Not every perianal lump is 'piles': look first, then touch

Not every perianal lump is 'piles'. The first diagnostic instrument is inspection, before any finger touches the anus.

Stepwise approach (adapted from Common Anal Conditions v2.0, Chapter 2)

1. Fever, induration, constant throbbing. Perianal abscess: same-day incision and drainage. Antibiotics alone are not treatment.
2. Afebrile, sudden tense bluish lump. Thrombosed external haemorrhoid. <72 h with severe pain: excise the whole clot under LA. >72 h or easing: conservative care.
3. Large mass: read the colour first. Black or grey: do not reduce (ischaemia). Concentric rings = full-thickness rectal prolapse; radial grooves = prolapsed haemorrhoids.
4. Viable, oedematous prolapse. Sugar (osmotic) reduction can help before definitive planning.
5. Indurated, ulcerated or pigmented lesion. Urgent biopsy. Cirrhosis: think rectal varices; do not band.

Recent evidence

• Systematic review and meta-analysis 2025 (6 studies, 851 patients): surgery for thrombosed external haemorrhoids lowered recurrence, RR 0.49 (95% CI 0.26–0.91); bleeding RR 0.96, no difference.
• AGA Clinical Practice Update 2026 (expert review): haemorrhoids cause significant pain only when acutely thrombosed; sharp pain on defecation is most likely a fissure; acute thrombosis is best treated surgically by incision and drainage.
• Guidance differs on technique: ASCRS 2024 and AGA 2026 diverge between early excision and incision and drainage. State the technique you used.

Caution: Mimics to exclude: melanoma, Crohn's disease, STI proctitis, varices. Never label a perianal lump 'piles' without looking.

Free open-access book: /books/common-anal-conditions/chapter-02

Educational content for healthcare professionals. Follow local guidelines and the treating team's judgement.