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Haemorrhoids

High EvidenceUpdated: 2025-12-23

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Red Flags

  • Unexplained rectal bleeding (exclude colorectal cancer)
  • Severe acute pain (suggests thrombosis or perianal abscess)
  • Incontinence or overflow diarrhoea
  • Anaemia
  • Change in bowel habit (red flag for cancer)
Overview

Haemorrhoids

[!WARNING] Medical Disclaimer: This content is for educational and informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. Medical guidelines and best practices change rapidly; users should verify information with current local protocols.

1. Overview

Haemorrhoids (piles) are enlarged, displaced anal vascular cushions. They are a common cause of rectal bleeding and discomfort. While primarily a quality of life issue, they must be distinguished from more serious pathology such as colorectal cancer.

Anatomical Classification

  • Internal Haemorrhoids: Originate above the dentate line. Covered by insensitive columnar mucosa. Typically painless (unless thrombosed/strangulated).
  • External Haemorrhoids: Originate below the dentate line. Covered by sensitive squamous epithelium (anoderm). Prone to painful thrombosis.

The Goligher Classification (Internal Haemorrhoids)

This system guides management:

  • Grade I: Bleed but do not prolapse.
  • Grade II: Prolapse on straining but reduce spontaneously.
  • Grade III: Prolapse on straining and require manual reduction.
  • Grade IV: Permanently prolapsed and cannot be reduced.

Clinical Scenario: The Painful Lump

A 30-year-old lorry driver presents to A&E with a 2-day history of an excruciatingly painful lump at the anal verge. On inspection, there is a tense, purple, cherry-sized lump covered in skin.

Key Teaching Points

  • This is a **Thrombosed External Haemorrhoid**.
  • The pain is due to the somatic innervation of the anoderm (below the dentate line).
  • Management depends on timing: If <72 hours and severe pain, evacuation of the clot (excision) under LA can provide instant relief.
  • If >72 hours, pain is usually subsiding; manage conservatively with analgesia and stool softeners.
2. Epidemiology
  • Prevalence: Very common; estimated to affect 4-5% of the general population, but up to 50% of people over age 50 report symptoms at some point.
  • Age: Peak incidence between 45–65 years.
  • Sex: Affects men and women equally.
  • Pregnancy: Very common in pregnancy due to increased intra-abdominal pressure and hormonal effects on vascular smooth muscle.
3. Pathophysiology

Haemorrhoids are not "varicose veins". They are normal vascular cushions (left lateral, right anterior, right posterior) that aid in anal continence (fine-tuning closure).

Pathogenesis: "The Sliding Anal Canal Lining Theory"

  1. Shearing Force: Straining during defecation exerts downward pressure.
  2. Degeneration: Connective tissue support (Park's ligament) weakens with age.
  3. Displacement: The vascular cushions slide downwards (prolapse).
  4. Venous Engorgement: Outflow obstruction leads to bleeding and swelling.

Risk Factors:

  • Constipation / Straining.
  • Low fibre diet.
  • Prolonged sitting on the toilet.
  • Pregnancy / Childbirth.
  • Obesity.
  • Chronic cough / Heavy lifting (increased intra-abdominal pressure).
  • Portal Hypertension (controversial – typically causes rectal varices, distinct from haemorrhoids).
4. Clinical Presentation

Symptoms

Signs

Rectal Bleeding
Most common. Bright red, painless. On toilet paper or dripping into the pan (splash). NOT mixed with stool (melaena suggests upper GI; darker blood suggests CRC).
Prolapse
Sensation of a lump coming down ("something coming out"). May reduce spontaneously or need pushing back.
Pruritus Ani
Mucous discharge from prolapsed mucosa irritates the perianal skin.
Soiling
Inability to wipe clean due to tags/prolapse.
Pain
Uncommon in uncomplicated internal haemorrhoids. Severe pain suggests: Thrombosis. Strangulation (Grade IV). Concurrent Fissure-in-ano (pain typically during passing stool). Abscess.
5. Clinical Examination

