Intended for healthcare professionals

Clinical Review

Management of haemorrhoids

BMJ 2008; 336 doi: (Published 14 February 2008) Cite this as: BMJ 2008;336:380
  1. Austin G Acheson, associate professor of surgery,
  2. John H Scholefield, professor of surgery
  1. 1Section of Gastrointestinal Surgery, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH
  1. Correspondence to: A G Acheson austin.acheson{at}

    Haemorrhoids or “piles” are enlarged vascular cushions within the anal canal that have been described for many centuries and continue to form a large part of a colorectal surgeon’s workload. The exact incidence of this common condition is difficult to estimate as many people are reluctant to seek medical advice for various personal, cultural, and socioeconomic reasons, but epidemiological studies report a prevalence varying from 4.4% in adults in the United States to over 30% in general practice in London.1 2 The treatment of haemorrhoids is still evolving, and this article provides an update on the role of established and innovative treatments (fig 1).

    Fig 1 Suggested algorithm for management of haemorrhoids (dotted arrows indicate failure of initial treatment)

    Sources and selection criteria

    Articles were retrieved from the Medline database and Cochrane library under the MeSH subheadings “hemorrhoid” and “haemorrhoid”. We included randomised controlled trials and meta-analyses.

    Summary points

    • Haemorrhoids are enlarged vascular cushions in the anal canal

    • Treatment depends on the degree of prolapse and severity of symptoms

    • Rubber band ligation is the best outpatient treatment for haemorrhoids—up to 80% of patients are satisfied with the short term outcome

    • Surgery is reserved for large symptomatic haemorrhoids that do not respond to outpatient treatment

    • Doppler guided haemorrhoidal artery ligation and stapled haemorrhoidopexy are new alternatives to the traditional and more painful open or closed haemorrhoidectomy

    What is the pathogenesis and aetiology?

    The anal canal consists of three fibrovascular cushions that are fed directly by arteriovenous communications. These cushions are supported within the anal canal by a connective tissue framework, and they are important in providing a watertight seal to the anus. The degenerative effects of ageing may weaken or fragment the supporting tissues, and this along with the repeated passage of hard stool and straining produces a shearing force on the cushions, leading to their descent and prolapse. The …

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