Intended for healthcare professionals

Clinical Review

Managing haemorrhoids

BMJ 2003; 327 doi: (Published 09 October 2003) Cite this as: BMJ 2003;327:847
  1. Pasha J Nisar, research fellow (,
  2. John H Scholefield, professor of surgery1
  1. 1 Section of Gastrointestinal Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH
  1. Correspondence to: P J Nisar

    Increased understanding of the anatomy of haemorrhoids has led to the development of new procedures to treat them. Among the surgical options for intractable prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows a shorter convalescence but may have a higher recurrence rate and needs further long term evaluation


    Improvements in our understanding of the anatomy of haemorrhoids have prompted the development of new and innovative methods of treatment. Unfortunately confusion still exists among lay people and doctors, who misuse the terms haemorrhoids and piles to cover a variety of complaints. This has led to estimates of prevalence varying from 4.4% among adults in the United States to 36.4% in general practice in London.1 2 This article describes the pathogenesis of haemorrhoids and management strategies (fig 1).

    Fig 1

    Suggested algorithm for management of haemorrhoids (dotted arrows indicate failure of initial treatment)


    We retrieved evidence based articles from the Medline database and Cochrane Library under the MESH subheading “hemorrhoid.” We included randomised controlled trials with valid end points and meta-analyses.


    The anal canal has a triradiate lumen lined by three fibrovascular cushions of submucosal tissue. The cushions are suspended in the canal by a connective tissue framework derived from the internal anal sphincter and longitudinal muscle. Within each cushion is a venous plexus that is fed by arteriovenous communications. These specialised vascular structures allow for enlargement of the cushion to maintain fine continence. In health as in disease the anal cushions appear in the right anterior, right posterior, and left lateral positions.3

    Fragmentation of the connective tissue supporting the cushions leads to their descent. This occurs with age and the passage of hard stools, which produce a shear force on the framework. Straining produces an increase in venous pressure and engorgement. The prolapsed …

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