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Difference Between Piles and Fistula and Fissure: Explained In-Depth

With inputs from Dr. Pragnya Rao - General Physician

Updated on: November 2023

With inputs from Dr. Pragnya Rao - General Physician

Updated on: November 2023

Reviewed by Dr Raja Indana

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People often misunderstand the difference between piles and fistula and fissure. It is assumed that these conditions share similar characteristics. However, this is not the case. In this blog, we decode the difference in Indian patients in detail – the what, how, why, and helpful treatments recommended to use for each condition.

What is the difference between piles and fistula and fissure?
In brief, piles (also known as haemorrhoids) are swollen veins or blood vessels in the rectum while an anal fistula is a formation of an abnormal canal between the anal and the skin. Fissures, on the other hand, are a sharp cut in the anus lining and can be very painful.

If you have been diagnosed with either piles, fistula or fissure recently, read along to delve deeper into understanding the difference between piles and fistula and fissure in Indian patients, their primary symptoms and treatment.

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Important:

“Piles fistula and fissure are often confused for one another. While piles is swollen blood vessels surrounding the anal canal, fissure is a tear or crack in the tissue of the anus and fistula is an abnormal tunnel between the anus and the surrounding skin. If you notice any bleeding or discomfort while passing stools, you should consult with a physician to understand the underlying cause and get treatment for it.”
– Dr. Pragnya Rao, General Physician

If you are dealing with any one of these conditions, getting treatment during the COVID-19 pandemic can seem quite daunting. That is why we have made it easier for you with MFine. Through instant chat or video call, you can consult leading general physicians on MFine mobile app for an accurate diagnosis and treatment plan for your condition. They are available to provide you with the best support anytime, any place.

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Chapter 1: Understanding the difference between Piles and Fissure and Fistula

The critical difference between Piles and Fistula and Fissure is:

Piles affect the blood vessels inside the anal canal
Fistula is an abnormal tunnel between the anus and the surrounding skin
Fissure is a visibly painful crack on the lining of the anus tissue

The symptoms and causes of piles, fistulas, and fissures help differentiate (and diagnose) these conditions accurately. The table below highlights the differentiating criteria:

Symptoms	PILES	FISTULA	FISSURE
	Lump, redness, sore anus	Anorectal pain and swelling	Visible tear around anus
	Painful excretion	Pus discharges	Hard and blood spotted stool
	Painless bleeding	Skin redness and irritation	Intense pain before and after defecation
	Mucus discharge	Fever and tiredness
	Constant feelings of constipation	Rectal bleeding
		Painful urination and excretion
		Painful urination and excretion
		Foul-smelling liquid in anal

Symptoms	PILES	FISTULA	FISSURE
	Chronic constipation	Anal gland infection	Hard faeces
	Obesity	Rectal cancer	Surgical procedures
	Pregnancy	Tuberculosis	Inflammatory bowel diseases
	Low fiber diet	Crohn’s disease	Multiple pregnancy
	Less hydration	Urinary tract infection	Laxative abuse
	Genetics or ageing	Ulcers in large intestine and rectum	Sexually transmitted diseases

Summary
– Based on their symptoms and causes, piles, anal fistulas, and fissures are distinctly different from each other.
– To avoid these diseases, patients must maintain a healthy lifestyle that entails a fibre-rich diet, good liquid intake, and regular exercise.

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Chapter 2: Piles Symptoms and Characteristics

The rectum is an organ at the end of the human gastrointestinal system that is responsible for the storage of stools and evacuation through the anus. When the blood vessels (and the surrounding tissues) around the anus develop a swelling, the condition is known as piles.

India records more than 10 million
piles cases every year!

Piles are divided into two broad categories:

Internal Hemorrhoids:

As the name suggests, it is present deep inside the anus
Not visible to naked eye
Needs rectal examination for diagnosis
May cause painless bleeding

External Hemorrhoids:

Formed on the outer lining of the anus
Forms small lump on the anus surface
Can be visible to the naked eye
Requires medical assistance

Causes of Piles

The key to understanding the difference between piles and fistula and fissure, is first of all understanding what piles is. Piles is caused due to high pressure in the veins of the lower rectum and anal canal. This build-up, in turn, leads to inflammation and swelling in the area.

