Hemorrhoids (Piles): Causes, Symptoms, Treatment & Prevention

Hemorrhoids, known in Bangladesh simply as "piles," are one of the most common anorectal problems worldwide — yet most people are too embarrassed to talk about them, and many never seek proper treatment until symptoms become severe. A large 2025 meta-analysis pooling data from roughly 150 studies and about 9 million people estimated a global point prevalence of around 26%, meaning more than one in four adults experience hemorrhoids at some point. Despite being so common, hemorrhoids are widely misunderstood: many people confuse them with anal fissures, assume any rectal bleeding is "just piles," or believe liver disease directly causes them (it does not, as explained below). This guide walks through what hemorrhoids actually are, how they are graded, when home care is enough, when a doctor visit is essential, and how to tell hemorrhoid bleeding apart from a warning sign of something more serious.

What Are Hemorrhoids?

Hemorrhoids are swollen, engorged cushions of veins and supporting tissue inside and around the anal canal. Everyone has these vascular cushions normally — they help with stool control — but when they become enlarged and inflamed, they are called hemorrhoids.

• Internal hemorrhoids form above the dentate line, deep inside the anal canal. They are usually painless (there are few pain-sensing nerves there) but can bleed, and in advanced stages can prolapse (bulge out) through the anus.
• External hemorrhoids form under the skin around the anal opening, where nerve endings are dense. They can itch, ache, swell, and become very painful if a blood clot forms inside them — a condition called a thrombosed external hemorrhoid.

Causes and Risk Factors

Hemorrhoids develop when repeated pressure on the veins in the lower rectum and anus causes them to swell. Common contributing factors include:

• Chronic constipation or chronic diarrhea
• Straining during bowel movements
• A low-fiber diet
• Pregnancy — due to the combined effect of mechanical pressure from the growing uterus and progesterone's relaxing effect on vein walls
• Prolonged sitting, including long hours of driving or desk work
• Heavy lifting
• Aging, as the tissue supporting the anal veins naturally weakens over time
• Obesity — several case-control studies have found a statistically significant association between higher body weight and hemorrhoid risk, though the effect sizes reported are modest

An important myth to correct: many people believe liver disease or cirrhosis directly causes hemorrhoids because both can cause rectal bleeding. Research has actually found that ordinary hemorrhoids occur independently of liver disease and portal hypertension. What liver disease can cause is a different condition called anorectal varices — enlarged veins caused by increased pressure in the portal blood system — which can also bleed but needs a different diagnostic and treatment approach. Anyone with known liver disease who develops rectal bleeding should have this distinction checked by a doctor rather than assuming it is "just piles."

The Four Grades of Internal Hemorrhoids

Doctors commonly use the Goligher grading system to describe the severity of internal hemorrhoids. Understanding your grade helps explain why your doctor recommends a particular treatment:

• Grade I: The hemorrhoid stays inside the anal canal and does not prolapse, though it may bleed.
• Grade II: The hemorrhoid prolapses (bulges out) during straining or a bowel movement but goes back in by itself.
• Grade III: The hemorrhoid prolapses with straining and must be pushed back in manually with a finger.
• Grade IV: The hemorrhoid is permanently prolapsed and cannot be pushed back in. Acutely clotted (thrombosed) or trapped internal hemorrhoids are also grouped here because they need urgent attention.

Studies assessing how consistently different doctors apply this grading system have found only fair-to-moderate agreement for the middle grades (II and III), which is one reason a hands-on examination by a qualified doctor — not a photo or a guess — is important for deciding treatment.

Symptoms

Symptoms depend on whether the hemorrhoid is internal or external, and how advanced it is:

• Painless bright-red bleeding during or after a bowel movement — typically seen on toilet paper or dripping into the toilet bowl (internal hemorrhoids)
• A sensation of a lump or bulge around the anus, sometimes needing to be pushed back in
• Itching or irritation around the anus
• Pain, swelling, or a hard, tender lump near the anus — especially with a thrombosed external hemorrhoid
• A feeling of incomplete emptying after passing stool
• Mucus discharge

Hemorrhoids vs. Anal Fissure: Know the Difference

Hemorrhoids and anal fissures (small tears in the lining of the anus) are often confused because both cause pain and bleeding, and the two conditions can even occur together.

• Pain pattern: A fissure typically causes sharp, cutting pain that is most intense during and right after passing stool. Internal hemorrhoids are usually painless unless prolapsed; external hemorrhoids cause more of an ache or throb.
• What you can feel: Hemorrhoids often present as a soft or firm lump; a fissure is a small tear, usually not felt as a lump, and is typically seen on close visual examination of the anal opening.
• Overlap in care: Both conditions generally improve with the same first-line measures — more fiber, more fluids, warm sitz baths, and avoiding straining — but a doctor's examination is still the only reliable way to know which condition (or both) you actually have.

