PassFinals
Colorectal Surgery

Haemorrhoids

Haemorrhoids are symptomatic anal cushions causing bleeding, prolapse, itching or pain; do not assume rectal bleeding is haemorrhoidal without appropriate examination and cancer-pathway judgement.

In a nutshell

Haemorrhoids cause bleeding, prolapse, itch or a lump. Confirm the diagnosis and investigate rectal-bleeding red flags; correct stool/straining first, use office treatment for persistent internal disease and refer advanced or refractory prolapse.

Classic presentation

Painless bright-red bleeding with prolapse or itch; acute severe pain suggests external thrombosis, strangulation, fissure or abscess.

Key points

  • Internal haemorrhoids are above the dentate line and usually bleed/prolapse without severe pain; external thrombosis is acutely painful and blue.
  • Grade I does not prolapse; grade II reduces spontaneously; grade III needs manual reduction; grade IV is irreducibly prolapsed.
  • Fibre, fluid, laxatives, avoidance of straining and shorter toilet sitting are first-line.
  • Do not attribute persistent rectal bleeding, anaemia, weight loss, change in bowel habit or a mass to haemorrhoids without appropriate investigation.
  • Rubber-band ligation or other office treatments suit persistent internal disease; advanced/refractory prolapse may need colorectal surgery.
  • Topical steroids/local anaesthetic are short-term symptom treatments, not a cure; check BNF cautions (see BNF/local protocol for medicines).
  • Severe constant pain, fever, pus or spreading erythema suggests thrombosis, strangulation or abscess and needs urgent assessment.

First-line investigation

History, inspection and DRE/anoscopy when tolerated, with colorectal-cancer investigation when bleeding is not clearly explained.

Management

Confirm and screen red flags

  • Inspect and examine when tolerated; investigate unexplained bleeding, anaemia, weight loss, bowel-habit change or mass.1,3

Correct stool and toilet factors

  • Fibre/fluid, suitable laxative, avoidance of straining and shorter toilet sitting are the foundation.1

Use short-term symptom relief

  • Use analgesia or topical preparations briefly and safely; check BNF cautions (see BNF/local protocol for medicines).1,4,5

Offer office or surgical treatment

  • Persistent internal disease may need banding/sclerotherapy; advanced or refractory prolapse needs colorectal assessment for an appropriate procedure.2,6

Escalate painful or infected presentations

  • Severe pain, strangulation, fever, pus or spreading inflammation needs urgent specialist/abscess assessment.1,3

Review bleeding and recurrence

  • Check symptoms, bowel habit and healing; return to the colorectal or cancer pathway if bleeding persists or the lesion is atypical.1,3

Exam traps

  • Uncomplicated internal haemorrhoids are usually painless; severe pain is a diagnostic warning.
  • Rectal bleeding can coexist with haemorrhoids and colorectal cancer.
  • Grade III prolapse requires manual reduction; grade IV cannot be reduced.
  • Routine prolonged steroid cream is not definitive treatment.

Illustrations

Anatomy of the anal cushionsDiagram of the anal canal showing the vascular cushions at 3, 7 and 11 o'clock above the dentate line, and the sensory transition below it.PassFinals · original
Haemorrhoid grading I-IVIllustration showing the spectrum from non-prolapsing grade I cushions through to permanently prolapsed grade IV haemorrhoids.PassFinals · original
Thrombosed external haemorrhoidClinical photograph of a tender, bluish perianal swelling representing an acutely thrombosed external haemorrhoid.Braegel Home, Wikimedia Commons · CC-BY-3.0

Key sources

  1. NICE CKS: Haemorrhoids (UK diagnosis, conservative treatment and referral topic)Updated 1 Jan 2025
  2. ACPGBI/ESCP guideline for haemorrhoidal disease (UK colorectal guideline on assessment, office procedures and surgery)Published 1 Jan 2020
  3. NHS: Piles (haemorrhoids) (Symptoms, self-care and urgent advice)
  4. BNF: Hydrocortisone (Current topical corticosteroid cautions)
  5. BNF: Lidocaine (Current topical local-anaesthetic cautions)
  6. NICE HTG218: Haemorrhoidal artery ligation (Technology guidance on haemorrhoidal artery ligation)Published 23 Jun 2010

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.