This may occur on account of various reasons:

Chronic constipation
Obesity
Pregnancy
Poor Diet – eating low fiber
Genetics or ageing

Symptoms of Piles

The most common symptoms of piles are:

Lump, Soreness, and/or Redness near the anus
Pain during excretion
Painless bleeding
Mucus discharge from the anus
Persistent feeling of constipation – even after excretion

Classification of Piles Into Grades

Doctors categorize piles into four grades:

Grade I: Minor inflammations on the insides of the lining of the anus.
Grade II: They too remain inside the anal cavity. They may come out during excretion but often return spontaneously.
Grade III: Also known as prolapsed haemorrhoids, these lumps hang from the rectum, but can be easily re-inserted.
Grade IV: Large lumps around the anus that require medical treatments.

Treatment for Piles

Depending upon the severity of the condition, there are different kinds of treatment for Piles, like the following:

Non-Operative Treatments

For grade I and II piles, it is possible to treat the disease with the following non-surgical treatment options:

Fibre Supplementation
Increased Fluids
Bulk Purgative (Laxatives)
Relax during bowel movements – don’t strain
Exercise regularly and follow a weight loss diet plan chart

Remember this as
FIBRE

Moreover, various creams, ointments, and pads are available as over-the-counter (OTC) medicines that help ease the symptoms.

In situations of colorectal malignancy (a malignant tumor of the large intestine), it is essential to normalize bowel habits. The solution for this condition includes:

The adoption of stool softeners
Inserting collapsible tubes into the rectum to apply proprietary creams before defecation
Inserting suppositories

Surgical Alternatives

Banding: The Barron’s bander is a commonly available device that slips tight elastic bands onto the base of the organ affected with haemorrhoids. This band cuts off the blood supply, thereby causing ischemic necrosis or death of the piles within 10 days.
Sclerotherapy: This treatment for Piles option involves injecting 5% phenol in peanut or almond oil for treating first and second-degree piles whose symptoms are not cured with conservative measures.
Infrared Coagulation: Here, doctors use devices that emit infrared lights to incinerate the internal haemorrhoid tissues.
Hemorrhoidectomy: It is necessary to opt for surgery to treat grade II and III haemorrhoids. This is done via 3 routes: open, closed, and with a stapler. The previous two cause more discomfort than its stapler counterpart but lead to fewer recurrences.
Hemorrhoid Stapling: A novel method to curing grade III and IV haemorrhoids, it also goes by the name of Procedure for Prolapse and Haemorrhoids [PPH]. The surgical technique uses a circular anal dilator and is less painful than an excisional haemorrhoidectomy.

COVID-19 lockdown: Tips to prevent hemorrhoids at home

While effective medical options are available to treat hemorrhoids or piles, the second wave of COVID-19 in India and its subsequent lockdown has made it difficult for the patients to get their treatment on time. According to reports, several people dealing with piles are taking longer to get cured due to the delayed medical care in the wake of COVID-19 spread triggered lockdown. However, the medical professionals have now made it possible to give their expertise through online doctor consultation, which one could refer to follow up their treatments. As the adage goes, precaution is better than cure, it is better to take some actions beforehand to eliminate the chances of getting hemorrhoids, especially during COVID in India:

Drink six to eight glasses of water daily
Eat fruits and vegetables that soften the stool. This will help you to avoid the straining that can cause hemorrhoids.
Do not withhold to pass the stool
Do any form of exercise. Staying physically active helps prevent constipation.
Avoid sitting for too long, especially on the toilet which can increase the pressure on the veins in the anus

Additionally, visit MFine’s COVID-19 Care page for more information on all things COVID related as well to help keep you safe during the second wave.

Summary
– Piles are the result of the swellings of the blood vessels and tissues surrounding the anal canal.
– Everyday habits determine the chances of developing haemorrhoids. Therefore, it is important to maintain a healthy lifestyle.
– Piles are categorized into four grades. This distinction defines the course of treatment – surgical or non-surgical.

Now that we know what Piles is, read on to further understand the difference between Piles, Fistula, and Fissure.

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Chapter 3: How to treat fistula?

Many people confuse fistula with piles without knowing the difference between them. A fistula-in-ano is the infected channel between the anal canal and rectum with the perianal (exterior) skin.

The key difference between piles and fistula is the latter induces pain and pus discharge from the anal area, whilst the former is usually painless.

