Piles, Fissure and Fistula: Treatment Options and When to See a Surgeon

Piles (haemorrhoids)

Haemorrhoids are enlarged, engorged blood vessels — veins and arteriovenous connections — in and around the rectum and anal canal. They are extremely common; most people have some degree of them by middle age. They are described as internal (above the dentate line, typically painless) or external (below the dentate line, more likely to cause pain if they thrombose).

Grading internal haemorrhoids

• Grade 1 — bleed but do not prolapse (come down outside the anal opening). Often no symptoms other than bright-red blood on toilet paper.
• Grade 2 — prolapse during straining but return spontaneously.
• Grade 3 — prolapse during straining and need to be pushed back manually.
• Grade 4 — permanently prolapsed and cannot be reduced. May also have thrombosis or strangulation.

What causes haemorrhoids to become symptomatic?

Chronic constipation and straining, low-fibre diet, prolonged sitting, pregnancy, and increased intra-abdominal pressure from heavy lifting are all contributing factors. They do not arise from a single identifiable cause in most people.

Treatment of piles

Conservative management (Grade 1 and 2, many Grade 3 cases):

• High-fibre diet — vegetables, fruits, pulses, whole grains — and adequate water intake to produce soft, easy-to-pass stools.
• Stool softeners or bulk-forming agents if dietary change alone is insufficient.
• Topical preparations for symptom relief (creams, suppositories).
• Avoiding prolonged straining or sitting on the toilet.

Minimally invasive office procedures (Grade 2 and 3):

• Rubber band ligation — a small rubber band is placed at the base of an internal haemorrhoid, cutting off its blood supply. It shrinks and falls off within days. An effective, well-established outpatient technique.
• Sclerotherapy — injection of a sclerosing agent into the haemorrhoid. Used mainly for Grade 1 and 2.

Surgical haemorrhoidectomy (Grade 3 not responding to banding, Grade 4):

Surgical removal of the haemorrhoidal tissue. The most effective definitive treatment for large or prolapsed haemorrhoids. Modern techniques aim to minimise post-operative pain, though discomfort in the days following surgery is expected. Stapled haemorrhoidopexy (PPH) is an alternative for Grade 3 that does not remove the haemorrhoids but repositions and fixes them; it is associated with less post-operative pain but a somewhat different risk profile — suitability is patient-specific.

Anal fissure

An anal fissure is a small tear or crack in the lining of the anal canal. It typically causes a sharp, severe pain during and after passing a stool — often described as passing glass — along with a small amount of bright-red blood. The pain can persist for an hour or more after defaecation, making patients reluctant to go to the toilet, which then worsens constipation and perpetuates the problem.

Acute vs chronic fissure

• An acute fissure — present for less than six weeks — has clean edges and often heals with conservative treatment.
• A chronic fissure — lasting longer — typically has thickened edges, a visible white base of exposed sphincter fibres, a skin tag below it (sentinel pile), and a hypertrophied anal papilla above. Chronic fissures rarely heal without intervention.

Treatment of anal fissure

Conservative (acute fissures): High-fibre diet and fluids, stool softeners, topical anaesthetic creams, and relaxants for the internal anal sphincter — primarily glyceryl trinitrate (GTN) ointment or diltiazem cream. These work by reducing the internal sphincter spasm that impairs blood supply to the fissure and prevents healing. Headache is a common side effect of GTN.

Botulinum toxin injection — injection into the internal sphincter to achieve temporary relaxation; effective in a proportion of chronic fissures, with healing rates varying in published studies. The main advantage is that it avoids cutting the sphincter muscle.

Lateral internal sphincterotomy (LIS) — a small division of part of the internal anal sphincter, surgically or with an instrument. Highly effective for chronic fissure. The small risk of altered sphincter control is the main consideration; this is why it should be performed by a surgeon with specific experience, and why a careful pre-operative discussion is essential. Dr. Khanna takes this discussion seriously — particularly for young patients and women, in whom sphincter preservation matters most.

Anal fistula

An anal fistula is an abnormal tunnel — a tract lined with granulation tissue — connecting an internal opening in the anal canal to an external opening on the skin around the anus. Most fistulas arise from a previous anal abscess that burst spontaneously or was drained but did not heal completely. The tract, perpetuated by ongoing infection, does not close on its own.

Symptoms of anal fistula

• Persistent or intermittent discharge from a small opening near the anus — may be clear, mucous, or blood-stained.
• History of a recurrent perianal abscess (swelling, redness, pain around the anus that burst or was drained).
• Discomfort and irritation in the perianal area.

Why fistula surgery is complex

The critical issue with fistula surgery is the relationship of the fistula tract to the sphincter muscles. Fistulotomy — simply opening the tract along its length and letting it heal — is straightforward and highly effective for superficial (intersphincteric or low trans-sphincteric) fistulas, where cutting does not risk sphincter damage. For fistulas that run through a substantial part of the sphincter (high trans-sphincteric, suprasphincteric), other techniques must be used to preserve continence:

• Seton placement — a thread passed through the fistula tract; either a loose marking seton (to define anatomy before a staged procedure) or a cutting seton placed under tension.
• LIFT procedure (Ligation of Intersphincteric Fistula Tract) — closure of the internal opening and division of the tract in the intersphincteric space, without cutting through sphincter muscle.
• Advancement flaps — covering the internal opening with healthy rectal mucosa.
• Video-assisted anal fistula treatment (VAAFT) and plug-based techniques — used selectively.

The right technique depends on the anatomy of the individual fistula, which must be defined — by examination under anaesthesia and often by MRI — before any operation is planned. Attempting fistula surgery without this assessment risks both recurrence and sphincter injury. This is an area where senior surgical judgement matters: not every fistula should be treated the same way, and the choice of technique should be guided by a surgeon who has managed a wide range of fistula anatomy over years of practice.

A note on rectal bleeding

Bright-red blood on toilet paper or in the pan is the most common symptom of haemorrhoids — but it is also the symptom of anal fissure, rectal polyps, colitis, and colorectal cancer. Assuming rectal bleeding is haemorrhoids without an examination is a mistake; the examination takes minutes and is much safer than an assumption. Please see a doctor if you notice blood in or around your stools, particularly if it is associated with a change in your bowel habit, weight loss, or if you are over 40.

Related reading and next steps

For the service page: piles and fistula treatment in Surat. To plan a consultation: OPD hours and directions. See also: all conditions treated and laparoscopic vs open surgery compared.