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What is Piles?

When the pressure on the veins in the rectal region increases, they swell. These swellings resemble a bag of worm and are referred as Piles or Haemorrhoids. The term Haemorrhoids is more used in the American continent. Piles or Hemorrhoid is also the ultimate penalty we pay as a result of our evolution that has made us to walk upright.

More About Piles or Haemorrhoids

Types of Piles

There are two types of piles, namely, internal piles and external piles. Internal piles are more common than external piles.

Internal Piles

When these swelling are present internally within the anus, on the anal lining, they are termed as internal piles. They are formed slightly above a line called dentate line or pectinate line. The entire anal canal is divided into an upper two third portion and a lower one third portion by this dentate or pectinate line. They are precisely formed between 2 and 4 centimeters above the anal opening. There are four grades of Internal Piles.

External Piles

When these swelling are present externally outside the anus, precisely beneath the skin that surrounds the anus, they are termed as external piles.

Grade-1 Internal Piles

The piles condition is fresh and asymptomatic and is present internally above the pectinate line. Pain does not manifest at this budding grade of piles. Just that the veins that are facing the intense pressure are beginning to show symptoms of piles. The patient rarely feels discomfort at this stage. Some patients might experience itching and discomfort

Grade-2 Internal Piles

The piles condition begins to experience something called “prolapsed”.  Prolapse is nothing but the veins becoming weak and beginning to be pushed out of the anal canal. The secondary grade piles condition is painful. The prolapsed veins get pushed up inside or reversed into the anal canal spontaneously. The patient feels discomfort and itching at this stage.

Grade-3 Internal Piles

This condition or grade is when the prolapsed veins becomes more painful and causes more discomfort because the spontaneous reversal or reduction of the prolapsed veins does not happen. However the patient can manually push the prolapsed veins inside.

Grade-4 Internal Piles

This final condition or grade is where the prolapsed piles cannot be pushed inside the anal canal manually also. The pileshangs outside and causes immense pain and discomfort.

Though internal piles is generically classified as per the above grades, the clinical classification based on what the gastro surgeon or piles specialist observes can be classified rather differently. These can be called stages and each stage is characterized by how piles manifests further.

Clinical Classification of Four Stages of Internal Piles

Stage-1 Internal Piles

When proctoscopy is done, less than 25% of the lumen is occupied by piles veins. Simply put, piles veins are beginning to appear to the piles surgeon upon observation.

Stage-2 Internal Piles

During proctoscopy session with the patient, if the piles specialist observes that the lumen of the proctoscope is occupied 25% by the veins of piles, then it can be categorized as Stage-2.

Stages-3 Internal Piles

Similarly if the lumen of the proctoscope is 50% occupied by the veins of piles during proctoscopy by piles specialist, then it is Stage-3. Additionally prolapse of the vein could be clearly observed by the piles surgeon and the surgeon could also confirm that the vein tuft automatically goes in.

Stages-4 Internal Piles

In this stage, the lumen of proctoscope is completely accumulated by veins of piles. The prolapes of the vein also takes place and it needs be pushed inside manually. In this stage, the veins cease to prolapse automatically inside.

Complicated Piles

The extreme end stage of the internal piles is termed as complicated piles. The veins are fully thrombosed and are completely prolapsed. Manually pushing the veins inside is absolutely not possible in this stage and it is extremely painful for the patients at this stage.

Dr. Maran M on Internal Piles Classification

Dr. Maran, a gastro surgeon in Chennai treats piles and does piles surgery in Chennai regularly observes that if anyone has pain or any discomfort in the anal region, they have to immediately consult. If they see any droplet of blood in the stools it is best to consult a good gastro surgeon. The diagnosis of what has caused blood in the stool is absolutely required. Because sometimes it may not be piles or fissures, it can be something else also. So Dr. Maran always advices to take blood in stool with extra caution and suggests to visit a piles specialist sooner.

General Symptoms of Piles

(1) Spots of blood in the stool

(2) Pain when passing the stool. The pain can range from mild to severe depending on the severity of the piles.

(3) An itchy sensation around the anus.

(4) In severe cases of piles, a hard lump may be found hanging from the anal region. This lump may be hanging externally or it can have its origin internally.

(5) A feeling of incomplete evacuation of stools.

