01OverviewDefinition, clinical context and the essential points that orientate the chapter.
The anal cushions are normal vascular and connective-tissue structures that contribute to closure of the anal canal. Haemorrhoidal disease describes symptoms arising from enlarged or displaced cushions, not simply the presence of visible veins. Internal cushions originate above the dentate line and have relatively insensitive mucosal covering; external disease lies below it under sensitive skin. This anatomical distinction explains why uncomplicated internal bleeding can be painless while an acutely thrombosed external swelling is intensely tender. Patients may have both components, and removing every cushion would jeopardise function.
Describe the symptom before assigning a grade. Grade I internal haemorrhoids do not prolapse; grade II prolapse with defaecation and reduce spontaneously; grade III need manual reduction; grade IV remain prolapsed. The grade refers to internal prolapse, not the size of an external skin tag or the volume of bleeding. A person with grade II disease and repeated disruptive bleeding may need treatment, while an incidental higher grade finding does not automatically determine the operation. Ask what interferes with life: bleeding, cleaning, soiling, prolapse, pain or embarrassment.
A diagnosis of haemorrhoids and a diagnosis explaining all rectal bleeding are different conclusions. Anal inspection may show a plausible bleeding point, but colorectal cancer, inflammatory bowel disease, diverticular disease and vascular lesions may coexist. Establish duration, bowel habit, weight change, abdominal symptoms, previous colonoscopy and family history. The appropriate extent of investigation follows the whole presentation. Continuing bleeding after an otherwise effective haemorrhoid intervention is a reason to reconsider the source rather than repeat the same procedure indefinitely.
Treatment aims to control the patient’s symptoms while preserving sphincter and cushion function. Changing stool consistency and toileting behaviour reduces repeated mechanical stress. Office interventions fix internal mucosa without removing external tissue; excisional surgery treats substantial external or combined disease more definitively at the cost of a more painful recovery. Explain these tradeoffs in advance so that the patient understands why banding, artery ligation, excision and rectal-prolapse surgery are not interchangeable operations.
Key points
- Internal haemorrhoids usually cause painless bright red bleeding or discrete prolapsing cushions; severe pain suggests thrombosis, strangulation, fissure or another diagnosis.
- Investigate concerning bleeding even when haemorrhoids are visible; a rectal or unexplained anal mass or ulcer does not require FIT before referral is considered.
- Start with assessed bowel habit, adequate fibre and fluid, less straining and shorter toilet visits; confirm unexplained bleeding before prescribing the selected ispaghula product.
- Grades I and II and selected grade III internal disease persisting after conservative care are suitable for office procedures, particularly rubber-band ligation.
- Combined troublesome external and grade III–IV internal disease may need excisional haemorrhoidectomy, with explicit pain, bleeding, stenosis and continence counselling.
- Banding-related fever, marked pain or urinary difficulty needs urgent review; anticoagulant interruption requires an individual bleeding-versus-thrombosis decision.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Mechanical and bowel influences
Repeated straining, prolonged toileting and constipation can contribute to displacement and symptomatic enlargement of the cushions. Frequent loose motions can also aggravate local symptoms.
Mixed anatomical disease
Internal and external components communicate and often coexist, so the symptomatic lesion can contain both mucosal prolapse and sensitive external swelling.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Loss of cushion support
Displacement of the vascular connective-tissue cushions permits mucosal prolapse and bleeding during defaecation, while friction and congestion can perpetuate symptoms.
- 2Painful external thrombosis
Thrombus and oedema stretch the richly innervated skin below the dentate line, producing a focal tender lump rather than the usual painless internal bleeding.
- 3Prolapse and mucosal irritation
Protruding mucosa can leak mucus and make cleaning difficult; retained moisture and friction can then produce itching and soiling.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Record whether blood coats stool, appears on paper, drips into the pan or is mixed with stool, and ask about clots, dizziness and anaemia symptoms. Colour alone does not establish a benign cause. Progressive constipation, abdominal pain, weight loss and relevant family history change the investigation threshold.
With consent, privacy and a chaperone where appropriate, inspect at rest and during straining. Discrete cushions with radial grooves favour haemorrhoidal or mucosal prolapse; a circumferential tube with concentric folds suggests full-thickness rectal prolapse. If the reported prolapse is absent, a patient-provided photograph may help the specialist assessment.
A tolerable digital examination assesses masses and baseline sphincter function; anoscopy helps identify internal cushions and another anal lesion. Do not force an acutely painful examination. An external tag may be the residue of old thrombosis or a fissure, and does not by itself explain current pain or blood.
