Synopsis
Distinguish haemorrhoidal symptoms from colorectal or inflammatory disease, grade prolapse accurately, and escalate conservative, office and operative treatment with safe follow-up.
- 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.
Key red flags
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.
A tense, irreducible, very painful circumferential prolapse with oedema or dusky tissue is not routine clinic disease and requires urgent colorectal assessment for ischaemia.
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.
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.
Investigation priorities
Identify external thrombosis, prolapse, skin disease, fissure, fistula or mass.
Management branches
Mild bleeding, itch or reducible prolapse with no red-flag alternative diagnosis.
- Confirm a compatible history and examination, assess cancer risk and actively look for fissure, abscess, prolapse, proctitis or a suspicious anal lesion.
- Optimise stool consistency with suitable fibre, fluids and a laxative when constipation persists; reduce straining, heavy breath-holding and prolonged sitting on the toilet.
- Offer 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.
- Review response and bleeding trajectory; investigate or refer if symptoms persist, anaemia develops, the diagnosis remains uncertain or prolapse materially affects quality of life.