Piles, Fissure or Fistula? Telling Anal Problems Apart
Problems around the anus are common, embarrassing and frequently self-diagnosed as “piles”. They are three distinct conditions with different treatments, and one critical rule applies to all: rectal bleeding should never be assumed to be benign without examination.
Haemorrhoids, piles
Swollen vascular cushions in the anal canal, present in everyone, becoming symptomatic when enlarged or prolapsed.
Symptoms: painless bright red bleeding, typically dripping after a stool or seen on paper; a lump that may protrude and reduce; itching; mucus discharge; a feeling of incomplete evacuation. Internal piles are usually painless unless they prolapse and become strangulated or thrombosed, which is suddenly very painful.
Grades: I bleed only; II prolapse and reduce spontaneously; III prolapse and need manual reduction; IV permanently prolapsed.
Treatment: fibre and fluids to soften stool, avoiding straining and prolonged sitting on the toilet, warm sitz baths, topical preparations for symptom relief, and procedures for higher grades: rubber band ligation, sclerotherapy, stapled haemorrhoidopexy, or excision.
Anal fissure
A tear in the lining of the anal canal.
Symptoms: severe pain during and after passing stool, often described as passing glass, lasting minutes to hours; a small amount of bright red blood on paper; spasm of the anal sphincter; and consequent fear of defecation, which causes constipation, which causes a harder stool, which tears again. Breaking that cycle is the treatment.
Treatment: stool softeners and fibre so that stools are soft, warm sitz baths which relax the sphincter, topical nitroglycerin or diltiazem to reduce sphincter spasm and improve blood flow for healing, local anaesthetic ointment, and for chronic fissures, botulinum toxin injection or lateral internal sphincterotomy.
Pain on defecation points to a fissure, not piles. This single distinction prevents a great deal of wrong self-treatment.
Anal fistula
An abnormal tunnel between the anal canal and the skin, usually resulting from a previous abscess.
Symptoms: persistent or recurrent discharge of pus or blood from an opening near the anus, recurrent swelling and pain that improves when it discharges, irritation of the surrounding skin, and sometimes fever.
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Treatment is surgical. It does not heal with ointments. Options include fistulotomy, seton placement, LIFT and advancement flaps, chosen according to how much sphincter the tract crosses, since the risk of incontinence governs the approach. MRI is often used to map complex tracts.
Recurrent or multiple fistulas should prompt investigation for Crohn’s disease and for tuberculosis, which is a recognised cause in India.
Perianal abscess
A collection of pus causing constant, severe, throbbing pain that is not related to defecation, with a tender swelling, fever and malaise. This needs urgent surgical drainage; antibiotics alone are not sufficient. Delay leads to extensive tissue destruction, particularly in people with diabetes.
Pilonidal sinus
A pit or sinus in the cleft above the anus, often with hair, causing recurrent infection and discharge. Different condition, different treatment, commonly in young men with a sedentary job.
The rule that matters most
Rectal bleeding must be examined, not assumed. Colorectal cancer frequently presents as bleeding attributed to piles, and the delay this causes is one of the commonest reasons for late diagnosis.
Investigate rather than treat empirically when there is:
- New bleeding after age 40 to 45
- Dark or mixed-in blood rather than bright blood on the surface
- A change in bowel habit lasting more than three weeks
- Unintentional weight loss
- Anaemia or iron deficiency
- A family history of colorectal cancer or inflammatory bowel disease
- Abdominal pain
- Bleeding that continues despite treatment
- A sense of incomplete evacuation that is new
A proper assessment includes inspection, digital rectal examination and proctoscopy, with colonoscopy where indicated. Many people avoid the examination out of embarrassment; it takes two minutes and it is the step that distinguishes a harmless condition from a dangerous one.
Prevention, which is the same for all of them
- Fibre, 25 to 30 g daily, introduced gradually with increased fluid. Psyllium husk is the most useful single addition
- Fluids, enough that urine is pale
- Do not strain. Do not sit on the toilet for more than a few minutes
- Do not take the phone to the toilet. Prolonged sitting with the anus unsupported is a genuine and very common contributor
- Do not delay the urge
- Feet on a low stool so that knees are above hips, which straightens the anorectal angle
- Regular physical activity
- Treat constipation and chronic diarrhoea
- Maintain a healthy weight
- Avoid heavy lifting with breath-holding
- Clean gently with water, pat dry; avoid vigorous wiping and scented wipes
In pregnancy
Piles and fissures are very common in pregnancy and after delivery, from hormonal effects, pressure and constipation. Most settle after delivery. Treatment focuses on stool softening and local measures, with medication choices discussed with the obstetrician.
This is general information. Rectal bleeding, severe anal pain or any discharge should be examined by a doctor; self-diagnosis as piles is the most common reason serious disease is found late.