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Grade 1 are small swellings on the inside lining of the back passage. They cannot be seen or felt from outside the anus. Grade 1 haemorrhoids are common. In some people they enlarge further to grade 2 or more.
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Grade 2 are larger. They may be partly pushed out (prolapse) from the anus when you go to the toilet, but quickly 'spring back' inside again.
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Grade 3 hang out (prolapse) from the anus. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.
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Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.
Symptoms can vary. Small haemorrhoids are usually painless. The most common symptom is bleeding after going to the toilet. Larger haemorrhoids may cause a mucus discharge, some pain, irritation, and itch. The discharge may irritate the skin around the anus. You may have a sense of fullness in the anus, or a feeling of not fully emptying your rectum when you go to the toilet.
A possible complication of haemorrhoids that hang down (grade 3-4) is a blood clot (thrombosis) which can form within the haemorrhoid. This is uncommon, but causes intense pain if it occurs.
External haemorrhoid (sometimes called a perianal haematoma)
This is less common than internal haemorrhoids. An external haemorrhoid is a small lump that develops on the outside edge of the anus. Many do not cause symptoms. However if a blood clot forms in the haemorrhoid ('thrombosed external haemorrhoid') it can suddenly become very painful and need urgent treatment. The pain due to a thrombosed external haemorrhoid usually peaks after 48-72 hours, and then gradually goes away over 7-10 days. A thrombosed external haemorrhoid may bleed a little for a few days. It then gradually shrinks to become a small skin-tag.
Some people have internal and external haemorrhoids at the same time.
What is the treatment for haemorrhoids?
Avoid constipation and straining at the toilet
Keep the faeces (sometimes called stools or motions) soft, and don't strain on the toilet. You can do this by the following:
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Eat plenty of fibre by eating plenty of fruit, vegetables, cereals, wholemeal bread, etc.
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Have lots to drink. Adults should aim to drink at least two litres (10-12 cups) per day. You will pass much of the fluid as urine, but some is passed out in the gut and softens faeces. Most sorts of drink will do, but alcoholic drinks can be deydrating and may not be so good.
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Fibre supplements. If a high fibre diet is not helping, you can take bran, or other fibre supplements ('bulking agents') such as ispaghula, methylcellulose, or sterculia. You can buy these at pharmacies or get them on prescription. Methylcellulose also helps to soften faeces directly which makes them easier to pass.
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Avoid painkillers that contain codeine such as co-codamol, as they are a common cause of constipation.
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Toileting. Go to the toilet as soon as possible after feeling the need. Some people suppress this feeling and plan to go to the toilet later. This may result in bigger and harder faeces forming which are then more difficult to pass. Do not strain on the toilet. Haemorrhoids may cause a feeling of 'fullness' in the rectum and it is tempting to strain at the end to try and empty the rectum further. Resist this. Do not spend too long on the toilet which may encourage you to strain. (For example, do not read whilst on the toilet.)
The above measures will often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small and non-prolapsing haemorrhoids (grade 1). There are separate pages called 'Constipation in Adults', 'Constipation in Children' and 'Fibre in the Diet' that provide more details about fibre and constipation.
Ointments, creams, and suppositories
Various preparations and brands are commonly used. They do not 'cure' haemorrhoids. However, they may ease symptoms such as discomfort and itch.
- A bland cream, ointment, or suppository may ease discomfort. They can be used as often as you like. Several brands are available without a prescription. Ask a pharmacist to advise.
- One that contains an anaesthetic may ease pain better. You should only use one of these for short periods at a time (5-7 days). If you use it for longer, the anaesthetic may irritate or sensitise the skin around the anus. A pharmacist can advise.
- One that contains a steroid may be prescribed by a doctor if there is a lot of inflammation around the haemorrhoids. Steroids reduce inflammation and may help to reduce any swelling around a haemorrhoid. This may help to ease itch and pain. You should not normally use these for longer than one week at a time.
- Very painful prolapsed haemorrhoids are uncommon. The pain may be eased by an ice pack pressed on for 15-30 minutes. Strong painkillers may be needed.
- Haemorrhoids of pregnancy usually settle after the birth of the child. Treatment is similar to the above.
Banding treatment
Banding is a common treatment for grade 2 and 3 haemorrhoids. It may also be done to treat grade 1 haemorrhoids which have not settled with the measures described above (such as an increase in fibre, etc).
This procedure is usually done by a surgeon in an outpatient clinic. A haemorrhoid is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid which then 'dies' and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.
Banding of internal haemorrhoids is usually painless as the base of the haemorrhoid originates above the anus opening - in the very last part of the gut where the gut lining is not sensitive to pain. Up to three haemorrhoids may be treated at one time using this method. In about 8 in 10 cases, the haemorrhoids are 'cured' by this technique. In about 2 in 10 cases, the haemorrhoids recur at at some stage. (However, you can have a further banding treatment if this occurs.) Banding does not work in a small number of cases. Haemorrhoids are less likely to recur after banding if you do not become constipated and do not strain on the toilet (as described above).
A small number of people have complications following banding such as bleeding, urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid.
Other treatment options
Injection of a 'sclerosing' chemical into the haemorrhoid, freezing of the haemorrhoid, and photocoagulation are alternatives to banding which can be done as an outpatient. However, these techniques are less commonly done than banding.
An operation to cut away the haemorrhoid(s) is an option to treat grade 4 haemorrhoids, and for grade 2 and 3 haemorrhoids not successfully treated by banding or other methods. This is done under general anaesthetic and is usually successful.
©EMIS and PIP 2005
