Hemorrhoids & Anal Fissures

📋 Key Information Summary

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Haemorrhoids and anal fissures are the most common benign anorectal conditions presenting to Australian GPs, with haemorrhoids affecting up to 40% of adults over 50 years.
Red-flag features requiring urgent colonoscopy or specialist referral include rectal bleeding with iron-deficiency anaemia, change in bowel habit, weight loss, family history of colorectal cancer in a first-degree relative <55 years, and age ≥50 with new-onset bleeding.
History must characterise bleeding (colour, volume, relationship to defecation), pain (acute vs chronic, relationship to defecation), prolapse, and bowel habit to distinguish haemorrhoids from fissure and exclude proximal pathology.
Perianal inspection and digital rectal examination are essential first-line; proctoscopy/anoscopy should be performed in the primary care setting where trained, with flexible sigmoidoscopy or colonoscopy for red-flag evaluation.
Conservative management is first-line for both conditions: dietary fibre supplementation (psyllium 3.5 g BD), adequate fluids (≥1.5 L/day), sitz baths (warm water 10–15 min TDS), topical agents, and toilet habit modification.
Topical GTN (0.4% rectal ointment, Rectogesic®) or topical calcium-channel blocker (diltiazem 2% ointment) are first-line pharmacological therapy for anal fissures, achieving healing in 60–70% of cases.
Haemorrhoid-specific topical agents containing corticosteroids should be limited to 5–7 days to avoid perianal skin atrophy and contact dermatitis.
Rubber band ligation (RBL) is the most common office-based procedure for grade II–III haemorrhoids, with success rates of 70–80% per session; it is PBS-indicated for specialist use.
Referral to a colorectal surgeon is indicated for: grade III–IV haemorrhoids failing conservative therapy, recurrent or chronic fissures not healing after 8 weeks of optimal medical therapy, and suspected fistula-in-ano or abscess.
Aboriginal and Torres Strait Islander peoples experience higher rates of constipation and anorectal disease due to healthcare access barriers; culturally safe education and accessible primary care pathways are essential.
Special populations require modified management: avoid systemic decongestants in pregnancy, cautious corticosteroid use in immunocompromised patients, and dose-adjustment considerations in the elderly with polypharmacy.

Introduction & Australian Epidemiology

Haemorrhoids and anal fissures represent the two most prevalent benign anorectal conditions encountered in Australian general practice and gastroenterology clinics. Together, they account for the vast majority of perianal complaints and rectal bleeding presentations in adults. Despite their benign nature, these conditions significantly impair quality of life, cause considerable anxiety (particularly regarding rectal bleeding), and impose a substantial burden on the Australian healthcare system.

Haemorrhoids — vascular cushions of the anal canal that become symptomatic when engorged, prolapsing, or thrombosed — affect an estimated 4.4% of the general population globally, with Australian studies suggesting a prevalence of 25–40% in adults over 50 years of age. The true prevalence is likely higher, as many patients self-manage without seeking medical attention. Risk factors include constipation, straining, low-fibre diets, prolonged sitting, pregnancy, obesity, and increasing age. Haemorrhoids are classified by the Goligher system: grade I (no prolapse), grade II (prolapse that reduces spontaneously), grade III (prolapse requiring manual reduction), and grade IV (irreducible prolapse).

Anal fissures — linear ulcers in the squamous epithelium of the anal canal, typically at the posterior midline — are the most common cause of anal pain and bright red rectal bleeding in young adults. Peak incidence occurs between 15 and 40 years, with a slight male predominance. Acute fissures (present for <6 weeks) heal spontaneously in approximately 50–60% of cases with conservative measures. Chronic fissures (≥6 weeks duration) are characterised by exposed internal sphincter fibres, sentinel skin tags, and hypertrophied anal papillae, and are less likely to resolve without targeted intervention.

The Australian Institute of Health and Welfare (AIHW) reports that anorectal conditions account for over 500,000 GP consultations annually. Rectal bleeding, the cardinal symptom of both conditions, must be carefully evaluated, as the Royal Australian College of General Practitioners (RACGP) red-book guidelines recommend colonoscopic evaluation for any patient aged ≥50 with new-onset rectal bleeding to exclude colorectal malignancy.

Pathophysiology

Haemorrhoids

The anal canal contains three principal haemorrhoidal cushions (left lateral, right anterior, and right posterior) composed of arteriovenous channels, smooth muscle (Treitz's muscle), and connective tissue. These cushions contribute to 15–20% of resting anal continence. Symptomatic haemorrhoids develop when the vascular plexus becomes engorged and the supporting connective tissue deteriorates, leading to downward displacement and prolapse. The primary mechanisms include:

Sliding anal lining theory: Degeneration of Treitz's muscle and submucosal connective tissue allows downward displacement of the haemorrhoidal cushions.
Hyperperfusion theory: Elevated anal canal pressures and increased arterial inflow to the haemorrhoidal plexus contribute to engorgement.
Internal sphincter dysfunction: Raised resting anal pressures are observed in many patients, though the relationship is complex.