When Bleeding Could Be More Than Piles — Red Flags

This is the single most important section of this guide. It is tempting to assume any rectal bleeding is hemorrhoids, but bleeding is also an early symptom of colorectal cancer and other bowel conditions. Many clinical guidelines recommend an age threshold of 50 years and above for prompt evaluation of new rectal bleeding, though any persistent or unexplained bleeding at any age deserves medical attention — rectal bleeding has also been identified as a strong predictor of colorectal cancer in younger patients in some research. See a doctor promptly — do not self-treat — if bleeding comes with any of the following:

• Dark, tarry-looking stool, or blood that appears mixed into the stool rather than just coating its surface or appearing on toilet paper
• Unexplained weight loss
• A change in bowel habits — new constipation, diarrhea, narrower stools, or altered frequency lasting more than a couple of weeks
• Unexplained fatigue, paleness, or signs of anemia
• Abdominal pain alongside the bleeding
• A lump or mass you can feel in the abdomen or rectum
• A family history of colorectal cancer or inflammatory bowel disease
• Bleeding that does not improve, or keeps recurring, despite proper hemorrhoid treatment
• Heavy or non-stop bleeding, dizziness, or a racing heartbeat — this needs emergency care immediately

Diagnosis

Diagnosis usually starts with a conversation about diet, bowel habits, and symptoms, followed by a physical examination.

• Visual inspection is usually enough to identify external hemorrhoids.
• Digital rectal examination (DRE): the doctor uses a gloved, lubricated finger to check for tenderness, blood, or masses. Internal hemorrhoids are not always felt this way unless they are large or prolapsed.
• Anoscopy: a short, lighted tube used in the clinic, usually without anesthesia, to directly view the lining of the anal canal and lower rectum — this is the main way internal hemorrhoids are confirmed.
• Colonoscopy: not routinely needed for typical hemorrhoid symptoms in otherwise healthy, lower-risk patients, but is recommended when any of the red-flag symptoms above are present, or when there is a personal or family risk factor for colorectal cancer.

Home Care and Non-Surgical Treatment

Most mild-to-moderate hemorrhoids (Grade I–II, and many Grade III cases) respond well to conservative treatment:

• Increase fiber intake: a commonly recommended target is roughly 25–35 grams of fiber per day from fruits, vegetables, whole grains, and legumes, increased gradually to avoid bloating and gas. Fiber supplements such as psyllium husk (sold locally as Isabgol) are widely used across South Asia, typically as 1–2 teaspoons mixed with water, and have been shown in studies to reduce hemorrhoid symptoms and bleeding.
• Drink enough fluids — at least 8 glasses of water a day is often advised, especially when increasing fiber, since fiber without enough fluid can worsen constipation.
• Warm sitz baths: sitting in a few inches of warm (not hot) water for about 10–20 minutes, two to three times a day and after bowel movements, is widely recommended to soothe irritation and reduce swelling.
• Topical treatments: over-the-counter hydrocortisone creams or suppositories, witch hazel preparations, and medicated anorectal creams can relieve itching and discomfort for limited periods. Oral pain relievers such as paracetamol can help with discomfort; check with a pharmacist before combining with other medicines.
• Venotonic medicines: flavonoid-based oral medicines (such as diosmin-hesperidin combinations, sold under brand names including Daflon) have been studied in several clinical trials and meta-analyses, which found they can meaningfully reduce bleeding and other symptoms compared with placebo. The evidence is encouraging but based on a relatively small number of trials, so these should be seen as a helpful adjunct rather than a guaranteed cure, and used under medical advice.
• Avoid straining and prolonged sitting on the toilet, and respond to the urge to pass stool rather than delaying it.

As a general rule, Grade I hemorrhoids often improve within days to about a week with these measures, Grade II within one to two weeks, and Grade III may take several weeks and often needs more than home care alone. Grade IV, persistently prolapsed, or thrombosed external hemorrhoids usually do not resolve on their own and need medical treatment. If there is no improvement within about a week of consistent home care, it is time to see a doctor.

