Haemorrhoids

• Haemorrhoids


  Swellings that develop from the lining of the anus and lower rectum. They widen and are engorged with blood.
• Internal haemorrhoids


  • 24cm above anal opening
  • Size & severity graded 1-4
  • Prolapsed - hang out, spring/push back
• External haemorrhoids


  • Small lump develops on the outside edge of the anus
  • Many do not cause symptoms
  • Thrombosed - blood clot
  • Intense pain, immediate treatment
• Grades of haemorrhoids


  • Grade 1 - small swellings on the inside lining of the back passage
  • Grade 2 - larger, may be partly prolapsed
  • Grade 3 - prolapse from the anus
  • Grade 4 - permanently prolapse from within the anus
• The exact prevalence of haemorrhoids is unknown, but it's very common. Upwards of one in two people will experience at least one episode at some point during their lives.
• Haemorrhoids can occur at any age but are rare in children and adults younger than 20 years.
• Haemorrhoids affect both sexes equally and are more common with increasing age, especially in people from 45 to 65 years.
• There's a high incidence of haemorrhoids in pregnant women.
• Haemorrhoids affect about 13-36% of people in the UK.
• Aetiology of haemorrhoids


  Multifactorial, with anatomical (degeneration of elastic tissue), physiological (increased anal canal pressure) and mechanical (straining at stool) processes implicated.
• Causes of haemorrhoids


  • Constipation (large/hard stools, straining at the toilet)
  • Pregnancy and labour (pressure of the baby, pregnancy hormones)
  • Aging (tissue less supportive)
  • Hereditary factors (inherited weakness of vein walls)
  • Others (chronic cough, heavy lifting, exercising)
• Symptoms of haemorrhoids


  • Bright red painless rectal bleeding
  • Itching and irritation
  • Pain (dull ache that increases with defecation, leading to ignoring urge to defecate)
  • Faecal/mucus soiling of clothing
  • Mucus discharge
  • Feeling that bowel has not been emptied after defecation
• Internal haemorrhoids are rarely painful, unless prolapse and strangulated, whereas external haemorrhoids can cause pain due to the cushion becoming thrombosed.
• General measures for managing haemorrhoids

  • Increase dietary fibre
  • Increase fluid intake (around 2L)
  • Fibre supplements (e.g. ispaghula, sterculia, methylcellulose)
  • Avoid codeine-based painkillers
• Correct anal hygiene for haemorrhoids

  • Keep clean and dry to aid healing
  • Careful perianal cleansing
  • Pat dry
• Toileting advice for haemorrhoids

  • Don't hold, go when needed
  • Avoid undue straining
• Skin protectants/soothing agents for haemorrhoids

  • Zinc oxide, balsam of peru, allotoin
  • Emollient and protective properties
  • Prevents local irritation
• Local anaesthetics for haemorrhoids

  • Lidocaine, benzocaine and cinchocaine
  • Relieve pain, burning and itching
  • Use for max 7 days as it may cause sensitisation
• Astringents/skin protectants for haemorrhoids

  • Bismuth oxide, witch hazel extract
  • Upon application, proteins are precipitated on skin
  • Forms a protective layer
  • Relieve local irritation and inflammation
• Topical corticosteroids for haemorrhoids

  • Hydrocortisone
  • Relieve pain associated with inflammation of more severe haemorrhoids
  • Reduces inflammation
  • Max. 7 days
• Other treatments for haemorrhoids

  • Antiseptics (resorcinol, medicated tissues)
  • Counter irritants (menthol, phenol)
  • Yeast cell extract - wound healing agent
• Secondary care treatments for haemorrhoids

  • Rubber band ligation
  • Injection sclerotherapy
  • Infrared coagulation/photocoagulation
  • Bipolar diathermy and direct-current electrotherapy
  • Surgery (haemorrhoidectomy, stapled haemorrhoidectomy, haemorrhoidectomy artery ligation)
• Medications for haemorrhoids


  • Simple analgesia for pain relief (e.g. paracetamol)
  • Creams, ointments, suppositories or sprays (containing skin protectants, local anaesthetics, astringents, topical corticosteroids, antiseptics, counter irritants)
  • Use laxatives if constipation is present
• Persistent or marked change in bowel habit in patients 40 years

  Suspect sinister pathology
• Unexplained rectal bleeding


  Suspect GI bleeds or inflammatory bowel disease
• Patients who have to reduce their haemorrhoids manually

  OTC treatment won't help
• Severe pain associated with defecation

  Suspect anal fissure
• Refer patients with the above issues to a doctor urgently or as soon as possible.