Causes of Anal Fistula

A fistula occurs due to persistent anal gland infection, which results in anorectal abscesses – when the anal or the rectum cavity is filled with pus.

Since the anal has multiple openings, treatment of one fistula does not guarantee the impossibility of spread to the rest of the areas.

In India, tuberculosis is a widespread disease. Patients suffering from pulmonary tuberculosis are at risk of developing multiple anal fistulae. These fistulae are not hard but experience watery discharge without pus.

Health Conditions That Cause Anal Fistula

Rectal Cancer
Crohn’s Ileitis: Inflammation of the ileum, which is the last part of the small intestine
Schistosomiasis: Infection of the urinary tract or the intestines
Ulcerative Colitis: Causes persistent inflammation and ulcers in the innermost lining of the largest intestine and rectum
Lymphogranuloma Venereum: An ulcerative disease of the genital area – can be acquired sexually
Diverticulitis: Inflammation of the large intestine

Symptoms of Fistula

Common Symptoms of Fistula

Perianal cellulitis, or redness of the skin
Anorectal pain and swellings
Pus discharges
Fever
Irritation of the perianal skin
Rectal bleeding
Painful bowel movements
Foul-smelling liquid from the anal hole

Diagnosis Procedure

Usually, a fistula is identified as an external opening in the anal cavity. It can be identified by four signs:

Opening at the bottom of a depressed area
Discharging pus
Palpable area
Granulation tissue, or new tissue and blood vessels healing the surface of the wound

Depending upon the complexity, the following methods can be used to identify the fistulas or determine the severity of the condition:

Proctoscopy or Sigmoidoscopy: Introducing a device with a lighting beam in one direction or a fibre-optic camera (respectively) to get a clear view of the rectum
Endorectal Ultrasonography: High-frequency sound waves to evaluate the fistula tract and its surrounding tissues
MRI: Analyses the details in the pelvic zone
Fistulography: Special x-ray to study the abnormal cavity
Anoscope: Small instrument inserted into the anus to study the internal anatomy
Fistula Probe: A long, thin device inserted through the opening of a fistula. It is accompanied by a special dye that helps understand the exact position of the fistula inside.

Methods 2 and 3 can be decided to use for special cases. Some of these examinations are conducted with regional anaesthesia.

Treatment for Anal Fistula

Being aware of the difference between Piles, Fistula and Fissure will make us understand, that when compared to piles, the treatment for fistulas can only be done through surgery.

Depending upon the complexity of the condition, the following lines of treatment for fistula are recommended:

Fistulotomy

In this procedure, a probe is inserted through the external opening into the rectum and along the track where the fistula is open. The wound is left open and left to heal with the natural formation of granulation tissues. Intersphincteric (found in the space between internal and external anal sphincters) and low transsphincteric fistulas of recent origins can be treated by this method.

The advantages are:

Fewer chances of recurrence
Easy procedure
Outpatient procedure – can return home on the same day

Fistulectomy

There are two kinds of fistulectomy:

Chronic fistulae (low) are treated by excising the entire fibrous tissues and the tract. The wound is left open. A minor drawback is that the patient may experience some incontinence, i.e. lack of voluntary control over urination and defecation.
To treat high fistula-in-ano, colostomy surgery can be conducted. Under colostomy, a portion of the colon is cut open and diverted into the abdominal wall to create a small opening for collecting faeces.

Fibrin Glue and Collagen Plug

This is a new method of treatment that includes a two-step process:

First, it closes the internal opening of the fistula. Then, fibrin glue is injected in the tunnel that the body eventually absorbs with time.

Ligation of the Intersphincteric Fistula Tract (LIFT)

LIFT is primarily performed for complex and deep fistulas. It enables the surgeon to access the fistula between the sphincter muscles to avoid cutting them.

A seton is placed into the fistula tract to widen the gap with time. After a few weeks, the surgeon removes the infected tissue and closes the internal fistula opening.

FiLaC: Fistula-Tract Laser Closure

A quicker method (done in approximately 30 minutes) to treating fistulas in India has been introduced.

In this laser treatments for fistulas, a laser fibre, with a set amount of laser energy is inserted from the external opening. It causes controlled destruction of the internal nodes by reducing the blood supply nourishing the abnormal growth.

