speak to your doctor, if you have piles and there's no improvement after 7 days of treatment at home. 

The specialist doctors that can help in this condition include: 

• General physician

• Gastroenterologist

• Colorectal surgeon

• Proctologist (specializes in performing surgeries and treatment of the diseases related to the anus, colon, and rectum)

To get the right diagnosis, it is important to consult the right doctor. Consult India’s best doctors online.
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Prevention Of Piles

The proper education about the piles, its triggers and proper diet is vital for preventing piles. The following measures can aid in preventing piles:

• Maintain a healthy weight

• Eat fiber rich food

• Keep the bottom clean and dry

• Exercise regularly 

• Avoid excessive consumption of tea and coffee

• Avoid long periods of sitting 

• Go to the bathroom immediately when there is an urge to defecate

• Avoid taking mobile phones to the bathroom

• Elevate your feet on a support while defecating

• Avoid pushing too hard while passing stool

• Stay physically active

Treatment Of Piles

The very first line therapy involves lifestyle modifications and self care. Patients should adopt dietary modifications with adequate fluid and fiber intake. The treatment regimen is based upon symptoms and grade of piles which can be grouped as:

A. Non-surgical treatment

It includes medications and office based treatments. They are initiated, if simple home remedies fail to resolve symptoms and includes:

1. Medications

Medications are generally prescribed to ease the symptoms such as pain, irritation, swelling, and to soften the stool. 

• Topical treatments: Creams, ointments and suppositories are given to relieve discomfort. These medications are to be applied only for 5 to 7 days in a stretch as they may irritate the sensitive skin of the anus. In case of severe inflammation in the anal region, corticosteroid cream that contains steroids is also given.

• Pain relief medications: The common painkillers such as paracetamol are also used to relieve pain associated with piles. However, medications such as ibuprofen are avoided in case of excessive bleeding.  

• Laxatives: These medications soften the stools and help in emptying the bowel. Commonly used laxatives are ispaghula husk and lactulose. 

• Phlebotonics: Phlebotonics are a class of drugs consisting of plant extracts. They are available as dietary supplements and include diosmin, troxerutin, hydroxyethylrutoside, and calcium dobesilate. They have shown to reduce bleeding, itching, and discharge in piles. 

2. Hospital-based treatments

These therapies are used in case home remedies and medications fail to resolve symptoms. The various hospital-based treatment include:

• Rubber band ligation: It is one of the most popular non-surgical methods to treat piles due to its safety and cost effectiveness. The procedure involves inserting a band at the end of the internal hemorrhoid. The band restricts the blood supply to the hemorrhoid tissue. This helps in reducing and fixing the internal hemorrhoid.
  This method has a very high cure rate with very less chances of recurrence. This therapy is effective for first, second, and third-degree hemorrhoids. Multiple treatments may be necessary for large and bulky hemorrhoids.

• Injection sclerotherapy: It involves injecting sclerosants at the base of hemorrhoids. Sclerosants are chemical agents that lead to an inflammatory response and kill the hemorrhoid tissue. The commonly used agents include 5% phenol in an oil base, hypertonic saline, 5% quinine, and urea. 

• Electrotherapy: This therapy coagulates the blood supply in the hemorrhoids which causes shrinkage of the swollen tissue. 

• Cryotherapy: It is a rarely used technique and involves freezing of the piles using liquid nitrogen. 

• Infrared coagulation (IRC): In this procedure, few bursts of infrared light are delivered using a small probe. This helps in the coagulating of the blood supply to the hemorrhoids. 

B. Surgical treatment 

The surgical intervention is required in case:

• Inability to tolerate the hospital procedures

• Large external hemorrhoids

• Failure of non-operative procedures

• Mixed hemorrhoids with prolapse

• Grade 3 and 4 hemorrhoids

• Coagulopathic patients requiring management of hemorrhoidal bleeding 

Surgery involves either removing the hemorrhoid or restricting their blood supply which causes them to shrink. The various surgical procedures include:

• Hemorrhoidectomy: It involves removal of extra tissue that causes bleeding and protrusion. It is done for both internal and external hemorrhoids under anesthesia using sutures. Hospitalization and rest is required as postoperative care. 