A suddenly tender blue external lump supports thrombosis. Fever, spreading erythema, fluctuance, tissue necrosis or pain out of proportion requires reassessment for abscess, strangulation or necrotising infection. Review diabetes, immunosuppression and recent banding because these change urgency.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Full blood count with indicated iron studiesFirst step - Why
- Assess the physiological consequences of recurrent or substantial blood loss.
- Interpretation and limitations
- Iron-deficiency anaemia strengthens the need to investigate the bowel rather than merely treat an anal finding. Normal haemoglobin does not exclude important colorectal disease, and unstable acute bleeding requires resuscitation while samples are processed.
- 02
Quantitative FIT when NG12 criteria apply - Why
- Guide the suspected colorectal cancer pathway in the appropriate symptomatic adult.
- Interpretation and limitations
- Offer quantitative FIT to adults with an abdominal mass, change in bowel habit or iron-deficiency anaemia; those aged 40 or over with unexplained weight loss and abdominal pain; those under 50 with rectal bleeding plus unexplained abdominal pain or weight loss; those aged 50 or over with unexplained rectal bleeding, abdominal pain or weight loss; and those aged 60 or over with anaemia even without iron deficiency. A result at least 10 micrograms haemoglobin per gram of faeces supports suspected-cancer referral. A low or unreturned result requires safety netting and must not delay appropriate referral when continuing symptoms create strong concern. A rectal mass or unexplained anal mass or ulcer warrants consideration of the direct suspected-cancer route without waiting for FIT. A previous negative screening FIT does not remove the need for symptomatic assessment.
- 03
Anoscopy and selected lower gastrointestinal endoscopy - Why
- Identify anal disease and investigate the colon when the clinical history requires it.
- Interpretation and limitations
- Anoscopy identifies internal anatomy but cannot examine the proximal colon. Colonoscopy is appropriate in selected patients, especially an uncertain bleeding source, associated abdominal or progressive bowel symptoms, or bleeding persisting after successful treatment. Choose the test through the relevant diagnostic pathway.
- 04
Pre-intervention medication and functional assessment - Why
- Establish the bleeding and continence risks relevant to the proposed procedure.
- Interpretation and limitations
- Record anticoagulants, antiplatelets, previous anorectal surgery, obstetric injury and baseline leakage. This assessment is clinically consequential even when routine imaging is unnecessary. There is no universal source-supported anticoagulant stopping schedule for banding; agree timing with the responsible prescriber.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Full-thickness rectal prolapse
A circumferential protruding rectal tube with concentric folds differs from separate cushions and needs its own pelvic-floor and operative assessment.
Fissure abscess and neoplasia
Pain related to a visible tear, a collection or an unexplained ulcer or mass must be interpreted on its own merits rather than subsumed under haemorrhoids.
Inflammatory and proximal bleeding sources
Colitis, diverticular bleeding and colorectal tumours may coexist with enlarged cushions; associated abdominal symptoms and the bleeding course help distinguish them.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Worked caseResolve persistent grade II symptomsFirst stepA 42-year-old woman reports six months of painless bleeding and spontaneously reducing tissue.+
- 1Examination and anoscopy show grade II internal cushions without an anal mass or fissure. The colorectal assessment includes her persistent bleeding and bowel history; completed lower gastrointestinal evaluation finds no other source. Haemoglobin is normal. She has no dysphagia, obstruction, unexplained new bowel change, relevant drug interaction or anticoagulant use, and the bleeding is attributed to the examined cushions.
- 2She starts the selected Fybogel Orange 3.5 g sachet in 150 mL water morning and evening after meals, separated from other medicines, together with less straining and shorter toilet visits. At six weeks her stool is soft but bleeding still disrupts work. After consent, rubber bands are placed above the dentate line on the symptomatic internal cushions; immediate severe pain is absent and she receives bleeding, fever and urinary-retention return advice.
- 3At the planned eight-week post-banding review she has had no bleeding for six weeks, no recurrent prolapse during bowel movements and no new urgency or leakage. Inspection on strain confirms no symptomatic protrusion. The result combines the reported outcome with examination rather than assuming that the procedure itself proved success.
- 4She continues a sustainable fibre and fluid routine and knows that new or recurrent persistent bleeding merits reassessment. The clinician records baseline and post-treatment continence, the intervention and the verified symptom response, allowing a later recurrence to be distinguished from incomplete initial treatment.
02Procedure selectionMatch treatment to the affected tissueA patient has persistent symptoms despite an adequately followed conservative programme.+
- 1For grade I–II and selected grade III internal disease, discuss banding, injection sclerotherapy or infrared coagulation. Banding generally offers effective office control but may be more uncomfortable than other office approaches. The band must sit above the dentate line; substantial immediate pain prompts reassessment of placement.
