Piles vs anal fissure: how to tell the difference

Piles, also called haemorrhoids, are described by the NHS as lumps inside and around the bottom. They are swollen blood vessels, and the NHS says it is not clear what causes them, though they are more likely with constipation, pushing too hard when pooing, heavy lifting, pregnancy, getting older and being overweight. They can be as small as a pea or grow to the size of grapes, and may be pink or purple.

An anal fissure is a small tear in the lining of the anus. The NHS says it is not always clear what causes one. They are more common in people aged 15 to 40 and in young children, and you may be more likely to get one if you have constipation (a common cause in children), frequent diarrhoea, are pregnant or have given birth vaginally, have inflammatory bowel disease, Crohn's disease or ulcerative colitis, or have a sexually transmitted infection such as syphilis or herpes.

The two can occur together. A person with constipation or straining, which is a risk factor for both, may have piles and a fissure at the same time, so it is not always a case of one or the other.

The following table is based on the NHS pages for each condition.

Pain on passing a stool is the feature that points most strongly to a fissure. The NHS describes severe, sharp pain when you poo, followed by burning pain that can last for hours, and bright red blood after the stool.

Piles tend to produce a different cluster: bright red blood after you poo, an itchy anus, a feeling that you still need to poo after going, mucus on your underwear or paper after wiping, lumps around the anus and sometimes pain.

It is worth remembering that the symptoms can overlap and that self-diagnosis is unreliable. The NHS fissure page itself states that there are other causes of pain around the anus and rectal bleeding, such as piles. A GP can usually tell the difference by asking about your symptoms and looking at the anus.

The first-line steps are similar because both are linked to hard stools and straining. The NHS says to drink plenty of fluid, eat plenty of fibre to keep poo soft, keep your bottom clean and dry, and not to ignore the urge to poo. A warm bath helps with itching and pain in piles, and the NHS advises a warm, shallow bath after you poo for an anal fissure.

There is one difference in the NHS wording on pain relief. The fissure page lists paracetamol or ibuprofen for pain. The piles page says to take paracetamol if piles hurt, and not to take ibuprofen if your piles are bleeding, and not to take painkillers that contain codeine as they can cause constipation. If you are not sure which of the two you have, paracetamol is the safer common option, and a pharmacist can advise on creams, laxatives and cold packs.

The NHS suggests asking a pharmacist about treatment for piles, such as creams to ease pain, itching and swelling and laxatives to soften poo. Many pharmacies have a private area if you do not want to be overheard.

For an anal fissure, the NHS says to see a GP if symptoms are getting worse or there is no improvement after 7 days of treating it yourself. For piles it says to see a GP if symptoms are getting worse or not improving after home treatment, if you keep getting piles, or if you notice a change around your anus that is not normal for you.

Some features need faster attention. The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have piles and a high temperature or feel hot, cold, shivery and generally unwell, painless bleeding from the bottom, or pus leaking from your piles. It says to go to A&E or call 999 if you are bleeding non-stop, there is a lot of blood or large clots, or you are in severe pain.

The NHS bowel cancer symptoms page lists blood in your poo, bleeding from your bottom and changes in your poo habit among symptoms to get checked, and stresses that these symptoms are very common and do not definitely mean cancer. Piles and fissures are common explanations for bleeding, but a new or persistent change deserves a check rather than an assumption.

For piles that do not improve, the NHS lists hospital treatments without surgery: rubber band ligation, sclerotherapy, electrotherapy and infrared coagulation, usually with the area numbed and a same-day return home. If those do not work or the piles are large, surgery options include haemorrhoidectomy, stapled haemorrhoidopexy and haemorrhoidal artery ligation. It adds that treatment does not always stop piles coming back.

For an anal fissure that is not healing, the NHS lists laxatives, medicines for pain after you poo and a cream that helps healing, which may be needed for up to 8 weeks. If those do not work or fissures keep coming back, a procedure under general anaesthetic may be recommended, either an injection to relax the anal muscles or a small cut in the muscle to reduce tension. Your GP may refer you to a specialist for an examination under general anaesthetic if they are unsure of the diagnosis or suspect something serious.