If a pile is very painful, it is usually a fissure (an ulcer or a tear) in the skin around the bottom rather than a pile causing the symptoms.  The optimum treatment of fissures after keeping bowel movements soft is a cream called Diltiazem (2%), which acts to relax the anal muscle and increase the healing blood supply.   My published study using Diltiazem showed two thirds of patients are improved.  Please click here for a list of my publications.

For some patients a tailored operation is the next step if the cream does not work.  For those at greatest risk of incontinence, Botox may be injected temporarily reduce the anal tone.  Please click here for further information on Botox for Resistant Chronic Anal Fissure.