Office-Based Procedures

When conservative treatment is not enough — typically for Grade I–II and select Grade III internal hemorrhoids — doctors often recommend simple, same-day office procedures performed with local anesthetic or no anesthesia at all:

• Rubber band ligation: a small rubber band is placed around the base of the internal hemorrhoid to cut off its blood supply; it is generally considered the most effective office procedure, though some bleeding afterward is a recognized and fairly common side effect.
• Sclerotherapy: a solution is injected into the hemorrhoid to shrink it.
• Infrared coagulation: infrared light energy is used to cut off blood flow to the hemorrhoid tissue.

These procedures are generally well tolerated, but hemorrhoids can recur after any of them, so the lifestyle and dietary measures above remain important even after a successful procedure.

Surgical Treatment

Surgery is generally reserved for large Grade III–IV hemorrhoids, cases that fail non-surgical treatment, mixed internal-external hemorrhoids, or urgent situations like an incarcerated or severely thrombosed hemorrhoid.

• Excisional hemorrhoidectomy (such as the Milligan-Morgan or Ferguson techniques) surgically removes the hemorrhoidal tissue. It tends to have a lower long-term recurrence rate but more postoperative pain and a longer return to normal activity.
• Stapled hemorrhoidopexy repositions the prolapsing tissue using a circular stapling device. Clinical trials have generally found faster early recovery and less pain in the first couple of weeks compared with excisional surgery, with one trial reporting a return to work in roughly a week versus about three weeks for conventional surgery.

Studies comparing long-term recurrence between these two techniques have produced mixed results — some trials show no meaningful difference, while others report higher recurrence after stapled surgery. This is a decision best made with a colorectal surgeon who can weigh your specific hemorrhoid grade, anatomy, and priorities around pain versus long-term recurrence risk.

Hemorrhoids During Pregnancy

Hemorrhoids are extremely common during pregnancy and the postpartum period — reported rates vary widely across studies, with some reviews reporting that roughly a third to more than half of pregnant and postpartum women experience them, driven by the growing uterus, hormonal changes, and constipation. Risk appears to be higher with a larger baby, prolonged straining during delivery, and pre-existing constipation. Encouragingly, a randomized trial combining dietary changes (more fluids, bran, prunes, nuts, fruits, and vegetables) with regular walking and better bowel habits found this combined approach reduced the risk of developing hemorrhoids during pregnancy by a meaningful margin. Pregnant women should discuss any hemorrhoid symptoms, fiber supplements, or medicines with their obstetrician before starting them, since not every treatment used in the general population is appropriate during pregnancy.

Prevention

• Eat a consistently high-fiber diet with vegetables, fruits, whole grains, and legumes rather than relying only on supplements
• Stay well hydrated throughout the day
• Avoid prolonged straining or sitting on the toilet; do not delay the urge to pass stool
• Take regular breaks from long periods of sitting, especially in desk jobs or long-distance driving
• Stay physically active, as regular movement supports healthy bowel function
• Manage body weight, as higher body weight has been associated with greater hemorrhoid risk in multiple studies
• If you have access to a squat-style toilet, some physiological studies suggest this posture widens the anorectal angle and may reduce straining compared with sitting — a reasonable, low-risk habit for anyone already using one, though it should not replace other preventive measures

Hemorrhoids in the Bangladesh Context

Reliable, large-scale local data on exactly how common hemorrhoids are in Bangladesh is limited in the available medical literature, so this guide avoids citing a specific local percentage. That said, several everyday realities in Bangladesh are plausible contributing factors worth paying attention to: long hours of sitting among office workers, garment-sector machine operators, and bus, truck, and CNG/auto-rickshaw drivers; a shift toward more processed food and polished rice with less overall fiber intake in many urban diets; and widespread under-treatment of constipation. On the positive side, squat-style toilets remain common in many Bangladeshi households, which — based on the physiological studies above — may be a modest protective habit worth preserving rather than abandoning. For medicines, fiber supplements such as Isabgol (psyllium husk) and venotonic tablets such as Daflon, along with topical anorectal creams, are available through local pharmacies, but any medicine should be used on a doctor's or pharmacist's advice rather than self-prescribed, particularly for anyone with bleeding, pregnancy, or an unclear diagnosis.

When to See a Doctor

See a doctor if home care does not improve symptoms within about a week, if pain or swelling is severe, if a hemorrhoid is prolapsed and will not go back in, or if bleeding is heavy, recurrent, or accompanied by any of the red-flag symptoms described above. Hemorrhoids are common and very treatable, but rectal bleeding should never be dismissed without a proper examination — getting it checked early is the safest approach.

Sources: Clinical guidance referenced from the American Society of Colon and Rectal Surgeons (ASCRS), the UK National Health Service (NHS), the Mayo Clinic, the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and peer-reviewed studies and meta-analyses on hemorrhoid epidemiology and treatment.