Haemorrhoids (Piles)

What are haemorrhoids?

Haemorrhoids are vascular-rich connective tissue cushions in the anal canal that become symptomatic when enlarged or displaced. The NHS describes them as very common, and many people have haemorrhoids without any symptoms at all.

They are classified as internal (above the dentate line), external (below the dentate line), or mixed (both). Internal haemorrhoids are typically painless but may bleed; external haemorrhoids can cause discomfort, itching, and swelling.

Common symptoms

• Bright red rectal bleeding, often seen on toilet paper or in the pan
• Itching or irritation around the anus
• Discomfort, swelling, or a lump near the anus
• Prolapse (a haemorrhoid protruding from the anus), which may retract spontaneously or require manual replacement
• Soiling or mucus discharge

How they are diagnosed

Diagnosis is primarily clinical. A healthcare professional may carry out a digital rectal examination and use anoscopy to assess internal haemorrhoids. In selected patients — particularly those with new rectal bleeding, a change in bowel habit, or iron-deficiency anaemia — flexible sigmoidoscopy or colonoscopy may be indicated to exclude other pathology. The NHS and BMJ Best Practice both emphasise that bleeding should not be automatically attributed to haemorrhoids.

Common patterns

• Grade I — internal haemorrhoids that bleed but do not prolapse
• Grade II — prolapse with straining but return spontaneously
• Grade III — prolapse and require manual reduction
• Grade IV — permanently prolapsed and cannot be reduced

Many haemorrhoids are asymptomatic and require no treatment at all.

Approaches people discuss

Management of haemorrhoids is stepwise, moving from conservative measures to office-based procedures and, for some, surgery.

• Established Conservative management first-line: increase dietary fibre gradually, maintain adequate hydration, avoid prolonged straining, and consider topical treatments. The NHS and NICE BNFC both place these measures at the foundation of care. Sources: NHS piles advice; NICE BNFC haemorrhoids treatment summary; BMJ Best Practice.
• Established Office-based procedures include rubber band ligation, sclerotherapy, and infrared coagulation. These are established options for symptomatic internal haemorrhoids that do not respond to conservative measures. Sources: NICE haemorrhoids topic page; BMJ Best Practice.
• Established Surgical options include haemorrhoidectomy (open, closed, or stapled) and haemorrhoidal artery ligation. NICE TA128 covers stapled haemorrhoidopexy and NICE HTG218 covers haemorrhoidal artery ligation. Sources: NICE TA128; NICE HTG218.
• Emerging Electrotherapy (low-level electrical current) is an emerging outpatient option. NICE HTG377 considers the evidence limited but notes it may be used with standard arrangements. Sources: NICE HTG377.
• Emerging Updated ESCP guidelines emphasise patient-reported outcomes and individualised treatment selection based on grade and symptom burden. Sources: ESCP guideline for haemorrhoidal disease.
• Limited Evidence for the optimal dietary fibre type and amount specifically for haemorrhoid prevention remains inconsistent. Sources: BMJ management of haemorrhoids.
• Limited Long-term comparative effectiveness of stapled haemorrhoidopexy versus conventional excisional techniques is debated. Sources: NICE TA128; BMJ.

What not to self-manage

These are cautions, not approaches people discuss: do not attribute all rectal bleeding to haemorrhoids without appropriate assessment; always seek evaluation for new or persistent bleeding, a change in bowel habit, or iron-deficiency anaemia. Many haemorrhoids are asymptomatic and require no treatment. Surgical interventions carry risks including bleeding, infection, anal stenosis, and incontinence; patient selection and specialist referral are essential.