Piles

Common symptoms of piles include:

• painless bleeding from your anus, which you may notice in the toilet bowl or when you use toilet paper, or from soiled underwear
• a lump on your anus
• a slimy discharge of mucus
• a feeling that your bowels have not emptied completely
• itchy skin around your anus
• swelling around your anus
• pain and discomfort after a bowel movement if you have external piles

These symptoms may be caused by problems other than piles. You should visit your GP for advice.

The exact cause of piles is not known. One theory is that piles are a result of a weakness of the tissue that connects the anal cushions to the muscle layers underneath. In combination with frequently straining while passing hard bowel movements, this can cause the anal cushions to slide out of their usual place and down the rectum.

You are more likely to develop piles:

• if you eat a low-fibre diet
• if you strain to empty your bowels (for example, if you have constipation)
• as you age because the support structures in your rectum weaken
• if you´re pregnant
• if you´re born with a weakness in your rectum or have a family history of piles

Visit your GP if you notice any signs of bleeding from your rectum.

Your GP will ask about your symptoms and examine you. This may involve a rectal examination, where he or she will gently insert a gloved finger into your rectum. Your GP may also ask you about your medical history.

Your GP may use a proctoscope to look inside your rectum. A proctoscope is a narrow, tube-like telescopic camera. Air can be blown through the tube to open up the bowel so it can be seen more clearly. This test can help to rule out problems in your rectum.

Alternatively, your GP may refer you for a flexible sigmoidoscopy or colonoscopy test that will need to be done in hospital. This allows your doctor to look inside your large bowel. These tests are sometimes done to check that your condition is not caused by something more serious.

There are a number of treatments that can help relieve the symptoms of piles, but there is not a cure.

Self-help

Regular warm baths may relieve irritation and help to keep the anal area clean. It is important not to strain your bowels during a bowel movement. If you have daily bowel movements that are solid but soft, you wont need to strain as faeces will pass easily and wont put pressure on the blood vessels in your anal area.

Medicines

There are a range of medicines that can help relieve the symptoms of piles.

• If you are passing hard or infrequent faeces, you could try a fibre supplement such as ispaghula husk (eg Fybogel) or mild laxatives such as lactulose, which will soften your faeces. Don´t use laxatives that stimulate the bowel, such as senna, unless your doctor advises you to.
• Soothing creams, ointments and suppositories may ease any pain and itchiness. There are many different products available. Some contain a local anaesthetic such as lidocaine.
• Products containing corticosteroids, such as Anugesic-HC and Proctosedyl, may reduce inflammation and pain.

Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your doctor or pharmacist for advice.

If these self-help measures and medicines do not work, or you have a higher grade of piles, you may need to go into hospital for one of the following procedures.

Non-surgical treatments

These are treatments that you can have in hospital, but you won´t need to stay overnight.

Banding

This is used mostly to treat second degree piles, but you can also have it with first degree piles if medicines haven´t worked for you.
This procedure needs to be done using an endoscope. Your doctor will place a small elastic band just above the pile. This will cut off the blood supply to the pile, causing it to die and fall off after a few days. The area left behind will heal up naturally.

Sclerotherapy

In sclerotherapy your piles will be injected with an oily solution, which makes them shrivel up. Its used for first or second degree piles.

Other treatments include:

• infrared coagulation or laser, where infrared light is used to seal the veins above the pile causing it to shrink
• cryosurgery, which destroys the pile by freezing it - the pile will later shrink and fall off
• bipolar diathermy and direct current electrotherapy, where an electrical current is used to burn the pile off

However, there is little scientific evidence to support the use of these treatments. More research is needed.

Surgery

There are various surgical treatments for piles.

Conventional haemorrhoidectomy

This is the surgical removal of piles and is only used if you have severe piles and other treatments - such as banding and sclerotherapy - haven´t worked.

Conventional haemorrhoidectomy is done under general anaesthetic. This means you will be asleep during the operation. Your surgeon will cut the pile away from the muscle underneath and tie off the blood vessels to prevent bleeding. The exposed wound area will then heal naturally. Your surgeon may use stitches to close the wound.

