Bleeding from your bottom: piles, fissures and when to see a GP

Seeing blood after a poo is unsettling, and bleeding piles are one of the most common reasons for it. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) says bleeding from the anus is nearly always due to benign conditions, usually piles (haemorrhoids, or hemorrhoids in US spelling) or small tears called fissures. The NHS says a small amount of one-off bleeding from the bottom is not usually a serious problem, but a GP can check.

Bleeding from the bottom (rectal bleeding) is also sometimes a sign of bowel cancer, the NHS says. This guide sets out what the blood can look like, what it might mean, and exactly when the NHS says to see a GP, contact NHS 111 or go to A&E.

Do piles bleed?

Yes, and bleeding is their most common symptom. NICE CKS, NICE's guidance for GPs, describes bright red, painless bleeding that usually comes with a poo and shows as streaks on the toilet paper, blood in the toilet bowl or blood on the outside of the poo, not mixed into it.

ACPGBI says the blood is usually bright red and fresh, as though you had been cut. The NHS describes piles as swollen blood vessels, and NICE CKS calls them abnormally swollen cushions of blood vessels in the anal canal. ACPGBI explains that these cushions are known as piles once they enlarge and can stick out and bleed, and expert opinion cited by NICE CKS is that passing hard poo increases the shearing force on them. ACPGBI adds that the blood is sometimes noticed as a stain on underwear or bedclothes rather than in the toilet. For what piles look like when they come down, see what piles look and feel like.

How much bleeding from piles is normal?

Neither the NHS nor ACPGBI gives a "normal" amount of hemorrhoid bleeding. ACPGBI describes how anal bleeding, usually from piles or a fissure, can look: slight, as a smear on the toilet paper, or heavier, colouring the water in the toilet bowl. Sometimes it splashes the bowl or drips into the toilet after the poo has passed.

The NHS says to go to A&E or call 999 if you're bleeding non-stop, there's a lot of blood or you see large blood clots. If you have piles and painless bleeding from the bottom, the NHS piles page says to ask for an urgent GP appointment or get help from NHS 111. The NHS also lists pink water in the toilet bowl as one of the signs of bleeding from the bottom, while toilet water that turns red is its example of a lot of blood.

What does the colour of the blood mean?

Colour gives doctors a clue to where the blood comes from. ACPGBI says bleeding from the anus, usually from piles or a fissure, is typically bright red and fresh, while blood that is dark, clotted or mixed into the poo may be coming from further up the bowel. The NHS says black or dark red poo needs an urgent GP appointment or NHS 111.

The NHS table of common causes, below, links what you see to what it might be. The NHS adds that you shouldn't self-diagnose, and should see a GP if you're worried.

Bleeding from the bottom: what the NHS says it might mean

	Other signs.	Possible cause.
Bright red blood	Pain when pooing, an itchy bottom, lumps	Piles (haemorrhoids)
Bright red blood	Pain when pooing, often after constipation	A small tear in the anus (anal fissure)
Bleeding	With or without lumps, itching or pain	Sexually transmitted infections (STIs) such as genital warts, or damage from anal sex
Bright red blood	No pain	A side effect of medicines that help prevent blood clots, such as warfarin, apixaban or aspirin; or broken blood vessels in the gut (angiodysplasia)
Blood and yellow slime	An irritated anus, non-stop bottom pain	Anal fistula
Bloody diarrhoea with clear slime	Feeling and being sick	A tummy bug (gastroenteritis)
Bloody diarrhoea	Tummy cramps and pain, feeling bloated	Inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn's disease
Blood in poo	A change in pooing habits (looser poo, diarrhoea or constipation), slime with poo	Bowel polyps, or early signs of bowel cancer
Dark or black poo	No other signs listed	Bleeding in the stomach or gut, which can be from an injury or from medicines that help prevent blood clots, such as warfarin, apixaban or aspirin
Dark blood or poo	Tummy pain or cramps	A stomach ulcer

Adapted from the NHS page on bleeding from the bottom, which says: do not self-diagnose, and see a GP if you're worried.

The NHS says poo can look as if it's mixed with blood if you've eaten a lot of red or purple foods like tomatoes and beetroot. It can also look very dark or black if you take iron tablets or eat a lot of dark foods like liquorice and blueberries. It is sometimes a sign of something else, though, and a GP can check if you're worried.

Medicines that help prevent blood clots, such as warfarin, apixaban or aspirin, are on the NHS list of causes too. Don't stop a prescribed medicine on your own: the NHS constipation page says to speak to the GP before you stop taking any prescribed medicine.

Is it piles or an anal fissure?

Both cause bright red bleeding, so the pain is a useful clue. The NHS describes an anal fissure as a small tear in the anus that causes severe, sharp pain when you poo and a burning pain afterwards that may last for several hours. ACPGBI says bleeding from a fissure may be quite painful, while piles are either painless or cause only mild discomfort.

ACPGBI adds that bright red blood with short-lived pain after passing a hard poo is highly likely to be a small tear. Our guide to piles or anal fissure compares the two symptom by symptom, and our anal fissure guide covers how a fissure heals.

