Executive summary
- Typical: bright red bleeding on paper/stool, pruritus/soiling, prolapse. Severe pain suggests fissure or thrombosis.
- Do not assume piles: screen for red flags (change in bowel habit, weight loss, IDA, family history, mass, persistent bleeding).
- First-line: treat constipation + toileting habits; topical preparations are short-term symptom relief only.
Assessment and differentials
- History: bleeding pattern (paper vs mixed), pain, prolapse, mucus, bowel habit/straining, anticoagulants, pregnancy.
- Examination: inspect (skin tags, fissure, thrombosis); DRE/proctoscopy if tolerated and clinically indicated.
- Differentials: fissure, proctitis, IBD, colorectal/anal cancer, polyps, diverticular bleed.
Management (primary care)
- Constipation/stool-softening: fibre + fluids; macrogol/bulk-forming agents as needed; avoid straining, limit time on toilet.
- Topicals: local anaesthetic ± mild steroid short-term; avoid prolonged steroid use.
- Thrombosed external haemorrhoid: analgesia + laxatives; consider urgent pathway input if severe/early and local services offer excision.
When to refer
- 2WW suspected cancer: features suggestive of colorectal/anal cancer per NG12/local criteria.
- Routine: persistent symptoms/bleeding despite optimised conservative care; recurrent significant bleeding; significant prolapse; consideration of banding/sclerotherapy/surgery.
Frequently asked questions
Can haemorrhoids cause iron-deficiency anaemia?
They can, but IDA should always prompt reassessment and investigation/referral per local colorectal pathways.
How long should steroid creams be used?
Short courses only. If symptoms persist or recur, reassess the diagnosis and consider referral.
What is the biggest “quick win”?
Optimise stool consistency and reduce straining; this often improves bleeding and discomfort substantially.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.