Piles are swellings that develop inside and around the back passage (anal canal). There is a network of small veins (blood vessels) within the lining of the anal canal. These veins sometimes become wider and engorged with more blood than usual. The engorged veins and the overlying tissue may then form into one or more swellings (piles). Piles often don’t cause any problems but can cause bleeding and sometimes pain. If they do cause any bleeding or pain then you should see a doctor.

Piles can be divided into either internal or external piles. Some people develop internal and external piles at the same time.

Internal piles are deeper and initially form above a point 2-3 cm inside the back passage (anal canal) in the upper part of the anal canal or lower rectum (the last part of the large bowel that connects to the anal canal).
External piles start off nearer the surface, below a point 2-3 cm inside the back passage.
Despite the name, external piles aren’t always seen outside of the opening of the back passage (anus). Equally confusing, internal piles can enlarge and drop down (prolapse), so that they hang outside of the anus.

Piles are also graded by their size and severity.

Piles symptoms can vary depending on the size, position and grade of the piles.

Grade 1 are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the opening of the back passage (anus). Grade 1 piles are common. In some people they enlarge further to grade 2 or more.

Grade 2 are larger. They may be partly pushed out from the anus when you go to the toilet, but quickly spring back inside again.

Grade 3 hang out from the anus when you go to the toilet. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.

Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.

A possible complication of piles that hang down is that they can ‘strangulate’. This means that the blood supply to the pile has been cut off. A blood clot (thrombosis) can form within the pile. This causes really severe pain if it occurs. The pain usually reaches a peak after 48-72 hours and then gradually goes away over 7-10 days.


An anal fissure is a tear in the lining of the anus or anal canal (the opening through which stool passes out of the body). The fissure can be painful and may bleed.

Anal fissures can occur in anyone at any age. The chance of having an anal fissure decreases as people get older. People who have had fissures in the past are more likely to have them in the future.

What causes an anal fissure?
Anal fissures can be caused by trauma to the anus and anal canal. The trauma can be caused by one or more of the following:

  • 1. Chronic (long-term) constipation
    2. Straining to have a bowel movement, especially if the stool is large, hard and/or dry
    3. Prolonged diarrhea
    4. Anal sex, anal stretching
    5. Insertion of foreign objects into the anus
  • Causes other than trauma include:
  1. 1. Longstanding poor bowel habits
    2. Overly tight or spastic anal sphincter muscles (muscles that control the closing of the anus)
    3. Scarring in the anorectal area
    4. An underlying medical problem, such as Crohn’s disease and ulcerative colitis (types of inflammatory bowel disease); anal cancer; leukemia; infectious diseases (such as tuberculosis); and sexually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)
    5. Decreased blood flow to the anorectal area

Anal fissures are also common in young infants and in women after childbirth.

Signs and symptoms of an anal fissure include:

  1. 1. Pain during, and even hours after, a bowel movement
    2. Constipation
    3. Blood on the outside surface of the stool
    4. Blood on toilet tissue or wipes
    5. A visible crack or tear in the anus or anal canal
    6. Burning and itching that may be painful
    7. Discomfort when urinating, frequent urination, or inability to urinate
    8. Foul-smelling discharge


An anal fistula is a small tunnel that connects an abscess, an infected cavity in the anus, to an opening on the skin around the anus.

The anus is the external opening through which feces are expelled from the body. Just inside the anus are a number of small glands that make mucus. Occasionally, these glands get clogged and can become infected, leading to an abscess. About half of these abscesses may develop into a fistula.

The leading causes of an anal fistula are clogged anal glands and anal abscesses. Other, much less common, conditions that can cause an anal fistula include:

  1. 1. Crohn’s disease (an inflammatory disease of the intestine)
    2. Radiation (treatment for cancer)
    3. Trauma
    4. Sexually transmitted diseases
    5. Tuberculosis
    6. Diverticulitis (a disease in which small pouches form in the large intestine and become inflamed)
    7. Cancer

The signs and symptoms of an anal fistula include:

  1. 1. Frequent anal abscesses
    2. Pain and swelling around the anus
    3. Bloody or foul-smelling drainage (pus) from an opening around the anus. The pain may decrease after the fistula
  2. drains.
    4. Irritation of the skin around the anus from drainage
    5. Pain with bowel movements
    6. Bleeding
    7. Fever, chills and a general feeling of fatigue

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