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Haemorrhoids

SNOMED: 23202007896 words•Updated 03/03/2026
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Exam Tips

  • Painless bright red bleeding with defecation suggests internal haemorrhoids; severe pain points to thrombosis, fissure, abscess, or strangulated prolapse instead.
  • Internal haemorrhoids are above the dentate line and classically painless; external haemorrhoids are below the dentate line and can be painful.
  • Know internal grading: I no prolapse, II prolapse then spontaneous reduction, III manual reduction needed, IV irreducible.
  • In OSCEs, always state chaperone, inspection before DRE, and that visible haemorrhoids do not exclude colorectal cancer.
  • Urgent referral triggers: suspected cancer, irreducible painful prolapse, systemic toxicity/sepsis, or heavy ongoing bleeding with anaemia.
  • See Figure: dentate line and haemorrhoid positions (3, 7, 11 o'clock) to explain symptoms and procedural choices.

Definition

Haemorrhoids (piles) are symptomatic enlargement and distal displacement of the normal vascular cushions of the anal canal, rather than simply "varicose veins". They are classified by position relative to the dentate line (internal above, external below) and, for internal disease, by degree of prolapse (grade I-IV), with mixed internal-external disease commonly seen in practice.

Pathophysiology

Normal anal cushions (classically at 3, 7, and 11 o'clock) contribute to fine continence. Repeated raised intra-abdominal/venous pressure (for example constipation, straining, pregnancy) and age-related connective tissue weakening cause cushion engorgement, sliding, and prolapse. Internal haemorrhoids are covered by columnar mucosa with visceral innervation (typically painless bleeding), whereas external haemorrhoids are covered by anoderm with somatic innervation (painful when thrombosed). Progressive venous congestion can lead to thrombosis, incarceration, ischaemia, ulceration, and rarely gangrene/sepsis in advanced prolapsed disease. See Figure: anal canal anatomy with dentate line and haemorrhoidal cushion positions (3, 7, 11 o'clock).

Risk Factors

  • Constipation
  • Excessive straining at stool
  • Low-fibre diet
  • Inadequate fluid intake with hard stools
  • Ageing with deterioration of supporting connective tissue
  • Pregnancy and childbirth
  • Raised intra-abdominal pressure (for example ascites, pelvic mass)
  • Chronic cough
  • Heavy lifting
  • Possible hereditary predisposition (connective tissue/venous wall weakness)

Clinical Features

Symptoms

  • Bright red rectal bleeding on defecation (on paper, in bowl, or coating stool rather than mixed within stool)
  • Anal itch/irritation, often with mucus leakage or soiling
  • Sensation of rectal fullness or incomplete evacuation
  • Prolapse during straining (spontaneous reduction, manual reduction, or irreducible depending on grade)
  • Pain is usually absent in uncomplicated internal haemorrhoids; severe acute pain suggests thrombosis/strangulation
  • Acute painful perianal lump in thrombosed external haemorrhoid

Signs

  • Possible normal perianal inspection in non-prolapsed internal haemorrhoids
  • Bluish soft mucosal bulges at anal verge with prolapse
  • Purplish tense tender perianal subcutaneous mass in thrombosed external haemorrhoid
  • Perianal skin maceration/excoriation from chronic mucus discharge
  • Residual skin tags from recurrent dilation/thrombosis
  • Associated anorectal pathology may coexist (fissure, fistula, prolapse, mass)

Investigations

Focused anorectal history and red-flag screen:Typical haemorrhoidal pattern is intermittent bright red bleeding linked to defecation, but red flags (weight loss, change in bowel habit, iron-deficiency anaemia, family history of colorectal cancer) mandate urgent exclusion of malignancy
Perianal inspection (with chaperone):May show prolapsed internal haemorrhoids, thrombosed external haemorrhoid, skin tags, maceration, or alternative lesions
Digital rectal examination:Usually does not palpate internal haemorrhoids but helps identify alternative diagnoses (mass, abscess, rectal prolapse) if tolerable
Anoscopy/proctoscopy/rigid sigmoidoscopy:Pink mucosal haemorrhoidal cushions; allows grading of internal prolapse and detection of coexisting pathology
Full blood count:Iron-deficiency anaemia if chronic/significant bleeding
Lower GI endoscopic assessment when indicated:Used to exclude colorectal/anal neoplasia or other causes of rectal bleeding; haemorrhoids do not exclude synchronous serious pathology

