Original Author: Han Hong Chong
Last Updated: January 23, 2019
Revisions: 24

Haemorrhoids are defined as an abnormal swelling or enlargement of the anal vascular cushions.

Fig 1 - Haemorrhoids located in the 3, 7, and 11 o'clock positions

Figure 1 – Haemorrhoids located in the 3, 7, and 11 o’clock positions

The anal vascular cushions act to assist the anal sphincter in maintaining continence. There are three vascular cushions in the anus, positioned at the 3-, 7- and 11- o’clock positions (when looked at with the patient in the lithotomy position, i.e. anterior is 12 o’clock).

When these cushions become abnormally enlarged, they can cause symptoms and become pathological, termed haemorrhoids.

The prevalence of haemorrhoids varies, mainly due to wrong attribution of anorectal symptoms; a review of US national data sources showed that 4% of US population complained of haemorrhoids and have a prevalence peak at age 45-65yrs.

Haemorrhoids are classified according to their size:

1st Degree Remain in the rectum
2nd Degree Prolapse through the anus on defecation but spontaneously reduce
3rd Degree Prolapse through the anus on defecation but require digital reduction
4th Degree Remain persistently prolapsed

Risk Factors

Most haemorrhoids are idiopathic, however the main risk factors for their development are excessive straining (from chronic constipation), increasing age, and raised intra-abdominal pressure (such as pregnancy, chronic cough, or ascites).

Other less common risk factors include pelvic or abdominal masses, family history, cardiac failure, or portal hypertension.

Clinical Features

Haemorrhoids typically present with painless bright red bleeding, commonly after defecation and often seen either on paper or covering the pan. Importantly, blood is seen on the surface of the stool, not mixed in.

Other symptoms include pruritus (due to chronic mucus discharge and irritation), rectal fullness or an anal lump, and soiling (due to impaired continence or mucus discharge).

Large prolapsed haemorrhoids can thrombose. These are very painful and these patients frequently present acutely as an emergency patient.

Examination will usually be normal unless the haemorrhoids have prolapsed.  So-called “external piles” are usually simple skin tags or “sentinel piles” from a fissure-in-ano.  A thrombosed prolapsed haemorrhoid will present as a purple/blue, oedematous, tense, and tender perianal mass.

Fig 2 - Types of Haemorrhoids (A) 1st Degree Haemorrhoids, as seen on endoscopy (B) 2nd Degree Haemorrhoid (C) Thrombosis and Ulceration of External Haemorrhoid

Figure 2 – Types of Haemorrhoids (A) 1st Degree Haemorrhoids, as seen on endoscopy (B) 2nd Degree Haemorrhoid (C) Thrombosed and Ulcerated External Haemorrhoid

Differential Diagnosis

It is important to exclude other cause of rectal bleeding such as malignancy, inflammatory bowel disease, or diverticular disease.

Other perianal differentials to consider include fissure-in-ano, perianal abscess, or rectal polyps.


Proctoscopy is typically performed to confirm the diagnosis. Any significant / prolonged bleeding or signs of anaemia would warrant a full blood count.

A flexible sigmoidoscopy or colonoscopy may also be considered to exclude malignancy or polyps if indicated in certain cases


95% of haemorrhoids can be managed conservatively, especially if asymptomatic.

Provide lifestyle advice, such as increasing daily fibre and fluid intake to avoid constipation, prescribing any laxatives if necessary. Topical analgesia (such as lignocaine gel) may also be required for pain relief (avoid oral opioids as they can compound any constipation).


Symptomatic 1st degree and 2nd degree haemorrhoids can be treated with rubber-band ligation (RBL)*.  This is where the haemorrhoid is drawn into the end of a suction gun and a rubber band placed over the neck of the haemorrhoid.

Other options include infrared coagulation / photocoagulation, bipolar diathermy, or direct-current electrotherapy. Often patients are not too troubled by the symptoms and simply want reassurance that the cause of the bleeding is not sinister. Reassurance alone may therefore be sufficient for many people.

*The main complications of this procedure include recurrence, pain (if the band is mistakenly placed below the dentate line), and bleeding

Fig 3 - Rubber-band ligation of haemorrhoids.

Figure 3 – Rubber-band ligation of haemorrhoids

A new non-surgical therapy that has gained recent popularity is haemorrhoidal artery ligation (HAL), due to an effectiveness level similar to that of surgical interventions. However, recent work suggests that rubber-band ligation still is likely to remain the preferred option for patients suffering with haemorrhoids.


5% of patients with haemorrhoids will eventually need haemorrhoidectomy*.

This is indicated if symptomatic and not responding to conservative therapies, yet unsuitable for banding / injection (mainly 3rd degree and 4th degree). Typically this is either as a stapled haemorrhoidectomy or Milligan Morgan haemorrhoidectomy.

*The main complications of a haemorrhoidectomy are bleeding, infection, constipation, stricture, anal fissures, or faecal incontinence


Complications of haemorrhoids include thrombosis, ulceration or gangrene (secondary to thrombosis), skin tags, or perianal sepsis

Key Points

  • Haemorrhoids are defined as an abnormal swelling or enlargement of the anal vascular cushions
  • There are four subtypes of haemorrhoids
  • Haemorrhoids typically present with painless bright red bleeding
  • 95% of haemorrhoids can be managed conservatively


Question 1 / 3
Which of the following best describes Type 3 haemorrhoids?


Question 2 / 3
A patient with known type 4 haemorrhoids presents to A&E with sudden onset severe perianal pain. On examination, the haemorrhoid appears swollen, purple, and is very tender. What is the likely diagnosis?


Question 3 / 3
What is the first line management for symptomatic 2nd degree haemorrhoids?


Medico Digital

Further Reading

Jacobs D, NEJM

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