Hemorrhoids (also spelt haemorrhoids and commonly called piles) are enlarged or symptomatic anal cushions in the lower rectum and anal canal. They may cause painless bright-red bleeding, itching, mucus, a lump, or prolapse. Many cases improve with softer stools and healthier bowel habits, but rectal bleeding must be assessed because it can also come from fissures, infection, inflammatory bowel disease, polyps or colorectal cancer.

Safety reminder: Do not assume that blood from the anus is caused by piles. Heavy or ongoing bleeding, faintness, black stool, severe pain, fever, a new bowel-habit change, weight loss, or a painful prolapse that will not reduce needs prompt clinical assessment.

These notes are for nursing education and revision. Assessment, medication, procedures and referral should follow the patient’s clinical condition, the clinician’s plan and current facility guidance.

After studying this lesson, the learner should be able to:

• Define hemorrhoidal disease and distinguish internal, external, mixed, prolapsed and thrombosed hemorrhoids.
• Explain the anal anatomy and the Goligher grades of internal hemorrhoids.
• Identify common risk factors, symptoms, complications and important differential diagnoses.
• Describe focused history, respectful examination and when further investigation of rectal bleeding is needed.
• Outline conservative care, office procedures and surgical options without treating a grade as the only factor in a treatment decision.
• Plan safe nursing care before and after procedures and teach practical bowel-health measures.

Hemorrhoidal cushions are normal vascular and connective-tissue structures in the anal canal. They contribute to fine closure of the anus and help maintain continence to gas and liquid stool. Hemorrhoidal disease describes symptoms or complications that arise when these cushions enlarge, bleed, prolapse, become thrombosed, or cause irritation. They are not simply abnormal “varicose veins”; connective-tissue support and local blood flow both contribute.

Hemorrhoids are classified as internal or external by their position relative to the dentate line. The two groups communicate and can occur together. The words “piles” and “hemorrhoids” describe a possible cause of symptoms; they do not prove that a patient’s bleeding or pain comes from hemorrhoids.

The anal canal is the terminal part of the large bowel. The dentate line is an important boundary inside it. Internal hemorrhoidal tissue lies above this line and is covered mainly by rectal-type mucosa. Sensation there is relatively poor for sharp pain, so uncomplicated internal hemorrhoids often bleed without hurting. External hemorrhoidal tissue lies below the line under sensitive skin (anoderm); swelling or a clot in this area can be very painful.

The anal cushions receive arterial blood and drain through venous channels. Their position, the surface covering and the local sensory nerves explain why internal and external disease can look and feel different. A painful lump, for example, may be a thrombosed external hemorrhoid, but an abscess, fissure, skin infection or another lesion can present similarly.

The Goligher system describes how far internal hemorrhoids prolapse. It does not grade external hemorrhoids and does not replace assessment of symptoms, bleeding, other disease, patient preference or local expertise.

Hemorrhoidal disease is associated with repeated pressure and straining and with weakening of the supporting tissue around the anal cushions. Risk factors and contributors include:

• Constipation, hard stool, straining or spending a long time sitting on the toilet.
• Low dietary fibre intake or inadequate fluid intake when the patient is not medically fluid-restricted.
• Chronic diarrhoea, frequent bowel motions or repeated urgency.
• Pregnancy and the postpartum period, when pelvic pressure and constipation may increase.
• Increasing age, sedentary habits, obesity or heavy straining.
• Medicines or illness that contribute to constipation, diarrhoea or bleeding; review the medication history with the clinician.

Portal hypertension can cause rectal varices, which are distinct from ordinary hemorrhoids and may bleed significantly. A patient with chronic liver disease or suspected portal hypertension needs clinical assessment rather than self-treatment for presumed piles.

When bowel habits repeatedly increase pressure in the anal canal, the supporting tissue around the cushions may stretch or descend. The vascular cushions can become congested and bleed, while prolapsing tissue may produce mucus and local irritation. If tissue is trapped outside the anus, venous drainage may be impaired and swelling, congestion, ulceration or severe pain may follow. A clot in an external hemorrhoid produces a sudden tender lump. Persistent bleeding can rarely contribute to iron-deficiency anaemia; the underlying source of blood loss must still be established.

