Piles is the common, everyday name for hemorrhoids. In medical terminology, the condition is called hemorrhoidal disease, and it refers to the symptomatic enlargement and downward displacement of the normal cushions of tissue inside the anal canal. Everyone has these cushions; they only become “piles” when the tissue swells, slips out of position, or starts causing symptoms like bleeding or discomfort. About 4% of adults report having symptomatic hemorrhoids at any given time, with a peak incidence between ages 45 and 65.
What Hemorrhoids Actually Are
The anal canal naturally contains three main cushions of spongy, blood-vessel-rich tissue. These cushions help with fine control of continence. In a healthy state, they stay in place, supported by a web of connective tissue and small muscle fibers. You never notice them.
Hemorrhoidal disease develops when that supporting framework breaks down. The connective tissue fibers weaken and stretch, allowing the cushions to slide downward. At the same time, the blood vessels within the cushions dilate and distort. The widely accepted explanation, known as the “sliding anal lining” theory, frames hemorrhoids not as new growths but as normal anatomy that has lost its structural support and shifted out of position. The tissue changes seen in hemorrhoidal cushions include swollen veins, small blood clots, breakdown of collagen and elastic fibers, and tearing of the tiny muscles that normally anchor the cushions in place.
Internal vs. External Hemorrhoids
The anal canal has a natural boundary called the dentate line, a ring of tissue roughly halfway up. Where a hemorrhoid sits relative to this line determines its type and, importantly, what it feels like.
- Internal hemorrhoids form above the dentate line. This tissue is covered in mucosa, which has very few pain-sensing nerves. That’s why internal hemorrhoids typically cause painless bleeding (bright red blood on toilet paper or dripping into the bowl) rather than sharp discomfort. As they enlarge, internal hemorrhoids can prolapse, meaning they push through the anal opening.
- External hemorrhoids form below the dentate line, under skin that is densely packed with pain-sensing nerves. These are the ones that cause the throbbing, tender lump you can feel. If a blood clot forms inside an external hemorrhoid (a thrombosed hemorrhoid), the pain can be intense.
The two types can occur together. A prolapsed internal hemorrhoid sometimes gets confused with an external one, but they’re covered by different tissue: mucosa for internal, skin for external.
Common Causes and Risk Factors
Anything that increases pressure inside the abdomen or weakens the connective tissue in the anal canal can trigger hemorrhoids. Chronic straining during bowel movements is the most frequently cited cause, often linked to constipation or prolonged time sitting on the toilet. Low-fiber diets contribute by making stools harder and bowel movements more effortful.
Pregnancy is a major risk factor. Hormonal changes soften connective tissue while the growing uterus raises intra-abdominal pressure. An estimated 25% to 35% of pregnant women develop hemorrhoids, and in some populations, up to 85% of pregnancies are affected by the third trimester. Vaginal delivery adds further strain. Other contributors include obesity, heavy lifting, chronic coughing, and aging, since connective tissue naturally loses elasticity over time.
How Piles Are Diagnosed
Diagnosis usually starts with a symptom history and a physical exam of the anal area. For internal hemorrhoids, a doctor may use an anoscope, a short, lighted tube inserted into the anus that gives a direct view of the lower rectum. In some cases, particularly when bleeding needs further investigation, a sigmoidoscopy (a longer scope that examines the rectum and lower colon) may be recommended to rule out other causes.
Several conditions mimic hemorrhoid symptoms. Anal fissures, which are small tears in the lining of the anus, also cause bleeding and itching but tend to produce sharp pain during and after a bowel movement, sometimes followed by hours of throbbing. Rectal polyps, abscesses, and more serious conditions can also cause rectal bleeding, which is why persistent or unexplained bleeding warrants a proper evaluation rather than self-diagnosis.
Grading Scale for Internal Hemorrhoids
Doctors classify internal hemorrhoids into four grades based on how far the tissue has prolapsed:
- Grade 1: The hemorrhoid bleeds but doesn’t protrude outside the anal canal.
- Grade 2: The tissue pushes out during a bowel movement but pulls back in on its own.
- Grade 3: The tissue protrudes and must be manually pushed back in.
- Grade 4: The tissue stays prolapsed and cannot be pushed back in.
This grading system, called the Goligher classification, guides treatment decisions. Lower grades respond well to diet changes and office-based procedures, while higher grades are more likely to need surgery.
Diet and Lifestyle Management
For most people with grade 1 or 2 hemorrhoids, the first line of management is straightforward: eat more fiber, drink more water, and stop straining. The U.S. Dietary Guidelines recommend 14 grams of fiber per 1,000 calories consumed, which works out to about 28 grams a day on a standard 2,000-calorie diet. Most people fall well short of that. Increasing fiber gradually through fruits, vegetables, whole grains, and legumes (or a supplement if needed) softens stools and reduces the pressure that worsens hemorrhoids.
Other practical changes include not sitting on the toilet longer than necessary, avoiding reading or scrolling on your phone in the bathroom, and staying physically active. Warm sitz baths (sitting in a few inches of warm water for 10 to 15 minutes) can relieve discomfort during flare-ups. Over-the-counter creams and suppositories help manage itching and swelling in the short term.
Office-Based Procedures
When lifestyle changes aren’t enough for grade 1 or 2 internal hemorrhoids, two common office-based procedures can help. Rubber band ligation involves placing a small elastic band around the base of the hemorrhoid to cut off its blood supply, causing it to shrink and fall off within days. Sclerotherapy involves injecting a chemical solution into the hemorrhoid tissue to shrink it. Both often require multiple sessions.
A systematic review comparing the two found similar effectiveness: rubber band ligation resolved bleeding in 73% to 84% of cases, while sclerotherapy resolved it in 69% to 88%. Complication rates and recurrence rates were broadly comparable, though each has trade-offs your doctor can walk you through based on your specific situation.
When Surgery Is Needed
Grade 3 and 4 hemorrhoids, or lower-grade hemorrhoids that haven’t responded to other treatments, may require surgery. The two main surgical options are conventional excisional hemorrhoidectomy (complete removal of the hemorrhoidal tissue) and stapled hemorrhoidopexy (repositioning the tissue and cutting off blood flow rather than removing it entirely).
Conventional excision is considered the gold standard when preventing recurrence matters most. A Cochrane systematic review found that the stapled approach, while associated with less immediate pain and faster recovery, carries a higher long-term risk of hemorrhoid recurrence and prolapse, along with a greater chance of needing additional operations. Recovery from excisional surgery is notoriously uncomfortable because the anal skin removed during the procedure is rich in nerve endings. Most people need one to three weeks off work, and full healing can take four to six weeks.