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Health condition · Clinically reviewed

Haemorrhoids, grading, red flags and the ladder from fibre to surgery.

Very common, mostly treatable and rarely dangerous - but rectal bleeding always deserves a proper look before it is called piles.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, ACPGBI and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including rubber band ligation, HAL-RAR and stapled haemorrhoidopexy.

Key facts

Haemorrhoids at a glance.

The essentials, in plain English - what they are, how they are graded and how they are treated in the UK today.

  • What they are

    Dilated vascular cushions in the anal canal - not simply veins - that can prolapse and bleed. Very common, affecting up to 40 to 50 percent of adults at some point.

  • Types

    Internal (above the dentate line, graded Goligher I to IV), external (below, can thrombose painfully) and mixed disease.

  • Cardinal symptoms

    Bright red rectal bleeding on the paper or coating stool, prolapse, itch, mucus discharge and - if thrombosed - severe pain.

  • Risk factors

    Chronic constipation, straining, pregnancy, heavy lifting, prolonged sitting, obesity, low-fibre diet and family history.

  • Critical caveat

    Rectal bleeding must never be assumed to be piles - colorectal cancer needs excluding under NICE NG12 in the right groups.

  • Treatment ladder

    Lifestyle and topicals first, rubber band ligation for Grade II to III, surgery (haemorrhoidectomy, HAL-RAR, stapled) for refractory or Grade IV.

Why this guide matters

Common, treatable - and not to be assumed.

Piles are common but rectal bleeding is not always piles. The three points below shape everything else on this page.

  • Exclude cancer first

    Rectal bleeding with a change in bowel habit, weight loss, anaemia or age over 45 is a two-week-wait referral under NICE NG12 - regardless of visible piles.

  • Treat the constipation

    Fibre, fluid and softer stools remove the mechanical driver. It is often the single most useful intervention.

  • Match treatment to grade

    Grade I responds to lifestyle and topicals; Grade II to III to rubber band ligation; Grade III to IV or refractory disease to surgery.

How the diagnosis is made

From first bleed to a clear plan.

The steps a UK GP or colorectal team will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Symptom and risk history

    Bleeding pattern, prolapse, pain, bowel habit, fibre and fluid intake, pregnancy, lifting and family history.

  2. 02

    Assessing

    Red-flag triage

    Persistent bleeding, change in bowel habit, weight loss, age over 45, anaemia or a positive FIT trigger a two-week-wait cancer referral under NICE NG12.

  3. 03

    Assessing

    External inspection and PR

    Perianal skin, tags, prolapse on straining and a digital rectal examination for masses, tenderness and tone.

  4. 04

    Confirming

    Proctoscopy

    A short, in-clinic look at the anal canal to grade internal haemorrhoids and rule out fissure or fistula.

  5. 05

    Confirming

    FIT and blood tests

    Faecal immunochemical testing helps stratify cancer risk. FBC picks up iron-deficiency anaemia from chronic loss.

  6. 06

    Planning

    Flexible sigmoidoscopy or colonoscopy

    Specialist endoscopy when bleeding is atypical, FIT is positive, or age and symptoms mandate ruling out colorectal cancer, IBD or polyps.

  7. 07

    Planning

    Colorectal specialist review

    For refractory, prolapsing or Grade III to IV disease - or diagnostic uncertainty - a colorectal surgeon plans office or theatre treatment.

Typical timeline: first visit to a settled plan in weeks, not months.

Symptoms

What haemorrhoids actually feel like.

The classic mix of bleeding, prolapse and irritation - and the features that mean it is time to think beyond piles.

  • Bright red rectal bleeding

    On the paper, in the bowl or coating - not mixed through - the stool. Darker blood suggests a source higher up.

  • Prolapse and a lump

    A soft lump that appears on defecation and reduces spontaneously (Grade II), needs manual reduction (Grade III) or stays out (Grade IV).

  • Itch and irritation (pruritus ani)

    Mucus soiling and skin irritation around the anus, often worse with tags and prolapse.

  • Thrombosed external haemorrhoid

    A sudden, exquisitely painful purple lump at the anal margin - most painful in the first 48 to 72 hours.

  • Mucus discharge and soiling

    Small volumes of mucus and staining underwear - common with prolapsing internal disease.

  • Iron-deficiency anaemia

    Chronic slow loss can cause tiredness, breathlessness and a low haemoglobin - always investigate the source.

  • Discomfort, not pain

    Uncomplicated internal piles rarely hurt. Significant pain points to thrombosis, fissure or abscess.

  • Red flag - change in bowel habit

    New looser stools, weight loss, tenesmus or bleeding over 45 needs urgent colorectal review to exclude cancer.

Treatment

How haemorrhoids are treated in the UK.

Lifestyle and topicals first, rubber band ligation for Grade II to III, and surgery for prolapsing or refractory disease under a colorectal team.

  • Dietary and lifestyle changes

    Fibre to 25 to 30g a day, plenty of fluid, avoiding straining, a squat position and a regular toilet routine - the foundation of every plan.

  • Treat the constipation

    Fibre supplements and osmotic laxatives soften stools and reduce straining. See our guide to chronic constipation for the full ladder.

  • Topical soothing agents

    Short courses of hydrocortisone with local anaesthetic (Anusol HC, Xyloproct, Proctosedyl, Scheriproct, Uniroid HC), zinc oxide and witch hazel help symptoms - not the pile itself.

  • Oral flavonoids

    Micronised purified flavonoid fraction (Daflon) has some evidence for reducing bleeding and acute symptoms.