• Stapled hemorrhoidectomy: In this, a stapler like device is used to reposition the hemorrhoids which eventually cut off their blood supply. 

• Haemorrhoidal artery ligation: In this procedure, the arteries supplying blood to the hemorrhoids are tied and cut off. 

Home-care For Piles

1. Follow good toilet practices

There are various toilet behaviors such as excessive straining, pushing, and prolonged time on the toilet that can contribute to piles. The following measures should be taken to follow good toilet practice:

• Limit the toilet time to 3 to 5 minutes to prevent protrusion

• Avoid excessive wiping 

• Avoid straining to pass the stool to reduce the pressure on piles

• Use moist toilet paper to clean your bottom after passing stool

• Avoid rubbing the area around the bottom 
  
  

2. Do sitz baths 

Sitting in warm water for at least 15 minutes in a stretch is very helpful for relieving itching, pain, and burning sensation in the anal region. It should be practiced 2-3 times to help the healing process. Avoid adding any salts, lotions, or oils to the water as it can cause inflammation. A warm bath also helps in relieving itching and pain. 

3. Take high fiber diet/supplements

It is very important to keep the stool soft and regular in piles to avoid straining as excessive straining can worsen the condition. This can be done by keeping a good amount of fiber in the diet by including foods such as whole grain bread, cereal, fruit and vegetables. High fiber diet i.e 25g/day for women and 38g/day for men is recommended in piles. 

OTC supplements such as ispaghula husk can also be taken to soften the stool. Low fiber foods such as white bread, red meat, processed foods, and fried foods should be avoided. 

Here, have a  look at what foods to avoid when you are suffering from piles.

tap To Know

4. Maintain proper hydration

The patient should also take an adequate amount of water to keep stool consistency. 

Watch this video by Dr. Suchin Bajaj in which he addresses the importance of water, the amount of water to drink each day, and the benefits of drinking water. 

5. Avoid caffeinated beverages

It is advised to avoid or limit caffeinated beverages (tea and coffee) as they may harden the stools and make the process of defecation even more painful. 

6. Indulge in some physical activity

Exercise is found to be related to the regular bowel habit. The light physical activity also helps in relieving constipation. The patient of piles should spare some time for physical activity. 

7. Avoid spicy and processed foods

Spicy foods can aggravate the symptoms of piles such as pain, burning sensation, and discomfort and hence should be avoided.

8. Avoid certain medications

Painkillers such as codeine should be avoided as it can cause constipation. NSAID such as ibuprofen should also be avoided as it can increase rectal bleeding.

9. Use ice packs

Ice packs are an excellent tool for reducing swelling and pain associated with piles. Ice pack wrapped in a soft towel is kept for at least 15 minutes on the affected area. The procedure should be repeated on an hourly basis for immediate relief.

10. Sit right

The people having piles should elevate their feet while passing stool. This changes the position of rectum that allows easy passage of the stool. 

11. Modify your clothing

Patients can increase the healing process of piles by wearing loose-fitting, breathable, cotton underwear and pants. This can help prevent the area surrounding the piles from becoming irritated by excess sweat, and help reduce symptoms.

Watch this video by our expert to know the home remedies to ease the symptoms of piles.

Complications Of Piles

Most of the hemorrhoids are resolved with the treatment but it can rarely lead to following complications:

1. Skin tags

It refers to the flap of tissue that hangs off from the skin of anus. It develops when the clot of a thrombosed hemorrhoid dissolves. It often irritates the patient.

2. Anemia

The patient’s blood count can also drop due to bleeding from a chronic hemorrhoid. 

3. Infection

Untreated external hemorrhoids can also get infected due to the presence of sores. 

4. Strangulated hemorrhoid

Sometimes, blood flow is cut off from the prolapsed hemorrhoid. This can be very painful and cause bleeding. 

5. Blood clots

In various cases, a blood clot is formed in the piles. It is extremely painful and sometimes needs to be drained. 

6. Hemorrhage

It is the most common complication of piles in which hemorrhoids can rupture and can cause serious rectal bleeding. This requires immediate medical attention. Passing a very hard stool can aggravate this process. Patients may also come across various complications due to various procedures that are performed to treat piles.

