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  3. Haemorrhoids

Haemorrhoids

NICE CKS Haemorrhoids. Last revised: Jul 2021. NICE BNF Treatment summaries. Haemorrhoids European Society of ColoProctology: guideline for haemorrhoidal disease. Published: Feb 2020.

Background Information

Grade Description
1 Do not prolapse outside the anus
2 Prolapse on straining but reduces spontaneously
3 Prolapse on straining but requires manual reduction (not spontaneous reduction)
4 Permanently prolapsed and cannot be reduced
 

Guidelines

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

Consider hospital admission in:
  • Acutely thrombosed external haemorrhoids who present within 72 hours of onset
  • Internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed
  • Perianal sepsis (rare but life-threatening complication)

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

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

There are no clean-cut guidelines regarding which approach should be used. This section is based on international guidelines and expert consensus from the literature and should be sufficient for exam purposes.

If patient prefers an outpatient procedure: rubber band ligation should be offered

If 1st and 2nd degree haemorrhoids did not respond to conservative care:
  • Rubber band ligation is next on the line
  • Only consider haemorrhoidectomy if rubber band ligation fails

Surgical management is usually indicated in:
  • 3rd and 4th degree haemorrhoids
  • Combined internal + external haemorrhoids with severe symptoms
  • Perianal haematoma
  • Thrombosed haemorrhoids with problematic bleeding or chronic irritation / leakage

It is more important to appreciate that rubber band ligation is non-surgical 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 and are more than sufficient to just be aware of their existence and whether they are surgical or non-surgical.

Non-surgical options:
  • Rubber band ligation - can be performed as an outpatient procedure
  • Injection sclerotherapy
  • Infrared coagulation / photocoagulation
  • Bipolar diathermy and direct-current electrotherapy

Surgical options:
  • Haemorrhoidectomy - best long-term effect
    • Faecal incontinence is an important complication
    • Other complications: anal stricture, abscess, fistual, skin tags
  • Stapled haemorrhoidectomy
  • Haemorrhoidal artery ligation

References

Author: Adams Lau
Reviewer:
Last edited: 11/08/25