Haemorrhoids

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Normal anal cushions contribute to continence. Symptoms occur when their supporting tissue stretches, vascular channels enlarge or cushions prolapse. The diagnosis therefore requires concordant symptoms and examination; incidental haemorrhoids do not automatically explain bleeding.

The central decision is whether symptoms are genuinely haemorrhoidal and uncomplicated, or whether investigation for another diagnosis is needed before treatment. Age, unexplained anaemia, weight loss, altered bowel habit, family history and an abnormal abdominal or rectal examination increase the need for colorectal investigation.

Treatment intensity follows symptom burden and anatomy rather than grade alone. Lifestyle and bowel regulation remain important after a procedure, because intervention does not remove the drivers of straining or hard stool.

Key points

Haemorrhoids are symptomatic vascular anal cushions; internal disease arises above the dentate line and external disease below it.
Uncomplicated internal haemorrhoids commonly cause painless bright-red bleeding, prolapse, mucus or soiling rather than severe pain.
Grade I internal haemorrhoids bleed without prolapse; grade II reduce spontaneously, grade III need manual reduction and grade IV remain prolapsed.
A suddenly painful blue perianal lump suggests thrombosed external haemorrhoid, while severe pain in presumed internal disease should trigger a search for fissure, abscess or strangulation.
Never attribute rectal bleeding to haemorrhoids without considering colorectal cancer, inflammatory bowel disease, polyps, proctitis and anticoagulant-related bleeding.
First-line care corrects constipation or diarrhoea, increases appropriate fibre and fluid, reduces straining and prolonged toilet sitting, and uses topical treatments only briefly for symptoms.
Persistent grade I to III internal disease is often treated with rubber-band ligation or another office procedure; advanced, recurrent or mixed disease needs colorectal assessment.
Delayed major bleeding, fever, escalating anal pain or urinary difficulty after banding can signal a serious complication and must be assessed urgently.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Support-tissue deterioration

Fragmentation of the connective tissue anchoring normal anal cushions permits vascular tissue to enlarge and descend, especially with increasing age.

Raised evacuation pressure

Constipation, prolonged straining and repeated time on the toilet increase venous engorgement and shear forces, worsening symptomatic prolapse.

Pregnancy and bowel disturbance

Pregnancy, obesity and recurrent diarrhoea can increase pelvic venous pressure or local irritation, precipitating symptoms in susceptible cushions.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Cushion enlargement
Vascular sinusoids dilate while supporting smooth muscle and connective tissue weaken, producing bulky internal or external tissue.
2
Descent and mucosal trauma
Internal cushions slide distally during defaecation, causing prolapse, mucus, soiling and painless bright-red bleeding from fragile mucosa.
3
Thrombosis or strangulation
Acute clot in an external vein or compromised blood flow in an irreducible prolapse causes sudden severe pain and swelling.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Internal bleeding pattern

Bright-red blood on paper, coating stool or dripping into the pan, usually without sharp pain, supports internal haemorrhoids when inspection, digital examination and anoscopy exclude another lesion.

Prolapsing internal disease

Tissue emerging with defaecation may reduce itself, need manual reduction or remain outside. Ask specifically about mucus, pruritus, soiling and difficulty cleaning as well as bleeding.

Thrombosed external haemorrhoidRed flag

A tender bluish perianal swelling appears abruptly and is often worst over the first few days. Skin necrosis, expanding haematoma or diagnostic uncertainty warrants surgical review.

Strangulated prolapseRed flag

A tense, irreducible, very painful circumferential prolapse with oedema or dusky tissue is not routine clinic disease and requires urgent colorectal assessment for ischaemia.