Stapled haemorrhoidopexy

This is an alternative surgical technique that uses a specially-designed circular stapler. The stapler is inserted into the rectum and used to remove a doughnut-shaped piece of tissue above the piles. This pulls the haemorrhoids back up the anal canal and also reduces the blood supply to the piles, which shrink as a result. Recently a review of the value of this operation showed that compared with conventional haemorrhoidopexy, stapled haemorrhoidopexy led to less pain afterwards, a shorter stay in hospital and a shorter recovery time. However, there was a greater risk of piles returning and hanging down from your anus.

Haemorrhoidal artery ligation

In this procedure the small arteries that supply blood to the piles are tied with sutures. This causes the piles to shrink. It is sometimes referred to as HALO (haemorrhoidal artery ligation operation).

Special considerations

Piles are common in pregnant women. However, surgery is rarely considered an appropriate treatment since piles should get better after giving birth.

If you are pregnant, its important to modify your diet to include more fibre as this will help to soften your bowel movements. If this doesn't help, ask your GP about mild creams and ointments.

You can reduce your risk of developing piles. If you have daily bowel movements that are solid but soft, and you do not need to strain, faeces will pass easily and wont put pressure on the blood vessels in your anal area.

To keep your bowel movements soft try to:

• eat plenty of fibre-rich foods such as fruit, vegetables and wholegrain cereals (for example, brown rice, wholemeal bread and wholemeal pasta)
• drink plenty of fluids

1. Why does the skin around my anus get itchy when I have piles?

Itching is a common symptom of piles. It can happen if your piles are internal or external - each has a different underlying cause.

The itching you get when you have internal piles is caused by mucus passing from the lining of your rectum onto the skin around your anus. Your rectum is lined with a thin film called the rectal mucosa. It produces mucus to help keep the area lubricated and stop infections from entering your body through your anus. Piles can cause the rectal mucosa to slip down out of place. The mucus then passes onto the skin around your anus causing it to become irritated and itchy. This can also soil your underwear.

If you have external piles, the itching is usually caused by skin tags. These can trap moisture around the skin of your anus, which irritates the area. Skin tags can also make it difficult to clean yourself properly after you have had a bowel movement, which can lead to itching and discomfort.

You may find creams, ointments and suppositories ease any pain and itchiness. There are many different products available. Some contain a local anaesthetic such as lidocaine. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your doctor or pharmacist for advice.

It's important to remember that none of these treatments will cure your piles, they will only give short-term relief.

2. Are there any natural or herbal remedies that can help piles?

A number of herbal and natural remedies have been suggested as treatments for piles. In general, however, there is not enough evidence to show that they work. The best way to reduce symptoms without taking conventional medicines is to eat a healthy diet with enough fibre and drink plenty of water, as well as taking care to clean yourself after each bowel movement.

Sitz baths have long been considered a natural remedy for piles. A sitz bath is when you sit in a bath or basin filled with warm or cold water so that only your hips and buttocks are immersed. It's thought that the warm water draws blood flow to the area and relaxes the sphincter muscle (which controls the opening and closing of the anus), relieving pain. Cold water is thought to draw heat out of the piles and reduce the blood flow into them, so there is less pressure inside to make them feel inflamed.

Sitz baths are also considered helpful in keeping your anal area clean.

However, there is little evidence to show that sitz baths are effective, and there is uncertainty over the use of hot or cold water and how long you should immerse yourself for. As such, doctors don't recommend them as a treatment for piles.

Other remedies that have been suggested include flavonoid supplements. Flavonoids are water-soluble plant pigments found in some foods, for example soya and onions. It's not exactly clear how they work, but it's thought that taking flavonoid supplements has an anti-inflammatory effect and can strengthen blood vessels. However, flavonoids aren't licensed in the UK for treating piles and there is little evidence to show that they do actually work.

The best way to treat your piles naturally is to make changes in your diet so that you have softer, bulkier, more regular bowel movements. This will help to relieve constipation and reduce your need for straining on the toilet. Try to:

• eat plenty of fibre-rich foods such as fruit, vegetables and wholegrain cereals (for example, brown rice, wholemeal bread and wholemeal pasta)
• drink plenty of fluids - aim to drink six to eight glasses of fluids a day, and don't have caffeinated drinks

Good hygiene is also key in preventing symptoms. Cleaning yourself after a bowel movement can be uncomfortable when you have piles, but poor hygiene around your anus can make your symptoms worse and cause skin conditions such as dermatitis. Try using moistened towels or baby wipes rather than toilet paper and pat the area dry instead of rubbing it.