A systematic approach to the perianal exam ("PR Exam"):

  1. Position: Left lateral decubitus with knees drawn up.
  2. Inspection:
    • Spread buttocks.
    • Look for fissures (posterior midline usually), fistulae, skin tags, prolapse.
    • Ask patient to strain: Look for descending prolapse.
  3. Palpation (DRE):
    • Assess sphincter tone (resting and squeeze).
    • Sweep 360 degrees for masses, tenderness (fissures are exquisitely tender/unable to tolerate DRE).
    • Check prostate/cervix anteriorly.
    • Examine glove for blood/mucus.
  4. Proctoscopy:
    • Insert lubricated proctoscope. Remove obturator.
    • Slowly withdraw while asking patient to bear down.
    • Look for bulging pink mucosa.
6. Investigations

The primary goal is to exclude more serious pathology (Cancer, IBD).

Essential

  • Proctoscopy: (As above). Diagnostic for haemorrhoids.
  • FBC: Check for anaemia if bleeding is heavy/chronic.

Indications for Further Endoscopy (Flexible Sigmoidoscopy / Colonoscopy)

  • Age ≥ 40-50 with new rectal bleeding (guidelines vary locally).
  • Iron Deficiency Anaemia.
  • Change in Bowel Habit (loose stools/constipation).
  • Family History of Colorectal Cancer (CRC) or IBD.
  • Weight Loss.
  • Positive FIT test (if used in screening pathway).
  • Rule of thumb: Assume bleeding is cancer until proven otherwise in older adults. "Piles" is a diagnosis of exclusion in the presence of red flags.
7. Management

Management follows a stepwise ladder based on severity (Goligher grade) and patient preference.

Conservative (First Line / Grade I-II)

  • Dietary Modification: Increase fibre (25-30g/day), increase fluid intake (>2L).
  • Laxatives: Bulk-forming agents (ispaghula husk/Fybogel) or osmotic laxatives (Macrogol). Avoid stimulants that cause cramping.
  • Toilet Habits: Avoid straining, limit time on toilet ("don't read on the loo").
  • Topical: Creams/suppositories with local anaesthetic/steroid (e.g., Anusol HC, Scheriproct). Short-term use (<1 week) to avoid skin atrophy.
  • Sitz baths: Warm water soaks for hygiene and comfort.

Office-Based Procedures (Grade I-II, some III)

  • Rubber Band Ligation (RBL):
    • Gold standard non-operative treatment.
    • Band placed above dentate line (insensate).
    • Causes ischaemia and sloughing of the pile (ulcer heals -> fixation).
    • Complications: Pain (if placed too low), bleeding (primary or secondary at 10-14 days), pelvic sepsis (rare but serious - "Jerry's triad" of pain, fever, retention).
  • Injection Sclerotherapy: Oily phenol injected into submucosa. Induces fibrosis. Good for Grade I with bleeding.
  • Infrared Coagulation: For small bleeding piles.

Surgical Intervention (Grade III-IV, or failed non-op)

1. Haemorrhoidal Artery Ligation Operation (HALO / THD)

  • Doppler-guided ligation of the feeding arteries + recto-anal repair (mucopexy/hitching up).
  • Pros: Less pain than excision. No open wound.
  • Cons: Higher recurrence rate than excision.

2. Stapled Haemorrhoidopexy (PPH)

  • Circular stapler excises a ring of mucosa above dentate line.
  • Pros: Less pain.
  • Cons: Risk of chronic pain, urgency, rectal perforation (rare), rectovaginal fistula. Falling out of favour.

3. Excisional Haemorrhoidectomy (Milligan-Morgan / Ferguson)

  • Gold standard for recurrence and large external components (Grade IV).
  • Excision of the cushions. Wounds left open (Milligan-Morgan) or closed (Ferguson).
  • Pros: Lowest recurrence rate.
  • Cons: Very painful recovery (2-4 weeks). Risk of anal stenosis.
  • Indications: Strangulated piles, large skin tags, mixed internal/external.

