Understanding Piles

What are Piles?

Piles (or hemorrhoids) are engorged blood vessels around the anus that occurs due to excessive straining at stools or after pregnancy in women. These engorged vessels can be easily traumatised by passage of stools, leading to bleeding during defecation. Excessive straining at stools also causes these engorged anal cushions to be pushed out during defecation. Bad toileting habits such as reading newspaper or surfing the internet on the iPad while sitting on the toilet bowl prolongs the period of straining.

To prevent piles from developing, it is important to avoid constipation or excessive straining at stools by adopting good toileting habits. Frequent air travel, with its propensity to induce constipation because of the poor oral fluid intake and irregular dietary intake from the jet-lag and time zone differences, tends to accentuate haemorrhoidal symptoms.

Piles are divided into four grades of severity, based on their sizes and the symptoms that they produced:

Grade I: Enlarged internal piles that usually presents with bleeding during defecation. These can be easily treated with medications.
Grade II: These larger piles tend to protrude out during straining at stools but are able to spontaneously return back into the anal canal after bowel movement.
Grade III: These large piles protrude during defecation causing significant bleeding and remain painfully outside the anus, requiring finger pressure to push it back inside the anus.
Grade IV: These piles are persistently outside the anus and the blood in the engorged vessels is usually clotted, leading to an extremely painful and swollen lump that requires surgery to achieve relieve.

Piles often present with bleeding during bowel movements. Cancers of the colon or rectum can also present with blood in stools. It is not always easy to differentiate bleeding arising from a benign condition such as piles, from other more sinister conditions like cancer. Therefore, it is important to perform diagnostic evaluations in patients with persistent bleeding to make an accurate diagnosis and exclude other more sinister conditions.

Treatments for piles

It is difficult to determine which treatment option is the most suitable without an examination, as small piles (grades I or II) will not require surgery and can be easily treated with simple medications or rubberband ligation in the clinic on the same day with minimal discomfort and no downtime from work or activities, while larger prolapsing ones (grades II or IV) will usually require surgery in the operating theatre for better symptom control. Surgery is advocated only for the treatment of larger symptomatic piles.

The aim of surgery is to remove the grade II or IV piles to relieve the symptoms of pain, swelling and/or bleeding. These symptomatic piles have progressed to such a stage where treatment with medication alone or with less invasive procedures will not be enough to treat and alleviate the symptoms.

Surgery, if needed, can be arranged on the same day or the following day after consultation. Surgery should take less than 30 minutes.


Conventional Hemorrhoidectomy An instrument delivering a high-energy electrical current that cuts tissues and stops bleeding at the same time is used to cut out the enlarged piles. This is the usual method employed for grade II or IV piles.

Ligasure Hemorrhoidectomy A special vessel sealing device is used to cut off the piles and seal off the engorged blood vessels, thus achieving the intention of removing redundant tissue while minimising the chances of bleeding.

Stapled Hemorrhoidectomy Stapled Hemorrhoidectomy is a more advanced procedure usually performed under general or regional anaesthesia. The piles are pushed back into their normal positions within the anal canal. A stitch is then placed around the anal canal, and then used to pull the hemorrhoid tissue into the stapler. The stapler is fired and the piles are removed, while the remaining tissue is simultaneously stapled together.

Trans-anal Hemorrhoidal De-arterialization (THD) A special device is inserted through the anus and the blood vessels supplying the piles are precisely located using Doppler ultrasound, and then tied off using surgical stitches. This will interrupt the blood supply to the engorged piles and is suitable if the piles are not too large or prolapsing, with bleeding as the predominant symptom.

Rubber-band Ligation Ligation of piles is an outpatient treatment that can be performed in the clinic without anaesthesia. In this procedure, a small rubber-band is applied to the base of the piles, stopping the blood supply to the piles. The piles will then shrivel and die within three t o five days.

Prepared by:
Dr. Koh Poh Koon
General Surgery
Capstone Colorectal Surgery Centre

Disclaimer: The views and opinions in the article are the writer’s own and do not necessarily reflect those of Mount Elizabeth Medical Centre (MEMC). The writer is fully responsible for the accuracy, completeness and usefulness of the information provided in the article. MEMC will not be liable for any errors, omissions or copyright issues with regard to the contents of the article.