Symptoms depend on the type and severity of disease. A patient may report one symptom or several:

• Bright-red blood: on toilet tissue, coating the stool or dripping into the toilet, often during or after defecation.
• Prolapse or a lump: tissue appears at the anus while passing stool, then reduces spontaneously or needs manual reduction.
• Itching or irritation: moisture, mucus, minor leakage or difficulty cleaning may irritate the perianal skin.
• Discomfort or pain: more likely with external disease, thrombosis, fissure, a trapped prolapse or another anorectal condition than with uncomplicated internal hemorrhoids.
• Soiling or mucus: prolapsing tissue can make hygiene difficult and cause a sensation of dampness or incomplete cleaning.
• Sudden severe pain with a firm lump: consider external thrombosis and arrange assessment.

Clinical pattern: painless bleeding can occur with internal hemorrhoids, while sudden painful perianal swelling can occur with an external clot. These patterns are clues, not a diagnosis by themselves.

• Thrombosis: clot formation in an external hemorrhoid can cause acute pain and swelling.
• Prolapse, congestion or strangulation: tissue may become swollen, trapped, ulcerated or difficult to reduce.
• Bleeding and anaemia: repeated blood loss can cause weakness, pallor, dizziness or iron deficiency and requires investigation.
• Perianal irritation: mucus, soiling, excessive wiping or unsuitable topical products can inflame the skin.
• Rare procedure complications: bleeding, infection, urinary retention, pain or recurrence may follow an office procedure or operation.

Do not anchor on hemorrhoids when a patient reports bleeding, pain or a lump. Consider, according to presentation:

• Anal fissure, perianal abscess, fistula, dermatitis, skin tags or rectal prolapse.
• Inflammatory bowel disease, infectious colitis, diverticular bleeding, polyps or colorectal cancer.
• Rectal varices in portal hypertension and other causes of lower gastrointestinal bleeding.
• Gastrointestinal bleeding higher in the tract when stool is dark, tarry or mixed with blood.

Escalate promptly for heavy or persistent bleeding, clots, dizziness, fainting, pallor, weakness, a fast pulse or low blood pressure. Urgent assessment is also needed for severe or rapidly worsening anal pain, fever, pus, a painful irreducible prolapse, black tarry stool, abdominal pain or distension, vomiting, inability to pass stool or gas, or a rapidly enlarging lump.

Arrange further clinical review when bleeding recurs, persists after hemorrhoid treatment, or occurs with unexplained anaemia, weight loss, a new or progressive change in bowel habit, abdominal symptoms, a personal or family history of colorectal cancer or inflammatory bowel disease, or when age-appropriate colorectal screening is due. The clinician decides which examination or investigation is appropriate.

Take a private, respectful and non-judgemental history. Ask about:

• When symptoms began, how often they occur, how much bleeding is seen, whether blood is mixed through stool, and whether there are clots.
• Pain, itching, discharge, prolapse, reducibility, soiling, hygiene difficulty and effect on sleep, work or daily activity.
• Bowel frequency, stool consistency, straining, urgency, time spent on the toilet, diet, fluid intake and use of laxatives or traditional remedies.
• Abdominal pain, distension, diarrhoea, constipation, fever, weight change, fatigue, dizziness or other systemic symptoms.
• Previous anorectal disease, procedures, investigations, bowel screening and response to treatment.
• Current medicines, including anticoagulants, antiplatelets, opioids, iron or other medicines affecting bowel habits; allergies and relevant chronic illness.
• Pregnancy or recent delivery when relevant, and family or personal history of colorectal disease.

The diagnosis is usually clinical, based on a focused history and examination. Explain each step, obtain consent, protect privacy, use a chaperone in line with facility policy and the patient’s preference, and stop if the patient is distressed or in severe pain.

1. General assessment: check vital signs and general appearance if bleeding, infection or significant pain is reported. Look for pallor or signs of haemodynamic compromise.
2. Inspection: with appropriate positioning and draping, inspect the perianal area at rest and, when suitable, while the patient strains. Note skin changes, external lumps, a visible prolapse, fissure, discharge, bleeding or a lesion.
3. Digital rectal examination: a trained clinician may perform a gentle examination to assess for a mass, tenderness, blood, sphincter tone or other pathology. It may be deferred or modified when pain is severe or a suspected abscess is present.
4. Anoscopy or proctoscopy: may help visualise internal hemorrhoids and other anal-canal pathology.
5. Further bowel evaluation: selected patients with rectal bleeding need sigmoidoscopy or colonoscopy, especially when there is no clear anorectal source, abdominal symptoms, changed bowel habit, persistent bleeding after treatment or a screening indication.
6. Laboratory tests: a full blood count and other tests may be requested when bleeding is repeated, heavy or associated with symptoms of anaemia or another illness.

Rectal bleeding should not automatically be attributed to hemorrhoids. A negative or incomplete anorectal examination does not exclude disease higher in the bowel.