- 2For troublesome combined external and grade III–IV internal disease, failed office treatment or inability to tolerate it, discuss excisional haemorrhoidectomy. Counsel about recovery pain, bleeding, urinary retention and the less common long-term consequences of anal narrowing or altered continence.
- 3First lineHaemorrhoidal artery ligation with or without mucopexy may reduce postoperative pain compared with excision but can have greater recurrence. ASCRS does not routinely recommend stapled haemorrhoidopexy as first-line surgery because recurrent prolapse and uncommon serious complications offset its early recovery advantage; it also does not treat external disease.
03Acute presentationReassess painful or bleeding prolapseA previously manageable anal swelling becomes acutely painful or bleeds substantially.+
- 1AlternativeAssess circulation, tissue viability and the alternative diagnoses before calling the episode a simple haemorrhoid flare. Substantial bleeding needs the appropriate acute bleeding pathway and review of anticoagulant exposure. A compromised circumferential rectal prolapse follows a different surgical assessment.
- 2For most thrombosed or strangulated haemorrhoids, the UK ACPGBI consensus favours initial conservative care and symptom control. ASCRS allows early excision in selected thrombosed external lesions; severity, duration, trajectory, patient preference and surgical expertise matter, and there is no universal evidence-based time cutoff that mandates excision.
- 3Persistent ulceration, ischaemia or uncontrollable bleeding warrants senior colorectal consideration of a limited effective intervention. Following banding, fever with severe pain or urinary difficulty demands urgent examination for sepsis, antibiotics and source control rather than another routine topical prescription.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Fybogel Orange ispaghula husk 3.5 g sachet
For an adult whose bleeding has been assessed and attributed to haemorrhoids, take one sachet orally morning and evening, preferably after meals, freshly mixed into at least 150 mL water. Separate it from other medicines by at least half to one hour and do not take immediately before sleep. Seek review if constipation persists or no bowel movement occurs after three days.Do not use for undiagnosed rectal bleeding, a sudden bowel-habit change persisting over two weeks, failure to defaecate after a laxative, faecal impaction, obstruction or gastrointestinal narrowing, reduced gut motility, oesophageal disease or swallowing/throat difficulty. Never take dry. Avoid concurrent opioids or other motility inhibitors except under medical supervision. Review renal potassium restriction, phenylketonuria because of aspartame, and allergy to ispaghula or excipients. Diabetes and thyroid-hormone treatment need supervision; absorption of lithium, carbamazepine, anticoagulants and other medicines can be delayed. Pregnancy or breastfeeding use may be considered if dietary change is insufficient. Stop for abdominal pain, choking or hypersensitivity and seek assessment.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Blood loss and acute congestion
Recurrent bleeding may produce anaemia, while prolapse can become thrombosed or strangulated and cause a sudden deterioration in pain.
Treatment-related harm
Bleeding, urinary retention and infection may follow intervention; stenosis or altered continence are important longer-term risks to include in consent and follow-up.
Hygiene and functional burden
Prolapse, mucus and soiling can cause skin irritation and social restriction even when the measured blood loss is modest.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Compare bleeding frequency, prolapse burden and cleaning difficulty before and after treatment, using the patient’s actual priorities.
- Check bowel consistency and adherence without producing diarrhoea or ignoring persistent constipation that needs another assessment.
- After an intervention, ask specifically about severe pain, fever, urinary retention and substantial delayed bleeding, and give an accessible return route.
- Record new urgency or leakage and reconsider another bleeding source if symptoms persist despite technically successful haemorrhoid treatment.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Grade is one dimension
A prolapse grade guides the conversation but does not measure bleeding burden, external disease, baseline continence or the patient’s tolerance of recurrence.
Preserve normal function
Cushions participate in fine continence; selective treatment and preservation of appropriate tissue bridges help explain why extensive indiscriminate excision is undesirable.
Explain delayed complications
A patient should know that a banded cushion sloughs later, so a symptom-free discharge does not eliminate delayed bleeding or infection risk.
Use outcomes that matter
No bleeding, easier hygiene, acceptable recovery and unchanged continence are complementary outcomes; a visually smaller cushion alone is an incomplete result.
11Common pitfallsFrequent interpretation and management errors.
- 01
Calling all bright red blood haemorrhoidal can delay a cancer or inflammatory diagnosis even when anal cushions are enlarged.
- 02
Banding an external swelling or placing a band too low exposes sensitive tissue and causes avoidable pain.
- 03
Automatically stopping antithrombotic treatment ignores thrombosis risk and exceeds the certainty of the banding evidence.
- 04
Promising that a topical cream reverses substantial prolapse confuses temporary symptom relief with correction of displaced tissue.