Haemorrhoids or piles are caused due to prolonged straining at bowel movements or due to weakened rectal and anal muscles. This increased pressure leads to swollen, inflamed and engorged anal blood vessels that are termed piles or haemorrhoids. 1-5
Based on location haemorrhoids may be of two types – internal and external.
These lie above the dentate line and usually lie within the rectum. These piles are covered with a layer of mucus that appears slimy. When they hang out of the anus during straining this mucus layer may be visible over them. These piles do not have sensation and are painless.
These may be classified as grades based on their features and symptoms:
The First-degree haemorrhoids (grade I) for example may bleed but not prolapse or hand out.
Second-degree haemorrhoids (grade II) may hang out but go back in by themselves.
Third-degree haemorrhoids (grade III) prolapse and need to be inserted back in manually.
Fourth degree haemorrhoids (grade IV) hang out permanently and cannot be pushed back in.
External haemorrhoids have a layer of skin or squamous epithelium covering them and have pain sensation over them. These lie around the anus and below the dentate line. These are visible on external examination.
Most cases of piles do not lead to overt symptoms however some may lead to bleeding and pain and alert the patient. Symptoms of piles may be outlined as:
Passage of bright red blood with stools. Blood is seen on the outside of the stool but is not mixed in with the stool.
With passage of stools the pile or the lump with the swollen blood vessel may move downwards and prolapse or hang outside of the anus. After passage of stools this may need to be pushed back in.
There may be a slimy discharge or mucus after passing a stool.
There is pain, discomfort or itchiness around the anus. This is aggravated on sitting.
There is redness, soreness and inflammation around the anus.
After evacuation of bowel as the piles remain within the rectum they may give the feeling of incomplete evacuation and need to pass stools again.
Severe pain of piles is usually not seen unless the pile is trapped outside the anus and the anal sphincter or muscles tighten around it leading to lack of blood supply. This is called “strangulation” of the piles. These strangulated piles are often red, hard and painful and called “thrombosed external haemorrhoids”.
There may be blood clots around the anus called perianal hematomas.
Symptoms are based on the grade of the piles. First-degree piles are painless but may show bleeding, second-degree piles may show mild discomfort and painless bleeding, third-degree piles have pain, bleeding and mucus discharge while fourth-degree manifests with pain, bleeding, clotting, hematomas and strangulation (possible).