Treatment depends on the symptom burden, internal grade, external component, complications, other diagnoses, patient preference and available services. Many patients begin with bowel-habit and dietary changes. Persistent or advanced symptoms may require an office procedure or operation performed by a qualified clinician.

• Increase fibre gradually: encourage vegetables, fruits, beans, peas, whole grains and other affordable local fibre sources. Increase slowly to reduce bloating. A clinician may recommend a fibre supplement when suitable.
• Drink adequate fluid: encourage regular fluids if there is no heart, kidney or other condition requiring fluid restriction.
• Soften hard stool: assess and address constipation with the clinician’s plan. A stool softener or laxative may be prescribed when indicated; do not begin repeated medication without reviewing the cause and risks.
• Avoid straining: respond to the urge to defecate and avoid prolonged sitting on the toilet or repeated forceful attempts.
• Keep the area comfortable: wash gently with water, pat dry and avoid vigorous rubbing, perfumed wipes or harsh soaps.
• Use topical medicines carefully: creams, ointments or suppositories may ease symptoms for a short time. Prolonged use, especially of steroid-containing products, can irritate or thin skin; follow product and clinician instructions.
• Review contributors: the team may adjust constipation-causing medicines or plan treatment for chronic diarrhoea. Do not stop prescribed medicines, including anticoagulants, without the prescriber’s advice.

Office procedures are performed by a trained clinician after assessment confirms that an internal hemorrhoid is an appropriate treatment target. They do not replace evaluation of unexplained bleeding. The patient should receive an explanation of expected discomfort, aftercare, warning signs and follow-up.

A small elastic band is placed above the dentate line around an internal hemorrhoid. The tissue shrinks and separates over several days, leaving a small healing area. It is commonly used for selected symptomatic internal hemorrhoids and is often considered the most effective office procedure. The patient should know that mild pressure can occur and that delayed bleeding may happen when the banded tissue separates. Heavy bleeding, fever, severe anal pain, difficulty passing urine or feeling acutely unwell needs urgent assessment. Anticoagulant or antiplatelet medicines must be reviewed by the treating clinician; the patient should never stop them independently.

A clinician injects a sclerosant into selected internal hemorrhoidal tissue to cause controlled inflammation and fibrosis, helping reduce bleeding and prolapse. The agent, suitability and monitoring depend on local expertise. Explain the procedure, maintain privacy and observe for the complications described in the procedure protocol.

Infrared energy is applied to selected internal hemorrhoidal tissue to create a small area of coagulation and fixation. It is another office option for appropriately selected disease. Procedure choice is individualised because benefits, discomfort, recurrence and availability differ.

Excisional hemorrhoidectomy may be offered to selected patients with external hemorrhoids, symptomatic combined internal and external disease (often grades III–IV), complications, or internal symptoms that do not respond to or cannot be treated with office procedures. Other operations may be considered for selected internal prolapse. Surgery is planned by a qualified clinician after discussing expected pain, recovery, recurrence, risks and alternatives. Stapled hemorrhoidopexy is not routinely recommended as a first-line surgical treatment in the 2024 ASCRS guideline.

Possible postoperative problems include pain, bleeding, infection, difficulty passing urine, constipation, delayed wound healing, recurrence and, rarely, anal narrowing or continence problems. New severe pain, significant bleeding, fever, inability to pass urine or progressive abdominal symptoms should be reported promptly.

A thrombosed external hemorrhoid usually presents as sudden, marked pain and a firm tender lump at the anal verge. Management is individualised according to timing, pain, examination, medical history and patient preference. Some patients improve with non-operative symptom care; selected patients may benefit from early surgical excision. The 2024 ASCRS guideline describes early excision as an option for selected patients but notes that the evidence is limited. Do not incise, squeeze or attempt to drain a lump outside a clinical setting.

Constipation and pelvic pressure can contribute to symptoms during pregnancy and after delivery. Begin with bowel-habit measures, fibre and fluids appropriate to the patient, and review persistent pain or bleeding with the maternity and medical teams. Medication choice should be checked for pregnancy and breastfeeding safety. Many symptoms improve after childbirth, but severe pain, heavy bleeding, fever or an irreducible prolapse still requires assessment. Procedures are considered only after an individual clinical review.

Nursing care supports accurate assessment, dignity, symptom relief, early recognition of complications and safe follow-up. The nurse works within scope, local protocols and the agreed multidisciplinary plan.

