Piles or anal fissure? How to tell them apart
By Dr Wong Nan-Yaw, MBBS (NUS), FRCS (Edinburgh). Published . 6 min read.
Pain is the main clue. An anal fissure is a small tear that causes a sharp pain when you pass stool and a burning ache that can last hours. Piles are swollen blood vessels that more often bleed painlessly, itch or form a lump (NHS). Dr Wong Nan-Yaw, a colorectal surgeon, can usually tell them apart with a short examination.
What is the difference between piles and an anal fissure?
Piles (haemorrhoids) are swollen blood vessels and tissue in or around the anus. An anal fissure is a small tear in the lining of the anus. Both can cause bright red blood on the toilet paper, which is why they are often confused, but they feel different and are treated differently.
| Piles (haemorrhoids) | Anal fissure | |
|---|---|---|
| What it is | Swollen blood vessels and tissue in or around the anus | A small tear in the lining of the anus |
| Pain | Often painless, especially small internal piles; external piles can hurt | Severe, sharp pain when passing stool, then a burning ache that can last several hours |
| Bleeding | Bright red blood after passing stool | Bright red blood on the paper or in the bowl |
| Other signs | Itching, mucus, a lump that may come down and go back | Often follows hard stool or constipation |
| Who gets it | More likely with constipation, straining, pregnancy, age and heavy lifting | More common between ages 15 and 40, with constipation, frequent diarrhoea, or after childbirth |
Sources for this table: NHS pages on piles and anal fissure, and HealthHub's guide to piles.
Piles are described as internal or external. HealthHub explains that internal piles sit inside the anus but may hang out during a bowel movement, then go back on their own, need to be pushed back, or stay outside permanently. External piles sit outside the anus and can be felt as lumps.
Fissures have their own list of risk factors. Besides constipation and frequent diarrhoea, the NHS lists pregnancy and vaginal birth, inflammatory bowel disease such as Crohn's disease or ulcerative colitis, and some sexually transmitted infections.
Why does a fissure hurt so much more than piles?
A fissure is a tear in the lining of the anus itself, which is sensitive, so stretching it during a bowel movement hurts sharply. Small internal piles sit inside the anus, where HealthHub notes there are no pain-sensitive nerves, so they tend to bleed without pain. External piles lie outside the anus, can be sore, and may contain blood clots.
This difference is useful, but it is not absolute, because external piles can also hurt. The two conditions share the same trigger as well: hard stool and straining, often from constipation.
What can I do at home for either condition?
Soft, regular stools help both. Eat more fibre gradually, drink plenty of fluids, go when you feel the urge, and do not strain or sit on the toilet for long. A warm, shallow bath eases pain. The NHS advises paracetamol for pain, and avoiding codeine, which constipates, and ibuprofen if piles are bleeding.
For piles, HealthHub lists pharmacy options including anti-inflammatory creams such as hydrocortisone, local anaesthetic creams such as lidocaine, soothing ointments, and stool softeners or laxatives. Use creams for the recommended time only, and ask a doctor if you are not sure which condition you have, because a fissure and piles respond to different treatments.
- Add fibre slowly with fruit, vegetables, oats or wholegrains, and drink more water
- Respond to the urge to go; delaying makes stool harder
- Avoid long sessions on the toilet, including with a phone
- Pat the area dry rather than rubbing
- Ask a pharmacist about creams and stool softeners if symptoms persist
How are piles and fissures treated if home care is not enough?
Treatment follows the diagnosis. A fissure that does not heal is treated with laxatives and a cream that helps healing, used for up to 8 weeks, then if needed an injection to relax the anal muscle or a small cut in that muscle. Clinic treatments such as banding or injections suit many piles, with surgery for large or persistent ones.
For piles, the NHS lists rubber band ligation, sclerotherapy (an injection that shrinks the pile), and infrared coagulation as clinic treatments done while you are awake. Haemorrhoidectomy, stapled haemorrhoidopexy and haemorrhoidal artery ligation are operations for piles that do not respond or are large.
For fissures, most heal on their own. The NHS notes that the muscle-relaxing injection and the small muscle cut are done under general anaesthetic. Treating the wrong condition rarely helps, which is one reason an examination matters before a procedure.
When should I see a doctor about anal pain or bleeding?
See a doctor if symptoms do not improve within about 7 days of home treatment or are getting worse, which is the point HealthHub and the NHS both use. See one sooner for bleeding between bowel movements, a change in bowel habit, weight loss, or a hard lump. Go to emergency care for heavy, non-stop bleeding or severe pain.
Bleeding from piles or a fissure can look the same as bleeding from other bowel conditions, so the cause should be confirmed rather than assumed. HealthHub notes that some symptoms of piles are similar to those of colon cancer.
The NHS also advises an urgent appointment if you have piles with a high temperature, feel generally unwell, or notice pus leaking from the area, as these can suggest infection.
An examination for these conditions is short. If a fissure makes examination too painful, the NHS notes that a specialist may examine the area under anaesthetic instead.
Sources
Medically reviewed by Dr Wong Nan-Yaw
MBBS (NUS), FRCS (Edinburgh). 33 years in medicine (since 1993), 23 years as an accredited specialist (since 2003) and 18 years in private practice at Mount Elizabeth (since 2008). Last reviewed 6 November 2026.
How this article is prepared
Statements are checked against the sources listed above. This article is general education and does not replace a consultation. It is reviewed and updated when guidance changes. In an emergency, call 995.