First-line treatment (works for most people)

1. Fibre and fluids. Aim for about 25 to 30 g of fibre a day from vegetables, fruit and oats. A psyllium (ispaghula) supplement works well. Drink plenty of water.
2. Soft stools. Add a stool softener or laxative (lactulose or macrogol) if you are constipated.
3. No straining. Don't sit on the toilet for more than a few minutes, and don't use your phone there. Go when you feel the urge.
4. Sitz baths. Sit in warm water for 10 to 15 minutes, 2 to 3 times a day, especially after a bowel movement. Evidence for this is limited, but it eases discomfort.
5. Gentle hygiene. Use plain water or unscented wipes and pat dry. Avoid scrubbing, soap and perfumed products.
6. Short-term creams. Lidocaine, witch hazel or combination creams and suppositories can ease itching or pain. Use steroid-containing creams for no more than 2 weeks at a time. The AGA clinical practice update says evidence for topical products is weak.
7. Pain relief. Paracetamol or ibuprofen is fine if you have no contraindication.
8. Flavonoids. Oral micronised purified flavonoid fraction (diosmin/hesperidin) may help bleeding and itching in some people. It is available in some countries.

If it is a thrombosed external pile

• If you are seen within 48 hours, the clot can be removed under local anaesthetic. This is the usual advice, and the AGA update also says incision and drainage works best for acute thrombosis.
• After 48 hours, or if pain is settling, conservative care is reasonable. Use sitz baths, painkillers, stool softeners and cold compresses. Most cases resolve or leave a skin tag (Bailey and Love, External haemorrhoids section). A 2026 meta-analysis compared operative and non-operative treatment of these.

If she has internal piles (bleeding or prolapse)

When to see a doctor

• Soon: If the lump is very painful, hard or blue. See a doctor within 48 hours.
• Soon: If she has sharp, tearing pain with bowel movements. That is more typical of a fissure than of piles, and fissures are treated differently (topical GTN or diltiazem, and stool softening).
• Soon: If bleeding is heavy, repeated or ongoing, or she feels dizzy, tired or looks pale. At 24, piles are common, but a doctor should rule out other causes of bleeding, such as inflammatory bowel disease.
• Soon: If she has persistent changes in bowel habit, weight loss, or a family history of bowel disease or cancer.
• Soon: If the lump is growing, ulcerated, or has discharge or fever. These suggest infection or an abscess.
• Routine: If the problem lasts more than 1 to 2 weeks despite the measures above.

Pregnancy

Which procedure for which problem

• third- and fourth-degree piles
• second-degree piles not cured by non-operative treatment
• mixed piles with a well-defined external component
• bleeding that causes anaemia

Trade-offs between operations

• Excisional haemorrhoidectomy has the lowest recurrence rate and is the standard for advanced piles. It is also the most painful, with a longer recovery. Rare complications include bleeding, urinary retention, anal stenosis and, uncommonly, incontinence.
• Doppler-guided ligation, stapled haemorrhoidopexy and laser hurt less and let you return to normal sooner. The trade-off is a higher chance the piles return. A 2026 systematic review of laser haemorrhoidoplasty versus excisional surgery describes this recovery versus durability trade-off. A 2024 meta-analysis compared conventional excision with transanal haemorrhoidal dearterialization. I only saw the titles and abstracts' headlines, not the full data, so I can't quote figures.
• Pain control after surgery: a 2026 meta-analysis found metronidazole effective for pain after haemorrhoidectomy. Stool softeners and sitz baths also help.

Before any surgery

1. Confirm the diagnosis. She needs a proper exam and anoscopy. Bailey and Love say examination under anaesthesia or endoscopy is needed if there is any doubt. Sharp pain with bowel movements suggests a fissure, which is managed differently.
2. Rule out other bleeding causes. At 24 this is usually piles, but if she has bleeding with changed bowel habit, weight loss, anaemia or a family history of bowel disease, she may need colonoscopy or sigmoidoscopy.
3. Try conservative care first. Fibre, fluids, no straining, sitz baths and short courses of topical treatment come first, as in my last message.
4. Plan for pregnancy. If she may become pregnant, surgery is often delayed. The AGA update also recommends banding or infrared coagulation before surgery for persistent postpartum symptoms.

Practical next step