Haemorrhoids
Date issued: February 2025
For review: February 2027
Ref: C-612/AC/Colorectal/Haemorrhoids
PDF: Haemorrhoids.pdf [pdf] 411KB
What are haemorrhoids?
Haemorrhoids (also known as piles) are a common problem. We all have haemorrhoidal cushions which are part of the normal structure of the back passage (anus). They can enlarge and swell, protruding outside the back passage causing symptoms. Symptoms range from temporary and mild, to persistent and painful, with many patients managing their symptoms with attention to diet or a topical treatment.
What causes haemorrhoids?
The back passage is normally lined with 3 areas of soft fleshy tissue (cushions) which are very well supplied with blood vessels, In some cases, often because of problems with passing poo, these cushions enlarge over time, forming what we call piles (haemorrhoids). Because of the good blood supply, these piles can cause bright red bleeding usually during or after having your bowels open. They may also prolapse (push out of the back passage) or can cause mucous leakage and skin irritation.
Symptoms of haemorrhoids
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Bleeding from the back passage
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Back passage itching
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Discomfort in the back passage area
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Swelling and feeling a lump at the back passage.
Common causes for haemorrhoids
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Constipation: The pressure in and around the veins in the back passage increases. This is a common cause for haemorrhoids developing. This is made worse with straining on the toilet.
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Pregnancy: This can cause haemorrhoids as the baby is lying above the back passage, causing pressure. Changes to hormones can also have an effect on the veins, with constipation more common in pregnancy.
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Ageing: The tissue in the lining of the back passage may not be as supportive as you get older.
Grades of haemorrhoids
Grade 1: The internal haemorrhoid bulges into the lining of your back passage (anus). They do not prolapse (protrude outside of your anus). These may bleed.
Grade 2: The haemorrhoid goes past the anal verge with straining for a bowel movement or passage of flatus (wind) but return to their original internal position once the straining has stopped.
Grade 3: The haemorrhoid may protrude past the anal verge without any straining and requires the patient to push them inside.
Grade 4: This is where the haemorrhoid is permanently prolapsed (outside of the anus).
Treatment
Grade 1 and 2 haemorrhoids may be treated by dietary changes and medicines. These medicines include creams and suppositories (medicine inserted into your back passage).
If these treatments don’t help, other treatments include:
Rubber band ligation (tying) of the haemorrhoids, to prevent bleeding. This is a minimally invasive procedure and is performed in outpatients, and usually only takes a few minutes.
Using a short telescope, tiny rubber bands are placed inside the back passage above the piles. This tightens and cuts off the blood supply to the piles. Over the next few weeks, the piles shrivel up, hopefully leading to an improvement in your symptoms.
What to expect after the procedure
Immediately after the banding there may be a sensation of needing to have your bowels open. This is normal, do not worry. The sensation will fade to a mild discomfort or ache lasting a couple of days.
You may feel a little lightheaded shortly after the procedure. If you feel faint, it is advisable to sit quietly to let things settle down for 20 to 30 minutes before driving or catching public transport.
Over the next few days, you can take mild pain relief, such as paracetamol, to help with any discomfort.
After 7 to 10 days the tissue in the band will fall away. You may get some dark red bleeding from the back passage at this stage. This is normal, do not worry.
Possible complications of the treatment
Occasionally, bands constrict a part of the lining of the back passage which is very sensitive. This usually gives severe pain at the time the bands are put on. If this happens, the bands may need to be removed.
Very rarely you may get large amounts of bright red bleeding after 7 to 10 days. If this happens you will need to be seen by your GP or at the Emergency Department.
This can be more common if you take any medications to thin your blood such as Clopidogrel, Warfarin or Rivaroxaban. If you are currently taking any of these medications your surgeon may recommend that you stop taking the medication before having the banding carried out.
Banding is a simple and effective treatment for piles but sometimes you may still have remaining symptoms that need repeat banding or alternatively, a different procedure.
When to see your GP
There is no need to be seen routinely after banding treatment. If you have severe pain in the back passage, persisting or heavy bleeding, you should see your GP for a check-up.
Often your surgeon will leave you with an ‘open appointment’ so that if you have ongoing symptoms (within 6 months of treatment) you can contact their secretary to book an appointment to be seen again in clinic, without having to go back through your GP.