Complications of hemorrhoidectomy

Patients who have undergone surgery usually experience pain and fullness within the first week following hemorrhoidectomy. The other complications include: 

Early complications:

• Bleeding

• Urinary retention

• Thrombosed external hemorrhoids

Late complications:

• Anal stenosis (narrowing of the anal canal that makes it difficult to pass stools)

• Skin tags

• Recurrent hemorrhoids

• Delayed hemorrhage

• Fecal or bowel  incontinence

Rare complications:

• Sepsis

• Abscess formation

• Excessive bleeding

• Peritonitis (inflammation of the inside of abdomen)

Complications of rubber band ligation

This procedure can be associated with delayed hemorrhage. The immunocompromised patients can develop sepsis that can be characterized as fever, perineal edema, and pain.

Alternative Therapies For Piles

1. Nutrition and dietary supplements

- Psyllium: It is a very well known fiber that is known for its stool softening effect. It reduces the pain associated with piles and makes the process of passing the stool smooth. It can be consumed with water or milk. Patients with inflammatory bowel disease should consult their doctor before consuming it. The dose of the psyllium should be gradually increased as excessive fiber can cause bloating. 

Looking for fiber supplements?

2. Herbs

The use of herbs in treating is a very well known and old practice. However, one should start taking the herbs under the supervision of a doctor. Some of the herbs that are used to manage piles are:

• Witch hazel (Hamamelis virginiana): This herb is either applied topically or used as a sitz bath. It is known to reduce the pain by temporarily shrinking piles. The various pads that are available in the market to treat piles contain witch hazel. 

• Goldenrod (Solidago virgaurea): It is used to reduce inflammation of hemorrhoids through topical application. 

• Gotu kola (Centella asiatica): It is used for venous insufficiency or varicose veins

• Yarrow (Achillea millefolium): It is used to treat bleeding that is associated with hemorrhoids. 

3. Other home remedies

• Castor oil: It reduces the size of the piles and eases the pain. It can be taken by adding in milk or can be applied topically on the affected region.

• Tea tree oil: It possesses antimicrobial properties and helps in keeping the inflamed site of piles germs free. It is applied topically on the affected area. 

• Coconut oil: It acts as a moisturizer and helps in relieving symptoms of piles such as swelling and inflammation. It also helps in reducing the urge of itching. 

• Myrtle essential oil: This oil improves bleeding, pain, irritation and itching for low-grade piles.

• Aloe vera: Aloe may provide relief from the burning, itching, and swelling caused by piles, when applied to the anus.

4. Homeopathy

The following homeopathic preparations are also used in piles.

• Aesculus: It is used to manage piles that have a burning sensation. 

• Collinsonia: It is used for chronic, itchy hemorrhoids with constipation. 

Living With Piles

The treatment of piles is not always satisfactory despite its easy diagnosis. It is best managed by a team of people dedicated to anorectal conditions. Piles are not life-threatening but seriously affect quality of life. 

Managing postoperative pain

The overall result of surgery varies from good to poor. The patient should expect pain and anal fullness in the first week after hemorrhoidectomy. The adequate pain control is achieved by using oral narcotics in addition to NSAIDs, muscle relaxants, and sitz baths. The use of stool softeners is also advised to avoid straining that may aggravate pain. Patients who have undergone surgery should reconsult their doctor, if their pain is getting worse as it may indicate a soft tissue infection. 

Educating patient

Patient education plays a very vital role in the post operative care and preventing recurrence. The nurse, dietitian, and pharmacist should encourage the patient to avoid constipation, drinking sufficient water, taking a stool softener, reducing body weight , avoiding prolonged seating, eating a high fiber diet, and avoiding excessive pain medication. These simple measures not only reduce the risk of hemorrhoids but also decrease healthcare expenses.

Managing relapse

The surgery for piles, especially for those who do not change their lifestyle are not always satisfactory. Pain, urinary retention, and recurrence are very commonly seen postoperatively. Individuals experiencing recurrence, prolapse, and bleeding of internal piles should immediately refer to a colorectal surgeon.