Proximal bowel warningRed flag

Iron-deficiency anaemia, dark or mixed blood, abdominal mass, weight loss, persistent change in bowel habit or a strong family history requires investigation beyond the anal canal.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

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
Perianal inspection during rest and strainFirst step
Why
Identify external thrombosis, prolapse, skin disease, fissure, fistula or mass.
Interpretation and limitations
Describe whether prolapse is radial cushions or circumferential mucosa, whether it reduces, and whether tissue is viable. Avoid forcing a painful examination when abscess or strangulation is possible.
02
Digital rectal examination
Why
Assess masses, tenderness, blood, stool loading and sphincter function.
Interpretation and limitations
Internal haemorrhoids may not be palpable. A normal examination does not end cancer assessment when symptoms are concerning, while severe focal tenderness should redirect toward fissure or sepsis.
03
Anoscopy or proctoscopy
Why
Confirm enlarged internal cushions and inspect distal mucosa.
Interpretation and limitations
Record position, bleeding and prolapse, but recognise that this limited field cannot exclude proximal colorectal disease. An ulcerated or indurated lesion requires biopsy planning.
04
Full blood count and ferritin
Why
Quantify blood loss and detect iron deficiency.
Interpretation and limitations
Anaemia out of proportion to visible haemorrhoidal bleeding demands broader gastrointestinal assessment. A normal haemoglobin does not remove the need to investigate red-flag symptoms.
05
Quantitative FIT and colorectal investigation
Why
Triage or investigate a possible colorectal source according to current pathways.
Interpretation and limitations
Use the symptomatic NICE and local criteria; a low FIT must not overrule a rectal mass, persistent symptoms, obstruction or strong clinical concern. Colonoscopy or CT colonography is selected by the diagnostic service.
06
Coagulation and medicine review
Why
Identify bleeding risk and plan any intervention safely.
Interpretation and limitations
Document anticoagulants, antiplatelets and haemostatic disorders. Do not stop prescribed antithrombotic treatment casually; coordinate interruption and restart with the procedural and prescribing teams.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Anal fissure

Sharp pain during and after defaecation with a visible linear tear contrasts with the usually painless bleeding of uncomplicated internal haemorrhoids.

Rectal prolapse

Concentric circumferential folds of full-thickness bowel distinguish prolapse from discrete radial columns of prolapsing haemorrhoidal tissue.

Colorectal or anal cancer

Persistent bleeding, altered bowel habit, weight loss, anaemia, ulceration or a mass requires cancer-pathway assessment despite visible haemorrhoids.

Additional chapter-specific clues

Alternative anorectal pathologyRed flag

Tearing post-defaecation pain suggests fissure; constant throbbing pain and fever suggest abscess; a hard ulcerated lesion, groin nodes or persistent discharge raises concern for anal malignancy or infection.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01First lineUncomplicated symptomatic haemorrhoidsFirst stepFirst lineAlternativeMild bleeding, itch or reducible prolapse with no red-flag alternative diagnosis.

1Confirm a compatible history and examination, assess cancer risk and actively look for fissure, abscess, prolapse, proctitis or a suspicious anal lesion.
2Optimise stool consistency with suitable fibre, fluids and a laxative when constipation persists; reduce straining, heavy breath-holding and prolonged sitting on the toilet.
3Offer short-term simple analgesia and a locally approved topical preparation for troublesome itch or discomfort, explaining that it does not correct prolapse and prolonged use can irritate skin.
4Review response and bleeding trajectory; investigate or refer if symptoms persist, anaemia develops, the diagnosis remains uncertain or prolapse materially affects quality of life.

02ProcedurePersistent internal haemorrhoidsRecurrent bleeding or grade I to III prolapse despite adequate bowel regulation.

1Discuss with a trained clinician which office treatment suits anatomy, previous procedures, antithrombotic therapy and patient preference; rubber-band ligation is commonly used.
2Place bands above the dentate line and provide written advice about expected discomfort, minor bleeding, bowel care and medication management according to the local protocol.
3Tell the patient to seek urgent help for heavy delayed bleeding, fever, worsening pain, urinary retention or feeling systemically unwell, because rare pelvic sepsis is time critical.
4For recurrent, grade IV, large external-component or combined disease, refer for discussion of excisional haemorrhoidectomy or other specialist operations and their pain, recurrence and continence trade-offs.

03Acute painThrombosed or strangulated presentationSudden severe perianal pain with a thrombosed external lump or irreducible prolapse.

