Haemorrhoids (Piles)
Conservative management, topical treatments, and surgical options per NICE guidance
Haemorrhoids are enlarged vascular cushions of the anal canal, causing bleeding, prolapse, pruritus, and discomfort. The vast majority respond to conservative dietary measures and topical treatment. Procedural and surgical options are reserved for grade III–IV or treatment failure.
Classification and Presentation
Haemorrhoids are classified by the degree of prolapse. Grade I: bleed but do not prolapse. Grade II: prolapse on straining but reduce spontaneously. Grade III: prolapse requires manual reduction. Grade IV: irreducible. External haemorrhoids arise below the dentate line and are covered by squamous epithelium — they are painful when thrombosed. Internal haemorrhoids are painless but bleed. Typical presentation is painless bright red rectal bleeding on defecation, perianal pruritus, and mucus discharge. Important: rectal bleeding in patients over 45 must not be attributed to haemorrhoids without appropriate investigation to exclude colorectal cancer.
Conservative and Topical Treatment
First-line management is dietary: a high-fibre diet and adequate fluid intake to produce soft, easy-to-pass stools. A bulk-forming laxative (ispaghula husk 1 sachet twice daily) is recommended to prevent straining. Topical preparations provide symptomatic relief: Anusol cream (zinc oxide and bismuth) reduces inflammation; Scheriproct ointment (prednisolone + cinchocaine) or Proctosedyl (hydrocortisone + cinchocaine) may be used for short-term pain relief — maximum 7 days to prevent skin atrophy. Warm sitz baths three times daily soothe acute symptoms. Topical GTN or nifedipine cream can relieve sphincter spasm in thrombosed haemorrhoids.
Procedural and Surgical Options
Rubber band ligation is the most effective outpatient procedure for grade II–III internal haemorrhoids — a band is placed at the base of the haemorrhoid causing ischaemia and sloughing. Injection sclerotherapy (5% phenol in oil) is used for grade I–II. Haemorrhoidectomy (surgical excision) is the most effective treatment for grade III–IV or failed outpatient procedures, with a higher complication rate including pain and urinary retention. The HALO procedure (haemorrhoidal artery ligation) is a less invasive surgical alternative. Thrombosed external haemorrhoids causing severe pain may require surgical excision within 72 hours of onset.