Emergency Management (Thrombosed External Pile)

  • < 72 hours: Examination under anaesthesia (EUA) + Excision of clot/pile. Instant relief.
  • > 72 hours: Conservative (Topical lidocaine, stool softeners, ice packs). Pain usually settles as thrombus organises.
8. Complications

Disease-Related

  • Anaemia: From chronic bleeding.
  • Strangulation/Gangrene: Ischaemia of prolapsed tissue. Medical emergency.
  • Thrombosis: Acute severe pain.
  • Skin Tags: Hygiene issues.

Post-Operative

  • Pain: Severe post-haemorrhoidectomy.
  • Urinary Retention: Common (up to 30%). May need catheter.
  • Bleeding:
    • Reactionary: <24 hrs (slipped ligature).
    • Secondary: 1-2 weeks (infection/sloughing of band).
  • Anal Stenosis: Narrowing of anal canal (if too much anoderm removed).
  • Incontinence: Damage to internal sphincter (rare).
9. Prognosis & Outcomes
  • Conservative: Effective for bleeding in 50% of Grade I/II.
  • RBL: 70-80% cure rate. Recurrence common, may need repeat banding.
  • Surgery: 95% cure rate for excision. HALO has approx 10-20% recurrence.
  • Post-op Recovery: Excision takes weeks; HALO/Banding takes days.
10. Evidence & Guidelines
  • ASCRS (American Society of Colon and Rectal Surgeons) Guidelines: Strong support for RBL as first-line office treatment. Excisional surgery for Grade III/IV or thrombosed piles.
  • eTHoS Trial: Compared Stapled Haemorrhoidopexy vs Traditional Excision. Stapled had less pain/quicker recovery but higher recurrence and symptom scores at 2 years.
  • HubBLe Trial: Compared HALO vs RBL. RBL was non-inferior for symptom relief and much cheaper/less painful, questioning the widespread use of HALO.
11. Patient & Layperson Explanation

What are haemorrhoids? They are swollen blood vessels in the bottom (anus). Everyone has these vessels, but they become a problem when they swell, bleed, or hang down (prolapse) due to straining or pressure.

What causes them? Constipation is the main cause. Straining to pass hard poo pushes the vessels out. Pregnancy and heavy lifting can also cause them.

What are the symptoms?

  • Bleeding: Bright red blood on the toilet paper or in the bowl.
  • Lumps: Feeling something come down when you go to the toilet.
  • Itching: Around the bottom.

How can I treat them at home? Most can be managed by:

  1. Avoiding constipation: Eat more fibre (fruit, veg, cereals) and drink plenty of water.
  2. Not straining: Go when you need to, and don't sit on the toilet for long periods.
  3. Creams: Over-the-counter soothing creams can help soreness.

When is surgery needed? If they bleed a lot, are very painful, or hang down permanently, you might need a procedure.

  • Banding: A small rubber band puts inside to cut off blood supply (they fall off).
  • Surgery: Cutting them out (haemorrhoidectomy) is effective but painful during recovery.
12. References
  1. Davis BR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284-292.
  2. Watson AJ, et al. Stapled haemorrhoidopexy versus traditional haemorrhoidectomy (eTHoS): a multicentre, randomised controlled trial. Lancet. 2016;388(10058):2375-2385.
  3. Brown SR, et al. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet. 2016;388(10042):356-364.
  4. Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view. World J Gastroenterol. 2015;21(31):9245-9252.

Last updated: 2025-12-23

At a Glance

EvidenceHigh
Last Updated2025-12-23

Red Flags

  • Unexplained rectal bleeding (exclude colorectal cancer)
  • Severe acute pain (suggests thrombosis or perianal abscess)
  • Incontinence or overflow diarrhoea
  • Anaemia
  • Change in bowel habit (red flag for cancer)

Guidelines

  • NICE Guidelines
  • BTS Guidelines
  • RCUK Guidelines