Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic


Types of haemorrhoids

  • originate below the dentate line
  • prone to thrombosis, may be painful

  • originate above the dentate line
  • do not generally cause pain

Grading of internal haemorrhoids

Grade IDo not prolapse out of the anal canal
Grade IIProlapse on defecation but reduce spontaneously
Grade IIICan be manually reduced
Grade IVCannot be reduced


  • Incidence: 1000.00 cases per 100,000 person-years
  • Peak incidence: 40-50 years
  • Sex ratio: 1:1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Clinical features
  • painless rectal bleeding is the most common symptom
  • pruritus
  • pain: usually not significant unless piles are thrombosed
  • soiling may occur with third or forth degree piles


  • soften stools: increase dietary fibre and fluid intake
  • topical local anaesthetics and steroids may be used to help symptoms
  • outpatient treatments: rubber band ligation is superior to injection sclerotherapy
  • surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
  • newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy


  • thrombosed haemorrhoid