Brief Answer:
Larger piles require surgery

Detailed Answer:
Hello,
1) Piles + Pain + blood suggest possibility of acute anal fissure, which develop due to more straining to pass hard stool or due to big piles
2) How much is blood loss? Do you feel piles in anal region with finger? Both this decide stage of piles
3) Generally small single episode of piles with mild to moderate pain without feel of piles does not require surgery. But otherwise surgery is suggested to prevent repeated blood loss.
4) Treatment for constipation is also important as it prevent progression of piles and provide relief from symptoms of fissure.
5) Fissure is condition in which inner layer of anal canal gets abrasion (small wound) due to excessive straining and it cause swelling in anal area. This itself make defecation difficult.
6) If you have blood loss since long time then it is advisable to check hemoglobin level

---