Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. These vascular cushions are a normal anatomical structure of the anal canal, and their existence does not necessarily indicate haemorrhoidal disease. Haemorrhoidal disease occurs when there are symptoms such as bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Rectal bleeding is the most common manifestation of haemorrhoidal disease. The bleeding tends to be bright red in nature and occurs on the toilet tissue or drips into the toilet bowl. Haemorrhoids can occur internally, externally, or can be mixed (internal and external components). If prolapse occurs, a perianal mass may be evident with defecation. Haemorrhoids are traditionally graded into four degrees. First degree (or grade): The haemorrhoids bleed with defecation but do not prolapse. First-degree haemorrhoids associated with mild symptoms are usually secondary to leakage of blood from mildly inflamed, thin-walled veins or arterioles. Conservative management with dietary manipulation (addition of fibre) and attention to anal hygiene is often adequate. Recurrent rectal bleeding may require ablation of the vessels with non-surgical ablative techniques, such as injection sclerotherapy, infrared coagulation, or rubber band ligation. Infrared coagulation is used infrequently in clinical practice in the UK today, whereas rubber band ligation and injection sclerotherapy are commonly used. Second degree: The haemorrhoids prolapse with defecation and reduce spontaneously. Second-degree haemorrhoids can be treated with rubber band ligation or other non-surgical ablative techniques. ...read more. Third degree: The haemorrhoids prolapse and require manual reduction. In third-degree haemorrhoids, where there is significant destruction of the suspensory ligaments, relocation and fixation of the mucosa to the underlying muscular wall is generally necessary. Prolapse can be treated with rubber band ligation initially, but haemorrhoidectomy may be required, especially if prolapse is seen in more than one position. Fourth degree: The haemorrhoids prolapse and cannot be reduced. If treatment is necessary, fourth-degree haemorrhoids require haemorrhoidectomy. Haemorrhoids are thought to be associated with chronic constipation, straining to defecate, pregnancy, and low dietary fibre. Frequency, duration, and severity of haemorrhoidal symptoms, such as bleeding, prolapse, or both, determine the type of treatment. Often, absent or episodic symptoms do not require treatment, and the presence of symptoms does not mandate invasive treatment. Some people decline treatment if they can be appropriately reassured that there is no other, more serious, reason for their symptoms.

Latest guidelines