• They are venous “vascular cushions” that have become enlarged due to increased pressure (e.g. secondary to straining in constipation)
  • 1st degree: no prolapse
  • 2nd degree: prolapse when straining and return on relaxing
  • 3rd degree: prolapse when straining, do not return on relaxing but can be pushed back
  • 4th degree: prolapsed permanently



  • No symptoms
  • Constipation
  • Painless bright red bleeding (on toilet paper or dripping)
  • Sore / itchy anus
  • Feeling a lump around or in anus


Thrombosed Haemorrhoid

  • Caused by strangulation at base of haemarrhoid causing thrombosis (a clot) in the haemarrhoid
  • Can be extremely painful
  • Appear as purple, very tender swollen lumps around anus
  • PR exam will be impossible due to pain



  • External haemorroids visible on inspection
  • Internal haemorrhoids difficult to feel (may not be possible) on PR exam
  • Appear as swellings covered in mucosa, may appear (prolapse) if the patient is asked to” bear down” during inspection
  • Proctoscopy is required for proper visualization and inspection



  • Consider differential diagnoses (e.g. fissure, cancer, inflammatory bowel disease)
  • Symptomatic (anusol cream, local anaestetic e.g. instillagel, topical steroids)
  • Laxatives
  • Band ligation (tight rubber band around base to cut off blood supply)
  • Surgical haemorrhoidectomy
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