Haemorrhoids

Overview

Haemorrhoids arise from abnormal engorgement and prolapse of the normal anal vascular cushions. The dentate line divides internal (above, visceral innervation = painless) from external (below, somatic innervation = painful/itchy).

Internal vs external haemorrhoids

Feature	Internal	External
Location	Above dentate line	Below dentate line
Innervation	Visceral (autonomic)	Somatic (inferior rectal nerve)
Pain	Painless (unless strangulated)	Painful and itchy
Bleeding	Bright red, per rectum	Less common

Grade	Description
I	Bleed but do not prolapse
II	Prolapse on straining, reduce spontaneously
III	Prolapse on straining, require manual reduction
IV	Permanently prolapsed, irreducible

💡

Thrombosed external haemorrhoid - sudden severe perianal pain with a tender, bluish lump. Manage with incision and evacuation of clot within 72 hours. After 72 hours: conservative management (analgesia, sitz baths, stool softeners) as clot begins to resolve spontaneously.

Presentation

•Bright red rectal bleeding - on paper or coating stool surface; blood separate from stool; painless

•Prolapse - lump at anus; spontaneous reduction (grade II), manual reduction (grade III), permanent (grade IV)

•Pruritus ani - from mucus secretion irritating perianal skin

•Mucus discharge - from exposed rectal mucosa of prolapsed internal haemorrhoid

•Perianal discomfort/heaviness - after defaecation; severe pain is unusual for uncomplicated internal haemorrhoids

⚠️

Pain from a presumed internal haemorrhoid should prompt consideration of another diagnosis - anal fissure, abscess, or strangulated prolapse. Internal haemorrhoids are painless.

🚨

Never attribute rectal bleeding to haemorrhoids without excluding colorectal cancer, especially if age ≥40, blood is dark/mixed with stool, bowel habit has changed, or there is unexplained weight loss or iron deficiency anaemia. Refer urgently via 2-week-wait if red flags are present.

Investigations

•Haemorrhoids are a clinical diagnosis - history, inspection, DRE, and proctoscopy sufficient in most cases

🥇 First-line

•Proctoscopy - direct visualisation, confirms and grades internal haemorrhoids; performed in left lateral position

•Full blood count - assess for iron deficiency anaemia from chronic blood loss

🥈 Second-line

•Flexible sigmoidoscopy or colonoscopy - if red flag features, age >40 with new rectal bleeding, or diagnostic uncertainty

Management

Step 1 · All grades - conservative (first-line foundation)

1. 1High-fibre diet (25-30 g/day) and increased fluid intake - most important lifestyle intervention
2. 2Ispaghula husk (bulk-forming laxative) - if dietary change insufficient
3. 3Avoid prolonged sitting on toilet and straining
4. 4Topical lidocaine cream / hydrocortisone ointment - short-term symptom relief only (corticosteroid max 7 days); not routinely prescribed on NHS (available OTC)

↓

Step 2 · Grade I-III - office-based procedures

1. 1Rubber band ligation (RBL) - most effective office procedure; for grade II-III; band placed above dentate line; haemorrhoid atrophies and falls off within days; may require repeat
2. 2Sclerotherapy - 5% phenol in almond oil injected above haemorrhoid; grade I-II; less effective than RBL for higher grades
3. 3Infrared coagulation - suitable for grade I-II; less effective than RBL for grade II-III

↓

Step 3 · Grade III-IV or failed office treatment - surgical

1. 1Haemorrhoidectomy (excisional) - definitive; most effective for grade III-IV; significant post-operative pain
2. 2Stapled haemorrhoidopexy (PPH) - less post-operative pain than excisional; higher recurrence rate

🎯

Rubber band ligation must be placed above the dentate line. Placement below it - on sensate squamous epithelium - causes severe pain and the band must be removed immediately.

Complications

•Strangulation - grade IV prolapse with blood supply cut off; extremely painful; urgent surgical assessment

•Iron deficiency anaemia - chronic low-level blood loss, especially grade I-II

•Post-procedural - pain (RBL, haemorrhoidectomy), bleeding (primary or secondary, up to 7-14 days post-haemorrhoidectomy), urinary retention, infection