Chances of reoccurrence are low with this route of treatment.

Summary
– An anal fistula is an infected channel between the anus and its surrounding skin. It is the result of persistent anal gland infection.
– Usually, it is diagnosed with a physical examination. However, the doctor may prescribe digital methodologies, depending upon the complexity of the situation.
– There is only one route of treatment for fistulas: surgery. In India, laser surgeries are rising in demand.

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Chapter 4: Anal Fissure Treatment

An anal fissure is characterised by a longitudinal tear in the mucosa (tissue) that lines the anus. It starts by passing hard stools that cause a crack. This is the most painful condition, commonly observed amongst the young population.

90% of anal fissures occur in the posterior part of the anal canal. The remaining 10% occur in the front.

Anterior fissures are commonly noticed in women subjected to multiple vaginal deliveries. The reason? A damaged pelvic floor and lack of support to the anal mucous membrane.

Signs of Anal Fissure

A noticeable tear around the anus
Burning and/or itching sensations in the anal area
Hard and bleeding stool
Intense pain during and after defecation
Small perianal abscess – a severe condition

Causes of Fissure

Hard faeces
Surgical procedures like hemorrhoidectomy
Inflammatory bowel diseases like Crohn’s
Multiple childbirths
Abuse of laxatives and ointments
HIV or Syphilis

Anal Fissure Diagnosis

A physical rectal examination can reveal the state of the tear and a hypertrophied i.e. thickened skin near the lower end of the fissure.

Depending upon the severity, further tests are recommended:

Proctoscopy
Anoscopy
Colonoscopy

The difference between piles and fistula and fissure is that a fissure is the tearing of the anus lining whereas a fistula is an abnormal connection between the anus and the skin. Now we shall look at the methods of treatment for fissure.

Treatment for Fissure

Conservative Alternatives

Eat fibre-rich diet, take mild laxatives, and don’t postpone defecation.
Apply anaesthetic creams to ease discomfort
Sitz bath (immersing your lower region in warm water)
Your doctor might prescribe antibiotics

Surgical Treatments

Lateral Internal Sphincterotomy (LIS)

In this procedure, the internal sphincter is divided away from the fissure. LIS has a high success rate and should be limited to the length of the fissure to avoid incontinence.

Fissurectomy and Local Advancement Flap

To treat persisting, chronic and non-healing fissures, the defect remaining after the excision of the fissure is closed by a small rhomboid advancement flap.

The recovery takes longer as compared to other kinds of treatment for fissure. It is advisable not to consider this as the first line of solution.

Summary
– A fissure is a noticeable cut in the lining of the anus. It leads to terrible pain during defecation.
– 90% of the fissures affect the posterior of the anal canal.
– Usually, fissures can be cured at home by resorting to home remedies and laxatives. Very few cases require surgery.

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References

Piles, Fistula, and Fissures are serious conditions. To acquire a good understanding of the difference between piles and fistula and fissures, read this set of the most Frequently Asked Questions below:

Piles

Q1. Do men and women suffer from haemorrhoids at the same rate?

Haemorrhoids affect both genders at the same rate. The risk is higher for adults between 45-65 years of age. Despite this widespread incidence, only 4% of the infected experience severe problems due to enlarged haemorrhoids.

Q2. How many pregnant women suffer from piles in India?

Pregnant women can experience piles due to an enlarged uterus or weaker muscles, a typical result of hormonal changes. It is found that 1 in every 10 expected mothers suffer from piles in India.

Q3. How do doctors diagnose piles?

Depending on the patient’s symptoms, a physician can diagnose piles with a visual examination of the anus. A physical test is the first (and most frequently) used procedure. Here, the doctor inserts a lubricated finger into the rectum to check for abnormalities.

To check for internal haemorrhoids, doctors prefer using the Proctoscopy methodology. Here, a device is inserted inside the rectum. The light on the lens gives a good view to make an informed diagnosis.

In some cases, a small fibre optic-camera, also known as sigmoidoscopy, is inserted into the rectum.

Q4. What are the chances of reoccurrence after surgery?

Usually, surgery cures piles. But the chances of reoccurrence depends on how well does a patient take care post-surgery. It is vital to maintain a fibre-rich diet along with hydrating the body.