How can you stop piles bleeding?

Bleeding piles are treated with the same self-care as other piles. The NHS advice is to drink lots of fluid and eat plenty of fibre to keep your poo soft, and not to push too hard or spend longer than you need on the toilet. It also says not to take ibuprofen if your piles are bleeding.

ACPGBI says a diet with extra fibre may help people who tend to get constipated, and that this change is often enough to stop the symptoms, particularly bleeding. Paracetamol is the painkiller the NHS suggests for piles, and it says to avoid painkillers containing codeine, which can cause constipation. A pharmacist can suggest creams to ease pain, itching and swelling, but NICE CKS quotes the British National Formulary (BNF): creams containing local anaesthetics and corticosteroids may relieve symptoms but do not affect bleeding. For gentle washing and drying, see our guide to how to use a bidet, wipe and wash.

If bleeding piles don't improve with home treatment, you may need hospital treatment, the NHS says. NICE CKS advises GPs to refer people who don't respond to treatment in general practice, including people whose symptoms keep coming back despite it. ACPGBI says piles that keep causing trouble can often be treated by placing small rubber bands around their base, which makes them fall away, often in an outpatient clinic. Our guide to piles in men covers home care and the hospital treatments in full.

When should you see a GP about bleeding from your bottom?

The NHS says a small amount of one-off bleeding can often go away on its own without treatment, but a GP can check any bleeding, and some signs need help quickly. These are the NHS's signs, in three levels of urgency. If you're worried, the NHS says, see a GP.

See a GP if:

• your child has blood in their poo
• you've had blood in your poo for 3 weeks
• your poo has been softer, thinner or longer than normal for 3 weeks
• you're in a lot of pain around the bottom
• you have a pain or lump in your tummy
• you've been more tired than usual
• you've lost weight for no reason
• you have piles that are getting worse or not improving after home treatment, you keep getting piles, or you notice a change around your anus that is not normal for you

Ask for an urgent GP appointment or get help from NHS 111 if:

• your poo is black or dark red
• you have bloody diarrhoea
• you have piles and painless bleeding from the bottom
• you have piles and your temperature is very high, or you feel hot, cold or shivery and generally unwell
• pus is leaking from your piles

You can call 111 or get help from NHS 111 online.

Go to A&E or call 999 if:

• you're bleeding non-stop
• there's a lot of blood: for example, the toilet water turns red or you see large blood clots
• you have piles and you're in severe pain

Do not drive yourself to A&E. Ask someone to drive you, or call 999 and ask for an ambulance, and bring any medicines you take with you.

If you think the bleeding could be from a sexually transmitted infection, or you've noticed lumps around your anus, you can also go to a sexual health clinic (NHS GUM clinic). The NHS says they're free and confidential, and many offer a walk-in service where you don't need an appointment.

What happens at the GP appointment?

A GP will ask about the bleeding and check what's causing it. The NHS says they might check your bottom with a gloved finger (a rectal examination), ask for a sample of poo for testing, or refer you to a specialist for tests. ACPGBI says the finger examination is done gently and is much less painful than many people imagine.

You'll be asked to undress from the waist down for the examination, and you can ask for a male or female doctor or nurse and for someone else to be in the room, the NHS says. It also asks you to try not to be embarrassed: the doctor or nurse will be used to talking about these symptoms. You may be given a home test kit called FIT, which checks a small sample of poo for bleeding from your bowel.

Specialist tests can include looking inside the anal canal with a proctoscope, or examining the bowel with a telescope (sigmoidoscopy or colonoscopy), ACPGBI says. A colonoscopy lets the doctor see the whole length of the bowel.

Should you worry if your piles are bleeding?

Usually it is piles or a small tear, but it's worth ruling out something more serious. ACPGBI says anal bleeding is nearly always due to benign conditions, usually piles or fissures. The NHS says bleeding from the bottom is sometimes a sign of bowel cancer, which is easier to treat if it's found early, so it's important to get it checked.

The NHS lists these symptoms of bowel cancer:

• changes in your poo, such as softer poo, diarrhoea or constipation that is not usual for you
• needing to poo more or less often than is usual for you
• blood in your poo, which may look red or black
• bleeding from your bottom
• often feeling like you need to poo, even if you've just been to the toilet
• tummy pain, a lump in your tummy, or bloating
• losing weight without trying
• feeling very tired or short of breath, which are signs of anaemia

Some of these symptoms are very common and can be caused by other conditions, the NHS stresses, and having them does not definitely mean you have bowel cancer. It says you may be more likely to get bowel cancer if you're over 50, you smoke, you're overweight, or a close relative has had it.

Bowel cancer screening, a home poo test (FIT) that the NHS offers every 2 years to people aged 50 to 74, can find cancer before symptoms appear. The NHS also points out that if blood is found in your poo, it does not always mean cancer: there are more common, less serious causes, such as an anal fissure or bowel polyps.