Anal conditions are among the most common problems in surgery and among the least discussed. People delay for months or years out of embarrassment, self medicate with creams bought over the counter, and arrive when the condition has progressed considerably.
All three of these conditions are treatable, and most do not need major surgery.
Telling Them Apart
The three conditions produce different symptoms, and the distinction determines treatment.
Piles, or haemorrhoids: swollen vascular cushions in the anal canal. Painless bright red bleeding, often noticed on the toilet paper or dripping into the pan. May cause a lump, itching or mucus discharge. Internal piles are typically painless unless they prolapse and become trapped.
Anal fissure: a tear in the lining of the anal canal. Severe sharp pain during and after passing stool, often described as passing glass, lasting minutes to hours. Small amounts of bright red blood. The pain is the defining feature.
Fistula: an abnormal tunnel between the anal canal and the skin, usually following an abscess. Persistent discharge of pus, recurrent swelling and pain, and a small opening near the anus that keeps discharging.
Pain on defecation means fissure far more often than piles. Patients who buy pile creams for a fissure get no relief, which is a common story.
Why Bleeding Still Needs Examination
This is the most important point in this article. Rectal bleeding is very commonly attributed to piles without an examination, and colorectal cancer is missed as a result.
Piles are extremely common, so most people who have bleeding do have them. Having piles does not exclude having something else at the same time.
Examination is essential if you are over forty, if bleeding is dark rather than bright red, if there is any change in bowel habit, weight loss or anaemia, if there is a family history of bowel cancer, or if bleeding persists despite treatment.
Assessment usually involves examination and proctoscopy, with colonoscopy where the picture warrants it.
The Grades of Piles
Internal haemorrhoids are graded, and the grade determines treatment.
- Grade 1: bleeding but no prolapse
- Grade 2: prolapse during defecation, reducing spontaneously
- Grade 3: prolapse requiring manual reduction
- Grade 4: permanently prolapsed and irreducible
Grades 1 and 2 are usually managed without surgery. Grades 3 and 4 more often need a procedure. External haemorrhoids can thrombose, producing a sudden acutely painful lump, which can be treated by removing the clot within the first day or two.
Conservative Treatment Works for Most
Constipation and straining drive all three conditions, and addressing that is the foundation of treatment.
- Fibre: gradually increase to 25 to 30 grams daily through vegetables, fruit, whole grains and pulses
- Water: adequate intake, since fibre without fluid worsens constipation
- Psyllium husk as a supplement where diet alone is insufficient
- Do not strain, and do not sit on the toilet for long periods reading or using a phone
- Squatting position or a footstool raising the knees, which straightens the anorectal angle
- Sitz baths: sitting in warm water for ten to fifteen minutes, which genuinely relieves both fissure and pile pain
- Do not delay when you feel the urge
Prolonged toilet sitting with a phone is a genuinely common contributor that patients rarely connect to their symptoms.
Treating an Anal Fissure
Fissures are painful and the pain causes spasm of the anal sphincter, which reduces blood flow and prevents healing. Breaking that cycle is the key.
- Stool softeners to make passing stool less traumatic
- Topical glyceryl trinitrate or diltiazem ointment, which relaxes the sphincter and improves blood flow
- Sitz baths after passing stool
- Local anaesthetic ointment for pain
- Botulinum toxin injection for fissures not healing with ointment
Most acute fissures heal within six to eight weeks with this approach. Headache is a common side effect of the nitrate ointment and usually settles with continued use.
Chronic fissures failing medical treatment may need lateral internal sphincterotomy, a small procedure dividing part of the sphincter, which has high healing rates.
Procedures for Piles
Where conservative treatment fails, several options exist, ranging from outpatient to surgical.
- Rubber band ligation: a band placed at the base of the pile, which then shrinks and falls off. Outpatient, effective for grades 1 to 3, may need repeating
- Sclerotherapy: injection causing the pile to shrink, used for small bleeding piles
- Stapled haemorrhoidopexy: less painful than conventional surgery, with a higher recurrence rate
- Haemorrhoidal artery ligation: tying the feeding arteries under ultrasound guidance
- Conventional haemorrhoidectomy: surgical excision, the most definitive and the most painful, reserved for grade 4 and large external components
Recovery after conventional surgery is genuinely uncomfortable for two to three weeks, and patients should be told this honestly. Stool softeners and sitz baths through that period make a substantial difference. Our colorectal surgery department discusses the trade offs before choosing.
Fistulas Need Surgery
A fistula does not heal on its own, because the tract remains lined and continues to discharge. Antibiotics settle infection temporarily but do not cure it.
Assessment usually includes examination under anaesthesia and often MRI, which maps the tract and its relationship to the sphincter muscles. That relationship determines the operation.
Simple low fistulas can be laid open with good healing. Complex fistulas crossing significant sphincter muscle need approaches that preserve continence, sometimes staged with a seton, a thread left in place to drain while inflammation settles.
Recurrent or complex fistulas should raise the question of Crohn disease, which needs assessment by our gastroenterology team.
Piles in Pregnancy
Haemorrhoids are very common in pregnancy and after delivery, driven by hormonal effects on veins, pressure from the growing uterus, constipation and straining during labour.
Management is conservative in almost all cases: fibre, fluids, stool softeners safe in pregnancy, sitz baths and avoiding prolonged standing. Most improve considerably in the weeks after delivery.
Surgery is generally deferred until at least six weeks after delivery unless there is a thrombosed pile causing severe pain. Discuss any treatment during pregnancy with your obstetrician, since not all topical preparations are appropriate.
These conditions are common, and the delay caused by embarrassment is the main reason they progress. Pain on passing stool suggests a fissure rather than piles, discharge suggests a fistula, and any rectal bleeding over forty needs examination rather than assumption.
Our colorectal surgery department at T. Nagar assesses and treats these conditions.
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