• Confirm patient identity, procedure, consent status and the clinician’s plan using the facility checklist.
• Review allergies, pregnancy possibility, relevant illnesses, bowel preparation orders and prescribed medicines, especially anticoagulants or antiplatelets.
• Explain what the patient may experience, expected aftercare and which symptoms require urgent help; allow questions and protect privacy.
• Prepare equipment, assist the clinician within scope and maintain infection-prevention practice.
• Document baseline pain, bleeding, observations and any concerns communicated to the team.

• Monitor vital signs, level of consciousness, pain and bleeding according to the procedure and recovery plan.
• Provide prescribed analgesia and reassess pain, sedation and ability to mobilise safely.
• Observe for heavy rectal bleeding, fever, worsening pain, faintness, urinary retention, vomiting or other deterioration; escalate promptly.
• Encourage fluids, gradual activity, hygiene and a bowel-softening plan as ordered. Avoid straining and follow the surgeon’s advice about bowel movements and activity.
• After banding, explain that tissue may separate after several days and that a small amount of spotting can occur; heavy bleeding, severe pain, fever or difficulty passing urine is not routine and needs urgent review.
• Before discharge, confirm the patient knows how to take medicines, when to return, whom to contact and how to access follow-up.

Individualise these examples to the patient’s assessment, local nursing language, clinician’s orders and facility policy.

• Choose fibre-containing foods that are available and acceptable, such as beans, peas, vegetables, fruits, millet, whole maize or other whole grains; increase fibre gradually.
• Drink enough fluid for the person’s needs unless a clinician has prescribed fluid restriction.
• Respond to the urge to pass stool, avoid forceful straining and avoid sitting on the toilet for a long time.
• Keep the anal area clean and dry with gentle washing; avoid harsh soaps, strong antiseptics and repeated rubbing.
• Use creams, suppositories, laxatives or pain medicines only according to instructions. Seek advice if symptoms do not improve or recur.
• Attend follow-up and complete any recommended assessment of rectal bleeding. Do not delay review because a previous episode was called “piles.”

Scenario: A 46-year-old patient reports bright-red blood on toilet tissue for several weeks and says a lump sometimes appears while passing stool. The patient has recently developed constipation and is spending a long time straining. They feel otherwise well and ask whether a cream is enough.

Approach: Take a focused bleeding and bowel history, assess observations and associated symptoms, and arrange the examination and further investigation indicated by the clinician. Do not diagnose from the history alone. Explain that improving constipation and avoiding straining may help symptoms, while recurrent bleeding still needs appropriate assessment. Ask about family history, abdominal symptoms, weight change, anaemia symptoms, medicines and prior colorectal evaluation. Give clear return precautions and follow-up.

They lie above the dentate line, where sensation to sharp pain is limited compared with the sensitive skin below the line. Prolapse, thrombosis or another condition can still cause pain.

It prolapses through the anal opening and needs manual reduction. This describes prolapse, not the overall severity of bleeding, pain or other disease.

No. Fissures, inflammatory bowel disease, infection, polyps, cancer and other causes can bleed. Assessment and further investigation are selected according to the patient’s history and findings.

Dietary and behavioural measures, especially improving fibre and fluid intake when suitable, treating constipation and avoiding straining or prolonged toilet sitting.

Heavy bleeding, severe anal pain, fever, difficulty passing urine, nausea or vomiting, or feeling acutely unwell requires urgent assessment.

Think PILES:

• P — Position: internal tissue is above and external tissue below the dentate line.
• I — Inspect: use a focused, consent-based assessment and do not guess from symptoms alone.
• L — Look for red flags: bleeding may have causes other than hemorrhoids.
• E — Ease constipation: gradual fibre, appropriate fluids and less straining are central first-line measures.
• S — Seek review: persistent symptoms, significant bleeding, severe pain, fever or an irreducible prolapse needs clinical care.

Hemorrhoids are common, but rectal bleeding is not a diagnosis. Good care combines a respectful assessment, bowel-habit support, appropriate referral and clear patient education.

1. Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Diseases of the Colon & Rectum. 2024;67(5):614–623. doi:10.1097/DCR.0000000000003276. Read the ASCRS guideline.
2. Ministry of Health, Uganda. Uganda Clinical Guidelines 2023: National Guidelines for Management of Common Health Conditions. Section 6.4.2, Haemorrhoids (Piles) and Anal Fissures. Uganda Ministry of Health guideline portal.

These notes support nursing revision and should be taught alongside supervised clinical practice and current local protocols.

Related nursing notes

Continue with the other Anal rectal conditions in the Diploma in Nursing Direct Curriculum.