1Examine gently for tissue colour, necrosis, spreading erythema, abscess and systemic toxicity; provide analgesia and obtain urgent colorectal review when viability or diagnosis is uncertain.
2For a small improving external thrombosis, use analgesia, bowel regulation, hygiene and observation; symptoms often settle as the clot organises.
3For severe very recent external thrombosis, discuss local excision by an appropriately trained clinician, taking account of timing, wound care, bleeding risk and patient choice.
4An acutely strangulated internal prolapse or septic presentation needs emergency specialist management rather than repeated forceful reduction in primary care.

Key medicines and prescribing safety3 treatments · regimens, roles and cautions

Reduces hard stool and straining that perpetuate bleeding and prolapse.

Bulk-forming or osmotic laxative

Select and titrate the current formulary preparation to produce soft formed stools.

Introduce fibre gradually with adequate fluid; avoid bulk agents in impaction or suspected obstruction and review diarrhoea, dehydration and electrolyte risk with osmotic products.

May reduce transient pruritus, swelling or discomfort while bowel habits improve.

Short-course topical haemorrhoid preparation

Apply only for the brief duration specified by the product and formulary.

Evidence for lasting benefit is limited. Local anaesthetic can sensitise skin, and prolonged corticosteroid exposure may cause atrophy or mask infection; it does not treat unexplained bleeding.

Supports comfort during thrombosis or recovery from an office procedure.

Simple oral analgesia

Use formulary paracetamol, with additional agents chosen for individual risk.

Avoid constipating opioids where possible and assess gastrointestinal, renal, hepatic and bleeding risks before non-steroidal anti-inflammatory medicines, especially after a procedure.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Thrombosis and strangulation

A thrombosed external cushion or incarcerated internal prolapse becomes acutely painful, oedematous and occasionally ulcerated or necrotic.

Chronic bleeding and anaemia

Repeated small-volume loss can contribute to iron deficiency, but anaemia should not be attributed without excluding more proximal pathology.

Soiling and dermatitis

Prolapse and mucus impair anal closure and hygiene, causing pruritus, skin inflammation and a substantial quality-of-life burden.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record bleeding frequency, prolapse grade, pain, soiling, bowel habit and effect on daily function rather than documenting haemorrhoids as a binary finding.
Recheck haemoglobin and iron indices when bleeding was substantial or iron deficient, while completing investigation of any non-haemorrhoidal source.
After banding, confirm the patient understands delayed-bleeding and pelvic-sepsis warning symptoms and knows which urgent service to contact.
Following surgery, monitor urinary retention, haemorrhage, wound infection, constipation, pain control and later stenosis or continence change through the colorectal pathway.
Revisit fibre, fluid, toileting behaviour and diarrhoea management after procedural success to reduce recurrence and protect the healing wound.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Painless is the usual clue

Internal cushions sit above somatic sensory innervation, so uncomplicated bleeding is usually painless. Sharp or escalating pain should prompt another diagnosis or a complication.

Grade is not the whole burden

A patient with modest anatomical prolapse may have major bleeding or hygiene problems, while a larger prolapse may be tolerated. Decisions should combine anatomy and priorities.

Blood colour is not a guarantee

Bright-red bleeding favours a distal source but does not prove haemorrhoids. Colorectal cancer can bleed brightly, particularly from the rectum or sigmoid.

Bands belong above sensation

Rubber-band ligation is intended above the dentate line. Immediate severe pain during placement suggests an unsuitable level and requires correction by the operator.

Delayed bleeding has a clock

Bleeding can occur when banded tissue separates days later. Antithrombotic management and a clear emergency plan are therefore as important as the procedure itself.

Constipation is modifiable

A technically successful treatment can fail when hard stool, straining and prolonged toileting continue; bowel habit is part of definitive management, not an optional add-on.

11Common pitfallsFrequent interpretation and management errors.

01
Assuming visible haemorrhoids explain every episode of rectal bleeding.
02
Missing an anal fissure or abscess in a patient with severe pain.
03
Using prolonged topical steroid or anaesthetic treatment without reassessment.
04
Stopping anticoagulation for a procedure without an authorised risk plan.
05
Failing to warn about delayed bleeding or pelvic sepsis after banding.
06
Treating prolapse repeatedly while leaving constipation or diarrhoea uncontrolled.