Specific Symptoms of Internal Piles

(1)    Often it starts as a painless bleeding when passing stools. You can observe red spots of blood in your stools. The bleeding is not profuse or uncontrolled. It is just that it is present.

(2)    In the next stage, when the internal hemorrhoid swells, they can be felt like a lump outside the anus. They can be often pushed back inside.

(3)    For the internal hemorrhoids that cannot be pushed back, they get stuck and sometimes it swells even more. This stage requires immediate medical attention.

Specific Symptoms of External Piles

(1)    There is a lump of tissue outside the anus. They are often painful and cause bleeding when passing stools.

(2)    Tendency for the hemorrhoid to develop swelling as it heals is high and this causes more pain.

(3)    Increased pain can be felt as the patient with external piles sits or is seated in a toilet.

What is a Prolapsed Piles?

The piles condition begins to experience something called “prolapsing”.  Prolapse is nothing but the rectal mucosa along with the piles blood vessels projecting out are pushed outside the anal canal.


When blood clots inside the veins that has caused piles then they are referred to as thrombosed piles. A thrombosed piles does not have any blood flow due to the clot. They are very painfully though not dangerous. In most cases, it has been observed that thrombosed piles resolve themselves as the clot is reabsorbed by the body. Sometimes it does not and hence requires external intervention by the piles surgeon.

Causes of Piles

There are several factors that cause pressure on the veins in the rectal region. The various factors that cause this pressure are

(1) Constipation – Generally chronic constipation which has been around for quite few years.

(2) Diarrhea – Chronic in nature

(3) Lifting heavy weights – This becomes a reason when improper lifting techniques are employed while lifting any kind of weights. Gyms are not the only place where weights are lifted. A bucket full of water, LPG cylinder, lifting heavy machinery at work are some of the activities where lifting of weight takes place. Men do most weightlifting in the gym and in the workplace while women lift weights as they perform household chores.

(4) Abdominal Exercises – The pressure exerted to the anal region when doing abdominal exercises is high and can lead to piles.

(4) Pregnancy – The growing fetus puts pressure on the abdomen cavity which in turn can cause the veins in the anus to swell. Also, women are more prone to constipation due to their pelvic shape. The instance of constipation increases during pregnancy which might also play a role.

(5) Straining while passing stools – This condition is closely tagged to constipation. Straining puts pressure on the veins and hence they are responsible for swelling of the veins in the anal region.

General Diagnosis of Piles

(1)    The diagnosis of piles or hemorrhoid is best done by a gastro surgeon. The surgeon initially questions the patients on the symptoms.

(2)    The surgeon then proceeds for physical examination of the anal region. Physical examination involves the surgeon wearing a glove, lubricating your anus and gently pushing his finger inside the anus to look for the presence of any lumps or other abnormal outgrowths. This examination is termed as DRE (Digital Rectal Examination).

(3)    In some cases, a physical lump may not be presented and cannot be felt by the surgeon. In such cases, to rule out the possibility, the surgeon would perform a proctoscopy. An instrument that is like a tube called proctoscope is inserted into the anal region and checked for the presence of piles and assessing the grade of it.  With this the surgeon can pinpoint the presence of piles or other medical conditions like tumor growth etc.

(4) The advantage of visiting a surgeon is, he is qualified to rule out other medical and surgical conditions that are causing discomfort or bleeding in the anal region. He may rightly prescribe other diagnosis methods if the medical condition is ruled out to pile.

General Treatment Procedures for Piles

Treatment for piles varies depending on the grade of the piles and also the intensity and status of bleeding.

  • As a general measure, if the grade of the piles is 1 or 2, and if bleeding is not persistent and is rare, the piles specialist prescribes over-the-counter laxatives for a few days.
  • In grades 2, if the bleeding is a cause to worry, Piles Surgery procedures like Banding or Sclerotherapy are recommended.
  • If the grade is 3 or 4 and the bleeding is also a cause of worry, the pile's surgery type recommended is Haemorrhoidectomy.

General Recommendations for Managing Piles

As part of managing piles, the piles specialist would recommend the patient to do the following,

  • Include more fiber in the diet.
  • Taking steps to reduce their weight (obesity)
  • Being physically active.
  • Watch out if there is excessive bleeding.
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