Haemorrhoids requiring surgery Grade 3 and 4 haemorrhoids, which hang outside your back passage, may require surgery.
HALO: Haemorrhoid Artery Ligation Operation
RAR: Recto-anal Repair
HALO: RAR
Haemorrhoidectomy
What if my haemorrhoids were left untreated?
Haemorrhoids can come and go, but if they are occurring frequently with bleeding or are outside of the bottom, you can become anaemic. However, if they occur infrequently, you probably don’t require surgery. Large haemorrhoids can get stuck outside the back passage and clot (thrombus), which is usually very painful and requires admission to hospital for treatment. You may also experience some leakage of mucus from the back passage which can cause soreness and irritation to the skin around the anus. Any bleeding that is different should be reported to your GP as it may not be caused by your haemorrhoids.
How will the operation help me?
The aim of the operation is to reduce discomfort and bleeding. The operation will be performed under a general or spinal anaesthetic.
Are there any risks or possible complications?
These risks apply to all surgery:
Bleeding: Bleeding from the operation site can happen for up to 1 week. If this bleeding continues and shows no signs of stopping, you may need another operation to stop the bleeding.
Risks associated with general anaesthetic: You will be given a leaflet, which will explain all about your anaesthesia in detail. Your Anaesthetist (a doctor with special training in anaesthetics) will discuss this with you.
Deep Vein Thrombosis: DVT (blood clots in the leg veins) or Pulmonary Embolism (PE) blood clots in the lungs.
All adult patients will have their risk of developing a blood clot assessed within 12 hours of admission. Patients who are being admitted for planned surgery may have their risk assessed at a pre-assessment visit.
The Nurse or Doctor who carries out the risk assessment will discuss your risk factors with you and talk you through treatment to reduce your risk.
You will also be given a leaflet, which will give advice about how to reduce your risk of developing a blood clot while you are in hospital and when you go home.
Infection: Signs of an infection include generally feeling unwell, a temperature or a very smelly discharge from your rectum that is not a stool (poo). This can be treated with a course of antibiotics, and you may need to stay in hospital for longer.
Incontinence: You may have some leakage of mucus or poo after your operation, which can cause staining on your underwear. This is due to the gentle stretching of the back passage (anus) during the operation. This can last for a few weeks and usually needs no treatment. You could wear a small underwear liner.
Difficulty passing urine: Some patients may find it difficult to pass urine after the operation. This is more common in people who have difficulty passing urine, such as men with prostate problems. If this happens, you may require a catheter (a tube into your bladder) to drain your urine for several days.
Recurrence (further haemorrhoids developing): If this happens, you may need further treatment or another operation.
Injury to nearby organs, nerves or tissues: If this happens, you may need further treatment or another operation.
Narrowing of the anal canal: This could mean that passing a stool (poo) could be more difficult.
Faecal incontinence (leakage of stools): This can be temporary or permanent.
Faecal impaction or constipation: This is where hardened faeces (stools) become lodged in the rectum (back passage). This may be because of discomfort after your surgery, which can worsen after passing a stool. This may make you hold your stool in to try to stop the pain. Holding in a stool is a common cause of constipation. Morphine based pain medicines may also cause constipation.
Drinking plenty of fluids, eating food that is high in fibre, such as bran, as well as taking medicines, such as Lactulose or Movicol, which will soften your poo and encourage bowel movement.
What does the operation involve?
An enema is usually given an hour or so before the operation to clear the lower part of the bowel.
HALO: A small narrow plastic tube, known as a proctoscope, with an embedded micro-doppler ultrasound, is placed in the back passage. The ultrasound probe is used to locate the exact position of the artery (vessel) supplying blood to the haemorrhoid. This vessel will be located within the rectum (bottom). Once located, a small dissolvable suture (stitch) will be placed around the vessel that supplies the blood flow. By stopping the blood flow, this should shrink the haemorrhoid, stop any bleeding and reduce pain.
Recto-anal Repair (RAR): This is when the Doppler probe is removed, and a running stitch is placed along the length of the prolapsed haemorrhoid. This fixes the prolapsing part of the haemorrhoid by lifting it up and stitching it back to its normal place inside the rectum.
HALO-RAR: This has the combined effect of making a large, sagging haemorrhoid shrink and drawing up the prolapsed haemorrhoid to its correct place within the rectum.
