Piles are swollen blood vessels in and around the lower rectum and anus. The medical term is hemorrhoids, and they’re one of the most common conditions affecting adults. About half of all people will have hemorrhoids by age 50, according to Johns Hopkins Medicine. They range from a mild nuisance that clears up on its own to a painful, persistent problem that needs treatment.
Internal vs. External Piles
There are two types, divided by where they form. A natural boundary inside the anal canal separates them.
Internal piles develop inside the rectum, above that boundary. They’re covered by the same type of tissue that lines the inside of your gut, which means they typically don’t hurt. The most common sign is painless bright red blood on toilet paper or in the bowl after a bowel movement. You usually can’t see or feel them unless they’ve grown large enough to push out through the anus.
External piles form under the skin around the outside of the anus. Because this area is rich in nerve endings, external piles are more likely to itch, ache, and feel tender to the touch. You can often see or feel them as a small lump. If a blood clot forms inside one (called a thrombosed hemorrhoid), you may notice a dark blue or purple lump that causes severe pain when sitting, walking, or having a bowel movement.
What Causes Them
Anything that puts repeated or sustained pressure on the veins in the lower rectum can trigger piles. The most common culprits are straining during bowel movements, sitting on the toilet for long periods, and chronic constipation or diarrhea. Pregnancy increases risk because the growing uterus presses on pelvic veins, and the hormonal changes soften supporting tissue. Heavy lifting, obesity, and a low-fiber diet all contribute as well.
As you age, the connective tissue supporting the veins in your rectum and anus naturally weakens and stretches. That’s why piles become progressively more common from your 30s onward.
How Piles Are Graded
Doctors classify internal piles into four grades based on how far they protrude:
- Grade I: The hemorrhoid bleeds but doesn’t push out of the anal canal.
- Grade II: It pushes out during a bowel movement but slides back in on its own.
- Grade III: It pushes out and needs to be manually pushed back in.
- Grade IV: It stays outside the anus permanently and can’t be pushed back in.
This grading system guides treatment decisions. Grade I and II piles usually respond to lifestyle changes and office procedures, while Grade III and IV piles more often require surgical options.
Symptoms and What They Feel Like
The experience differs depending on the type and severity. Internal piles often produce no pain at all, just occasional bleeding. You might notice streaks of bright red blood on toilet paper or dripping into the bowl. As they progress to Grade II or III, you may feel a soft bulge during bowel movements and a sense of incomplete emptying.
External piles tend to cause a dull ache, pressure, or irritation that can last throughout the day. They may be tender to the touch. Itching around the anus is common, especially if mucus leaks from an internal hemorrhoid onto the surrounding skin.
A thrombosed external hemorrhoid is the most painful presentation. The lump appears suddenly, feels firm, and is extremely tender. Pain typically peaks within the first 48 to 72 hours and then gradually improves as the clot is reabsorbed, though this can take two to three weeks.
How Piles Are Diagnosed
External piles are usually visible during a simple physical exam. Internal piles require a closer look. A doctor will typically start with a digital rectal exam, gently inserting a gloved, lubricated finger to feel for swelling or abnormalities. If that exam is inconclusive, the next step is an anoscopy: a short, hollow tube with a light is inserted into the anal canal, allowing the doctor to see the tissue directly. The procedure takes a few minutes, and topical numbing gel is applied beforehand to reduce discomfort.
This step matters because rectal bleeding isn’t always piles. Anal fissures (small tears in the lining of the anus) cause similar bleeding but with a distinctive sharp, tearing pain during bowel movements, unlike the dull ache of hemorrhoids. More seriously, conditions like colon polyps, inflammatory bowel disease, and colorectal cancer can also produce rectal bleeding. A proper examination rules these out.
Lifestyle and Home Treatment
Most Grade I and II piles improve with changes you can make at home. The single most effective step is increasing your fiber intake. The recommended target is about 28 grams of fiber per day on a 2,000-calorie diet. Good sources include beans, lentils, whole grains, vegetables, and fruits. Fiber supplements work too. Higher fiber softens stool and adds bulk, reducing the straining that worsens hemorrhoids.
Drinking plenty of water supports fiber’s effect. Warm sitz baths (sitting in a few inches of warm water for 10 to 15 minutes) soothe irritation and improve blood flow. Over-the-counter creams and suppositories can temporarily relieve itching and discomfort. Avoiding long stretches on the toilet and not delaying bowel movements when the urge hits both reduce unnecessary pressure on rectal veins.
Office Procedures
When home measures aren’t enough, several procedures can be done in a doctor’s office without general anesthesia. The two most common are rubber band ligation and sclerotherapy.
Rubber band ligation involves placing a tiny elastic band around the base of an internal hemorrhoid. This cuts off blood flow, and the tissue shrinks and falls off within a week or so. It controls prolapse in about 93% of cases and stops bleeding in roughly 89%. About one in four people experience some post-procedural pain, and delayed bleeding can occur 10 to 14 days afterward as the tissue separates. Patient satisfaction rates sit around 78%.
Sclerotherapy involves injecting a chemical solution into the hemorrhoid to shrink it. It’s less effective overall, controlling prolapse in about 66% of cases with a satisfaction rate closer to 47%. However, it causes less post-procedural pain (about 14% of patients report it), making it a reasonable option for smaller hemorrhoids or patients who want a gentler approach. Recurrence rates at three months are similar for both: roughly 10% for banding and 16% for sclerotherapy.
Surgical Options
Surgery is reserved for large Grade III or IV piles, thrombosed hemorrhoids that don’t improve, or cases where office procedures have failed. The traditional approach (hemorrhoidectomy) completely removes the hemorrhoidal tissue. It’s the most effective long-term solution, with a recurrence rate around 5%, but recovery involves significant pain for one to three weeks.
A newer alternative, stapled hemorrhoidopexy, repositions the tissue rather than removing it. Recovery is generally less painful and faster. The tradeoff is a higher long-term recurrence rate (around 7.5%) and the added cost of the stapling device. For most cases, traditional excision remains the standard because of its lower recurrence and cost.
Piles vs. Anal Fissures
These two conditions are often confused because both cause rectal bleeding. The key difference is pain quality. Piles produce a dull, continuous ache or throbbing, and internal piles often cause no pain at all. Anal fissures cause a sharp, searing pain specifically during a bowel movement, followed by a deep ache that can linger for minutes to hours afterward. Fissures are small tears in the anal lining, not swollen veins, and they’re treated differently. Both can leave skin tags near the anus after healing.
Any rectal bleeding that persists, worsens, or is accompanied by changes in bowel habits, unexplained weight loss, or dark-colored stool warrants further evaluation to rule out conditions like colorectal cancer that can mimic hemorrhoid symptoms.