Once healed, it is recommended to keep the body weight in check. Yoga is the best exercise to help a person remain healthy (physically and mentally).

Q5. What happens if piles is left untreated?

It is essential to treat piles at the earliest. If untreated, the internal haemorrhoids can stick out – leading to irritation, rashes, bleeding, and other severe complications during excretion.

Q6. Which other factors lead to stool bleeding?

Stool bleeding is not limited to haemorrhoids. It may also be due to:

Anal Fissure
Diverticulosis
Colon Cancer
Colitis – Inflammation of the colon
Peptic Ulcers

Anal Fistula

Q1. Which bacteria is most commonly associated with anal gland infection?

Common anal abscess causative bacteria include E.Coli, Bacteroides spp, and Enterococcus spp.

Q2. Does an abscess always convert into a fistula?

50% of abscess cases convert into a fistula. Thus, if you have an abscess, you might not necessarily develop a fistula.

Q3. Which other organs are susceptible to develop a fistula?

Fistulas can occur between different parts of the body. Some of them are:

Bile duct and the surrounding skin
Cervix and vagina
Neck and throat
Bowel and vagina
Stomach and surrounding skin
Navel and the gut
Artery and veins in the lung

Q4. Can an abscess or fistula recur?

There’s a good chance that a fistula will recur. Since the anal has multiple glands, it is recommended to prevent the symptoms by maintaining healthy hygiene habits and following a fibre-rich diet.

Q5. Is the operation painful?

The surgical treatment for the fistula depends upon its location and complexity in the body. If the operation is simple, chances are you can return home the same day. With complicated surgeries, the patient needs to stay at the hospital to get proper medical attention.

Some discomfort can be experienced post-surgery. However, it is short-lived. Proper medical attention and healthy habits speed-up the recovery timeline.

Q6. What precautions should be taken post-surgery to prevent recurrence?

It is natural to experience some pain and bleeding after surgery. However, it is important to rest well for at least 24 hours post-surgery.

If discharged immediately, follow the guidelines as suggested by your doctor to keep the wound clean and packed. A healthy diet, good liquid intake, and a temporary break from exercise are recommended.

Fissure

Q1. What should be done to treat chronic constipation?

Constipation is the most common cause of fissures. Therefore, it is essential to cure them at the earliest. Some effective remedies are:

Eating fibre-rich food like apple, oranges, carrots, broccoli, etc.
Drinking more fluids
Regular exercising to ease defecation

Further, on your doctor’s recommendation, it is ideal to consume bulk-forming agents like methylcellulose, stool softeners like docusate, osmotic laxatives such as Milk of Magnesia, and lubricant laxatives like mineral oil.

Q2. What is a Sitz Bath?

Sitz, meaning to sit, refers to a kind of bath that involves sitting on a bathtub filled with warm water. Add salt to the water and spread your legs for the water to touch your genitals. Regularly conducting sitz bath for one week should help heal the initial anal tear.

Q3. How many cases of fissure require surgery?

Most of the anal fissure cases heal on their own. Eating fibre-rich food, taking sitz baths, and applying anaesthetic creams should help fix the tear. Very few cases require surgery in India.

Q4. How long does a fissure take to heal without surgery?

Short-term anal fissures typically heal between 4-6 weeks without operations. When home-remedies are implemented regularly, the patient will be freed from the pain.

Q5. How does a fibre-rich diet treat constipation?

Soluble and insoluble fibre is vital for the human body. Soluble fibre (apple, oranges, carrots, etc.) allows water to remain in the stool; thereby, smoothening the digestive tract.

Insoluble fibre (brown rice, nuts, lentils, etc.) adds bulk to the faecal material that allows quick movement of the stool outside the body, thereby reducing the constipation feelings.

Q6. Do fissures recur?

Yes. There are good chances for fissures to recur if an individual develops constipation or any other inflammatory disease.

In order to prevent this recurrence, it is imperative to maintain a healthy lifestyle.

Conclusion

Piles, anal fistula, and fissures affect the anal canal. However, this commonality should not be mistaken as a single disease. Each of these diseases affects the human body in different sub-locations and with varying intensities.

It is important to carefully analyse every symptom and accordingly seek medical assistance. If you’re suffering from piles, anal fistula, or fissures, consult your doctor immediately, and things will soon be back to normal.

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