Background Information
Definition
Haemorrhoids are defined as abnormal dilation and distortion of the vascular submucosal cushions in the anal canal.
Aetiology
Key risk factors:
- Excessive straining (e.g. due to constipation, frequent bowel movement, weight lifting, chronic cough)
- Obesity
- Pregnancy
- Prolonged sitting (e.g. occupational needs)
Clinical Features
Clinical features largely depend on the location of haemorrhoids:
| Type | Definition | Clinical features |
|---|---|---|
| Internal haemorrhoids | Located above the dentate line (upper anal canal) | Common features:
Less common features (usually in severe cases:
Pain is classically absent or minimal in internal haemorrhoids, unless the internal haemorrhoid prolapses and becomes strangulated (see the anatomy explanation below) |
| External haemorrhoids | Located below the dentate line (lower anal canal) | Presents similarly as internal haemorrhoids
The main difference is that external haemorrhoids classically cause pain / discomfort (see anatomy explanation below)
|
Sensory innervation in upper vs lower anal canal (divided by the dentate line):
- The upper anal canal is innervated by visceral sensory fibres (part of the autonomic nervous system) → therefore insensitive to pain (that’s why internal haemorrhoids are painless)
- The lower anal canal is innervated by somatic sensory fibres (primarily the inferior rectal nerve, a branch of the pudendal nerve) → therefore highly sensitive to pain (that’s why external haemorrhoids are painful)
Other key anatomical differences between the upper and lower anal canal
| Feature | Upper anal canal (above dentate line) | Lower anal canal (below dentate line) |
|---|---|---|
| Epithelium | Columnar (rectal mucosa-like) | Stratified squamous (skin-like) |
| Innervation | Visceral (autonomic) – insensitive to pain | Somatic (inferior rectal nerves) – sensitive to pain |
| Sphincter muscle | Internal anal sphincter (smooth muscle, involuntary) | External anal sphincter (skeletal muscle, voluntary control) |
| Lymphatic drainage | Internal iliac lymph nodes | Inguinal lymph nodes |
| Blood supply | Superior rectal artery | Inferior rectal artery |
Grading of Haemorrhoids
The following grading applies to internal haemorrhoids. There is no widely used classification system for external haemorrhoids.
| Grade | Description |
|---|---|
| 1 | Do not prolapse outside the anus |
| 2 | Prolapse on straining but reduce spontaneously |
| 3 | Prolapse on straining but require manual reduction (no spontaneous reduction) |
| 4 | Permanently prolapsed and cannot be reduced |
Guidelines
Investigation and Diagnosis
Perform all the following if haemorrhoids are suspected:
- Clinical examination
- Inspection with the person in the left lateral position / lithotomy position
- Perform a DREDigital rectal examination
- Rigid anoscope / proctoscope / rectoscope – to visualise the haemorrhoid, classify their severity and exclude sinister pathology
Lower GI Cancer Red Flags
Offer FITFaecal immunochemical testing to those with any of the following red flags:
- With an abdominal mass
- With a change in bowel habit
- With iron-deficiency anaemia
- ≥40 y/o with unexplained weight loss and abdominal pain
- <50 y/o with rectal bleeding and either of the following unexplained symptoms:
- Abdominal pain
- Weight loss
- ≥50 y/o with any of the following unexplained symptoms:
- Rectal bleeding
- Abdominal pain
- Weight loss
- ≥60 y/o with anaemia even in the absence of iron deficiency
If FITFaecal immunochemical testing is +ve → refer with suspected cancer pathway (for colonoscopy)
Since June 2020, UK guidelines recommend FIT testing as the initial step for patients who meet the criteria for suspected colorectal cancer referral.
Only patients with abnormal FIT results proceed to colonoscopy. This represents a change from previous practice, where patients meeting referral criteria went straight to colonoscopy without prior FIT testing.
Management
Referral Criteria
Consider hospital admission in:
- Acutely thrombosed external haemorrhoids (within 72 hours of onset)
- Internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed
- Perianal sepsis
Perianal sepsis refers to an acute infectious process involving the tissues surrounding the anus, most commonly manifesting as a perianal abscess, but also encompassing more extensive or complicated infections such as ischiorectal, intersphincteric, or supralevator abscesses, and may be associated with fistula-in-ano or necrotizing soft tissue infection. The condition is characterized by local signs such as perianal pain, swelling, erythema, fluctuance, and sometimes purulent discharge. Systemic features, including fever, tachycardia, or hypotension, may indicate progression to severe sepsis or pelvic sepsis, necessitating urgent intervention.
(rare but life-threatening complication)
Conservative / General Management
Advise the following to ALL patients:
- Ensure stools are soft and easy to pass
- Advise adequate dietary fibre intake
- Anal hygiene
- Keep the anal region clean and dry to aid healing
- Advise against ‘stool withholding’ and undue straining during bowel movements
Pharmacological Management
Manage constipation if reported:
- 1st line: bulk-forming laxatives (e.g. ispaghula husk)
- 2nd line: osmotic laxative (lactulose)
Offer analgesia:
- Paracetamol
- Avoid opioids, as they can cause constipation
- Consider topical preparations containing local anaesthetics, corticosteroids, and soothing agents
Don’t mix up the treatment of haemorrhoids vs anal fissures. Remember, topical therapies like GTN/diltiazem are for anal fissures ONLY.
Otherwise, laxatives for constipation, and analgesia (paracetamol, ibuprofen, topical lidocaine etc.) are used in both conditions.
The surgical management is also different:
- Haemorrhoids → rubber band ligation / haemorrhoidectomy
- Anal fissure → lateral internal sphincterotomy
Interventional Management
Approach
There are no clean-cut guidelines regarding which approach should be used, as the decision is highly individualised.
This section is based on international guidelines and expert consensus from the literature and should be sufficient for exam purposes.
If 1st and 2nd degree haemorrhoids did not respond to conservative care:
- Try outpatient-based interventions: rubber band ligation, injection sclerotherapy etc.
Surgical management (most common is haemorrhoidectomy) is usually indicated in:
- Outpatient-based interventiosn failed
- 3rd and 4th degree haemorrhoids
- Combined internal + external haemorrhoids with severe symptoms
- Perianal haematoma
- Thrombosed haemorrhoids with problematic bleeding or chronic irritation / leakage
Treatment Options
It is more important to appreciate that rubber band ligation is a non-surgical intervention and can be done as an outpatient procedure, whereas haemorrhoidectomy is a surgical management with the best long-term benefits but carries the risk of complications.
Other treatment options are of less importance. It is sufficient to just be aware of their existence and whether they are surgical or non-surgical.
Outpatient-based (non-surgical) options:
- Rubber band ligation – most common
- Injection sclerotherapy
- Infrared coagulation / photocoagulation
- Bipolar diathermy and direct-current electrotherapy
Surgical options:
- Haemorrhoidectomy – provides best long-term effect
- Faecal incontinence is an important complication
- Other complications: anal stricture, abscess, fistula, skin tags
- Stapled haemorrhoidectomy
- Haemorrhoidal artery ligation
References
NICE CKS Haemorrhoids
NICE BNF Treatment summaries Haemorrhoids
European Society of ColoProctology: guideline for haemorrhoidal disease