Haemorrhoidectomy
The operation involves cutting the haemorrhoids out or trimming them.
What will happen after the operation?
You are likely to experience some pain following this procedure when the local anaesthetic wears off. This will get better but may take up to 6 weeks to resolve completely. Painkillers and laxatives will be prescribed to take home.
You may experience some bleeding, which is normal. You are likely to see blood on the first poo following the operation.
We recommend taking a warm water bath several times a day to reduce the discomfort in your anal area. Do not add bubble bath or soap to the water as this may cause irritation to the area.
You may also find that you have the feeling that you need to pass a poo, but you can’t. This feeling may last for up to 2 weeks. It is important that you do not sit on the toilet to pass something that is not there, as this can lead to further complications. You may also pass some mucous (jelly like liquid) from your back passage for about a week.
For the next 2 weeks, please follow the instructions below. This will help you to heal and to try and avoid putting pressure on your wound:
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No strenuous activity.
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No lifting items over 10lbs (5kg) such as children or heavy bags of shopping.
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No exercise beyond a gentle walk.
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Bathe the area with warm water to soothe and keep it clean.
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Do not apply any creams or ointments, unless they have been prescribed by your surgeon.
Will I have any stitches than need to be removed?
No. Dissolvable stitches will have been used. There is no need to have these removed, as your body will absorb them over the following weeks.
How long will I need off work?
This may vary, but you can usually return to work around 2 weeks after your operation, depending upon the type of work that you do. If you require a ‘Fit note’ for work, please let a member of staff know before you are discharged from hospital.
How can I help myself?
When you go home, if you notice any of the following:
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Severe pain in the lower abdomen, rectum or lower back or lower back passage.
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High temperature.
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Persistent nausea or vomiting.
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Persistent bleeding from the rectum.
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You must contact 111 or attend the Emergency Department.
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When can I drive again?
You can drive 2 weeks after the operation. However, if you do not feel ready, you should wait until you do. You should check with your insurance company as policies may vary with individual companies.
When can I play sport again?
You should not go swimming or do strenuous exercise until the area has healed and you feel comfortable to do so. Lifting heavy weights will have to be avoided following the operation, as this could cause strain.
How long should I wait before I have sexual intercourse?
You should not have vaginal sexual intercourse for a minimum of 2 weeks after the operation. You should not have anal sexual intercourse for a minimum of 6 weeks after the operation.
If you have sexual intercourse before this time, it is possible that this will disturb the operation site, delay healing and may even undo the operation.
You should not insert anything into your rectum or vagina (such as tampons) during this time. This is to avoid an increase of pressure on your rectal area, caused by the tampon pushing against it.
Will I have a follow up appointment?
A routine follow-up appointment is not usually necessary; however, we will give you an open access appointment whereby you can contact your consultant’s secretary within 6 weeks of your surgery if you have any concerns.
How to prevent haemorrhoids returning
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Increase the amount of fluid you drink to at least 6-8 glasses a day. This can include water, tea, coffee, fruit juice or soup.
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Stop the motions from being too hard. You can help to keep the motions soft by eating a diet high in fibre and drinking plenty of fluids with meals. If necessary, taking mild laxatives which act as stool-softeners such as Laxido® or Fybogel® are available buy at your local chemist. Alternatives may be using Milled Linseeds or Flaxseeds or Psyllium husk capsules. Additional information can be found in our Constipation in adults’ booklet.
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Try not to strain when passing motions. Different people have a different number of bowel actions in a day/week. Do not try and strain to have a bowel action unless you feel the need to go and do not try too hard to ‘push out every last little bit’. Some people find it helpful to raise their feet on a step/box to reduce straining.
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Adopt a good, seated position on the toilet and avoid straining.
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Do not spend too long on the toilet. When sitting down, the weight of the body pushes down into the pelvis causing the lining of the back passage to swell. Aim to spend around 5 minutes having a bowel action. Do not take any longer than necessary.
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Take special care not to become constipated if you become pregnant.
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Keep active, this doesn’t have to be with exercise, but short walks can encourage gut motility and prevent constipation and bloating.
Acknowledgement:
North Tees and Hartlepool NHS Foundation Trust.
Gloucestershire Hospitals Foundation Trust
Other sources for information
Haemorrhoids (2021) National Institute for Health and Care Excellence (NICE)
