Ask the doctor: I’ve had piles since the birth of my children 10 years ago – how do I stop them flaring up after exercise?

​Dr Grant replies: Haemorrhoids (piles) are very common, especially after childbirth and in patients who suffer with chronic constipation.

They are composed of abnormal collections of submucosal, fibrovascular, or arteriovenous sinusoids that form part of the normal anorectal anatomy. Internal haemorrhoids are also commonly noted during colonoscopy (camera test into the back passage) and often these patient have remained symptom-free all their lives. If they do not cause any symptoms, there is no need to treat them.

The typical presenting complaint is painless bright red rectal bleeding during the passing of a bowel motion, with or without tissue prolapse (bulge). Other symptoms include anal itch/pain and a lump at the anal margin due to thrombosis (blood clotting) or strangulation (a blood vessel becoming restricted/tightened).

There are many over-the-counter preparations for the treatment of low-grade internal haemorrhoids such as analgesic (pain-killing) ointments, hydrocortisone suppositories as well as mixed preparations with both analgesia and steroid. It is advised to use these topical treatment along with taking regular warm baths to ease the pain.

Suppositories should be inserted after a bowel motion once per day for one week. It’s also important to increase dietary insoluble fibre (eating fruit/vegetables with the skin on) to 20-30g per day and drink around two litres of water per day.

If this does not work, then add a stool softener (a gentle mild laxative) to help ease the passage of stool thus allow more healing and repair of the piles. Stronger topical medication can be prescribed by your GP.

If these topical remedies fail to improve or completely resolve your piles, then it is time to discuss referral for minor treatment options (e.g. rubber band ligation of the piles) as an outpatient with your GP.

A consultant colorectal surgeon will be able to determine if internal piles are above or below the dentate line. This is an important anatomical point as haemorrhoids that are proximal to or, above the dentate line receive visceral innervation, which is less sensitive to pain, therefore treatment can be performed with minimal or no anaesthesia.

Conversely, external haemorrhoids are distal to or below the dentate line, where tissues are innervated somatically, and therefore are more sensitive to pain.

If surgery is indicated for external piles, it is generally under anaesthesia, with the exception of small, acutely thrombosed external haemorrhoids, as these may tolerate minor treatment procedures.

Of course, you may have a combination of piles both above and below the dentate line. Piles can also be further classified into grades I-IV based on the degree of prolapse from the anal canal.

​Dr Jennifer Grant is a GP with Beacon HealthCheck