Speak to your GP if you have any questions or concerns about piles or treatments for them.

3. What treatments for piles can I get from the pharmacy?

There are several different kinds of creams, ointments and suppositories for piles that can be bought over-the-counter from your pharmacy. However, it's important to remember that these treatments will only relieve symptoms, they won't cure piles.

The aim of creams, ointments and suppositories is to soothe and relieve symptoms. There are several types of medicine available. They all contain different ingredients, which will have different effects on your symptoms.

• Local anaesthetics, such as lidocaine reduce pain by numbing the area.
• Local anaesthetics and astringents, such as Germoloids cream, ointment and suppositories and Hemocaine cream, reduce swelling and numb the area relieving pain.
• Corticosteroid and astringents, such as Anusol HC Plus and Anusol HC ointment and suppositories, help to reduce inflammation and swelling in the area.
• Corticosteroid and local anaesthetics numb the area giving pain relief, and reduce inflammation. Most of these are prescription-only. However, there are some over-the-counter brands available, such as Germoloids HC spray.

Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your doctor or pharmacist for advice. Don't use medicines containing anaesthetic for longer than a few days as your skin can become sensitive to them. Also, medicines containing corticosteroids should only be used for a maximum of seven days. If they are used for longer than this, your skin may become sensitive to them, begin to thin or develop ulcers. They can also cause dermatitis.

If you visit your GP, make sure you tell him or her if you're taking any over-the-counter medicines.

If you're pregnant, only use mild medicines that contain astringents and lubricants. Don't take medicines containing local anaesthetic or corticosteroid as it's possible that they may be harmful for you or your baby during pregnancy.

You can also take painkillers such as paracetamol to help relieve any pain you get from your piles. Don't take painkillers containing opioid analgesics, such as codeine, as they can cause constipation. Also, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aren't suitable if you have bleeding from your rectum.

It's important to remember that all these medicines are for the short-term relief of symptoms only and won't cure your piles. It's important to also change your diet to make your bowel movements softer, bulkier and more regular. This will help to relieve constipation and reduce your need for straining on the toilet.

If your symptoms continue to get worse despite using medicines, or if you have any questions or concerns, visit your GP.

4. What is haemorrhoidal artery ligation?

Haemorrhoidal artery ligation is a relatively new surgical procedure used to treat piles. It's also sometimes referred to as HALO (haemorrhoidal artery ligation operation).

Haemorrhoidal artery ligation is an operation that ties off certain arteries that supply blood to your piles. Surgery for piles is only considered if out-patient treatments haven't helped with your symptoms - only a small number of people with piles will need surgery.

The procedure is usually carried out as a day case under local anaesthetic. This completely blocks feeling from your bottom and you will stay awake during the operation.

In a haemorrhoidal artery ligation, a narrow, tube-like telescopic camera, called a proctoscope, is used to look inside your rectum. Air can be blown through the tube to open up your bowel so your doctor can see it more clearly. Your doctor uses this and an instrument called a miniature Doppler ultrasound probe to find the arteries that are supplying blood to your piles. These arteries are then tied off using dissolvable stitches. Once the blood supply has been cut off, the piles shrink in size.

The long-term effectiveness of this procedure is not yet clear, especially when compared to other treatments for piles. However, research has shown that people who have this operation spend less time in hospital and have fewer complications and less pain afterwards than those who have a haemorrhoidectomy (the surgical removal of piles).

If you have any questions or concerns about piles or surgical treatments for them, talk to your GP or doctor.

Once the blood supply has been cut off, the piles shrink in size. The long-term effectiveness of this procedure is not yet clear, especially when compared to other treatments for piles. However, research has shown that people who have this operation spend less time in hospital and have fewer complications and less pain afterwards than those who have a haemorrhoidectomy (the surgical removal of piles). If you have any questions or concerns about piles or surgical treatments for them, talk to your GP or doctor.