Management

Lifestyle Modifications

  • Increase dietary fibre gradually (whole grains, fruit, vegetables) and maintain adequate hydration to avoid bloating/obstruction and soften stool
  • Avoid straining and prolonged time on toilet; respond promptly to urge to defecate (avoid stool withholding)
  • Treat constipation proactively and review precipitating factors (opioids, low mobility, low fluid intake)
  • Perianal skin care: gentle cleansing, keep area dry, pat rather than rub
  • Safety-net urgently for severe pain, irreducible prolapse, fever/systemic upset, heavy ongoing bleeding, or red-flag cancer symptoms

Pharmacological Treatment

Bulk-forming laxative

  • Ispaghula husk 3.5 g sachet: 1 sachet twice daily (BNF adult dose), with plenty of water

First-line when stool is hard/infrequent. Contraindicated in bowel obstruction/faecal impaction; ensure adequate fluid intake to reduce risk of oesophageal or intestinal obstruction.

Osmotic laxative

  • Macrogol 3350 compound sachets: start 1 sachet daily, titrate up to 2-3 sachets/day as needed (BNF adult constipation dosing)

Useful if fibre alone insufficient. Avoid in intestinal perforation/obstruction; monitor fluid/electrolyte status in frail patients.

Stimulant laxative (short-term adjunct)

  • Senna: 15 mg at night (BNF adult dose range commonly 7.5-15 mg nocte)

Short-course rescue for persistent constipation; avoid long-term overuse and avoid in bowel obstruction or acute inflammatory bowel conditions.

Topical symptomatic therapy

  • Lidocaine 5% rectal ointment: apply thinly up to 4 times daily
  • Hydrocortisone-containing rectal preparations (for example hydrocortisone with local anaesthetic): typically applied morning and night and after stool for a short course (usually up to 7 days)

Provides short-term relief of pain/itch. Avoid prolonged topical steroid use (skin atrophy/sensitisation), avoid if untreated anorectal infection, and reassess persistent bleeding rather than repeated empiric treatment.

Oral analgesia

  • Paracetamol 1 g every 4-6 hours when required (maximum 4 g/day)

For pain in thrombosis/procedural discomfort. Avoid duplicate paracetamol-containing products; NSAIDs may worsen bleeding/gastric risk in susceptible patients.

Surgical / Interventional

  • Urgent surgical assessment for very painful thrombosed external haemorrhoid within ~72 hours (consider clot evacuation/excision)
  • Urgent secondary care for incarcerated/thrombosed prolapsed internal haemorrhoids or suspected perianal sepsis
  • Office procedures for persistent internal haemorrhoids (commonly rubber band ligation; selected cases sclerotherapy/infrared coagulation)
  • Excisional haemorrhoidectomy for large grade III-IV, mixed severe disease, or failure of non-operative treatment
  • Specialist referral for problematic large skin tags or recurrent bleeding/leakage with thrombosed disease

Complications

  • Perianal thrombosis
  • Incarceration of prolapsed haemorrhoid
  • Ulceration
  • Skin tags with hygiene difficulty/irritation
  • Perianal skin maceration from mucus leakage
  • Ischaemia, thrombosis, infarction, or gangrene in advanced irreducible internal haemorrhoids
  • Anal stenosis
  • Perianal or pelvic sepsis (rare but life-threatening)
  • Iron-deficiency anaemia from chronic blood loss (rare)

Prognosis

Overall prognosis is good: many flares settle with conservative management and recurrence is less likely when bowel habits are corrected. Around 10% of patients ultimately need surgery; recurrence after surgery is reported at roughly 13%, so long-term prevention of constipation/straining remains important.

Sources & References

🏥BMJ Best Practice(1)

💊BNF Drug References(1)

  • Phenol[management.pharmacological]

✅NICE Guidelines(1)

📖Textbook References(12)

  • David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 708)[context]
  • David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 708)[context]
  • Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 406, 407)[context]
  • Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 406, 407)[context]
  • [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 647)[context]
  • [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 647)[context]
  • [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1269)[context]
  • [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1243, 1244)[context]
  • [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1268)[context]
  • [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1237)[context]
  • [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1237)[context]
  • [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1244)[context]

Sources

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