  • Rubber band ligation

    First-line office procedure for Grade II to III internal haemorrhoids. Quick, well tolerated and effective. Delivered by a specialist colorectal team.

  • Sclerotherapy and IRC

    Injection sclerotherapy, infrared coagulation and bipolar diathermy are selective office options for smaller haemorrhoids.

  • HAL-RAR and stapled haemorrhoidopexy

    Doppler-guided artery ligation with rectoanal repair, or stapled haemorrhoidopexy - specialist day-case options for prolapsing disease.

  • Haemorrhoidectomy

    Milligan-Morgan (open), Ferguson (closed) or LigaSure excisional surgery - definitive for Grade III to IV and refractory disease. Painful recovery but durable.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or colorectal surgeon knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE Clinical Knowledge Summary. Haemorrhoids.

  • NICE NG12. Suspected cancer: recognition and referral (lower gastrointestinal).

  • Association of Coloproctology of Great Britain and Ireland (ACPGBI). Position statement on the management of haemorrhoidal disease.

  • European Society of Coloproctology. Guideline for the management of haemorrhoidal disease.

Red flags

When rectal bleeding is not just piles.

Most piles are manageable in primary care. These are the situations that are not - and where a specialist opinion is needed.

  • Persistent or heavy rectal bleeding

    Ongoing bleeding, clots, dizziness or a drop in haemoglobin needs urgent assessment - never assume it is just piles.

  • Change in bowel habit over 45

    New looser stools, tenesmus or narrower stools with bleeding meets NICE NG12 criteria for a two-week-wait colorectal referral.

  • Weight loss and anaemia

    Unintentional weight loss with rectal bleeding or iron-deficiency anaemia demands prompt lower GI investigation.

  • Positive FIT

    A positive faecal immunochemical test in a symptomatic patient triggers urgent colonoscopy - even when haemorrhoids are visible.

  • Thrombosed external haemorrhoid

    A painful purple perianal lump within 72 hours may benefit from surgical excision for immediate relief - see a colorectal team.

  • Strangulated Grade IV haemorrhoid

    A permanently prolapsed, painful, non-reducible haemorrhoid with signs of ischaemia needs urgent surgical review.

  • Sepsis or perianal abscess

    Fever, worsening pain, swelling and fluctuance suggest abscess rather than piles - a surgical emergency.

  • Immunosuppression or pregnancy

    Bleeding in immunosuppressed or pregnant patients needs a lower threshold for specialist review and imaging.

  • Family history of colorectal cancer

    Any rectal bleeding with a strong family history warrants earlier endoscopy - do not attribute to piles by default.

Living with it

A treatable condition, with a clear ladder.

Four things that make the biggest difference day to day - fibre, a sensible toilet routine, short-course topicals and knowing when to step up.

A quiet reminder

Softer stools, less straining, better outcomes.

Most people improve markedly with fibre, fluid and a squat position - even before any procedure is considered.

  1. 01 Fibre

    Feed your bowel

    Aim for 25 to 30g of fibre a day, spread across meals, with enough fluid. Wholegrains, pulses, fruit and veg do most of the work.

  2. 02 Toilet

    Don’t sit and strain

    Go when you need to, keep visits short and use a footstool for a squat position. Strain-and-scroll is a driver of piles.

  3. 03 Topical

    Short, targeted courses

    Anusol HC or similar for a week or two settles flare-ups. Long-term use is neither needed nor recommended.

  4. 04 Escalate

    Know when to ask for more

    Recurrent bleeding, prolapse that will not reduce or life-limiting symptoms are cues for banding or surgery - not tolerating them for years.

Frequently asked

Everything we get asked about haemorrhoids.

Quick answers on grading, red flags, banding and surgery.

  • What actually are haemorrhoids?

    Haemorrhoids - piles - are dilated vascular cushions in the anal canal, not simply varicose veins. Internal ones sit above the dentate line and are graded Goligher I to IV. External ones sit below and can thrombose painfully. Many people have both.

  • Are haemorrhoids dangerous?

    Piles themselves are not dangerous, but the symptoms overlap with colorectal cancer, inflammatory bowel disease and polyps. Any rectal bleeding - especially with a change in bowel habit, weight loss, anaemia or age over 45 - should be assessed under NICE NG12 before being attributed to piles.

  • What causes them?

    The main drivers are chronic constipation and straining, pregnancy, heavy lifting, prolonged sitting, obesity, a low-fibre diet and genetic predisposition. Treating the underlying constipation is often the single most useful step.

  • Do I need surgery?

    Most people never do. Lifestyle changes, fibre, treating constipation and short courses of topical treatments settle the majority. For Grade II to III disease, rubber band ligation in clinic is the usual first procedure. Haemorrhoidectomy, HAL-RAR or stapled haemorrhoidopexy are reserved for refractory Grade III to IV disease under a colorectal surgeon.

  • What is rubber band ligation like?

    A short outpatient procedure through a proctoscope: a tiny elastic band is placed at the base of the haemorrhoid, cutting off its blood supply so it drops off over about a week. Most people feel pressure or a dull ache for 24 to 48 hours and return to normal activities the next day.

  • What about a thrombosed external haemorrhoid?

    A thrombosed external haemorrhoid is a sudden, very painful purple lump at the anal margin. Within the first 72 hours, surgical excision by a colorectal team can shorten pain significantly. After 72 hours most settle on their own with stool softeners, warm baths and simple analgesia.

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