External haemorrhoids are covered by squamous epithelium and are innervated by somatic nerve fibres; thrombosis of external haemorrhoids causes acute severe perianal pain. Internal haemorrhoids are covered by columnar epithelium and are insensate; they typically present with painless bright red rectal bleeding.

Anal Fissures

Acute anal fissures most commonly result from mechanical trauma during passage of hard stool. The posterior midline is affected in approximately 80–90% of cases due to relatively poor vascular supply at this site. The pathophysiology of chronic fissures involves a self-perpetuating cycle:

Mucosal trauma leads to pain → internal sphincter spasm → raised anal resting pressure.
Elevated resting pressure reduces mucosal blood flow (ischaemia) at the posterior commissure.
Ischaemia impairs healing → chronic ulceration → further spasm → perpetuation of the cycle.

This pathophysiological understanding underpins pharmacological treatments targeting sphincter relaxation (GTN, diltiazem, botulinum toxin) to restore mucosal blood flow. Non-healing fissures (anterior midline, multiple, off-midline, or atypical) should raise suspicion for Crohn's disease, HIV, tuberculosis, syphilis, or malignancy.

Initial Assessment

History

A thorough history is the cornerstone of the initial assessment. The presenting complaint should be carefully characterised to distinguish haemorrhoids from fissures and to exclude more serious proximal pathology.

Symptom Domain	Haemorrhoids	Anal Fissure
Bleeding	Painless, bright red, on wiping or dripping into pan; coats the stool surface	Small amount of bright red blood on toilet paper or surface of stool
Pain	Usually absent unless thrombosed (acute severe perianal pain) or strangulated	Sharp, tearing pain during defecation; may persist for hours post-defecation
Prolapse	Lump at anal verge, reducible (grade II/III) or irreducible (grade IV)	Sentinel skin tag at anal verge; no true prolapse
Itching	Perianal pruritus common with prolapsing or mucoid discharge	Less common
Discharge	Mucoid discharge with internal haemorrhoids	Rarely significant

Red-Flag Features — Exclude Proximal Pathology

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Urgent colonoscopy or specialist referral required if any of the following are present:

Age ≥50 years with new-onset rectal bleeding (colorectal cancer screening mandate per RACGP Red Book)
Iron-deficiency anaemia (ferritin <30 µg/L, low MCV) with rectal bleeding
Change in bowel habit (persistent diarrhoea or constipation >6 weeks)
Unintentional weight loss (>5% body weight in 6 months)
Family history of colorectal cancer in first-degree relative <55 years
Dark or mixed rectal bleeding (melaena or maroon stool suggesting proximal source)
Palpable abdominal or rectal mass
New-onset symptoms in patients with inflammatory bowel disease, hereditary polyposis syndromes, or prior pelvic radiotherapy

Physical Examination

A systematic examination of the anorectal region should be performed with the patient in the left lateral position:

Inspection: Gently part the buttocks to examine the perianal skin. Look for external haemorrhoids (bluish-purple swellings), thrombosed external haemorrhoid (tender, firm, blue nodule), sentinel skin tag (fissure), excoriation (pruritus), abscess (erythema, swelling, fluctuance), fistula opening, and any suspicious lesions.
Digital rectal examination (DRE): Assess resting and squeeze anal tone, palpate for masses, tenderness, and induration. The posterior midline may be exquisitely tender in acute fissures (use gentle technique with adequate lubrication).
Proctoscopy/Anoscopy: Essential to visualise internal haemorrhoids and the anal canal mucosa. Should be performed in primary care where training and equipment allow. Reveals the triad of chronic fissure: visible internal sphincter fibres, sentinel tag, and hypertrophied anal papilla.
Flexible sigmoidoscopy/Colonoscopy: Required when red-flag features are present, or when the diagnosis is uncertain after initial assessment.

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Clinical pearl: Never attribute rectal bleeding to haemorrhoids without a thorough evaluation. Up to 10% of patients presenting with "haemorrhoidal" bleeding are found to have another significant pathology on endoscopy. The decision to investigate beyond clinical assessment should follow RACGP red-book principles, particularly in patients ≥50 years.

Goligher Classification of Internal Haemorrhoids

Grade I

No Prolapse

Haemorrhoids remain within the anal canal; may bleed but do not prolapse.

Management: Conservative + topical therapy

Grade II

Prolapse with Spontaneous Reduction

Haemorrhoids prolapse during defecation but reduce spontaneously.

Management: Conservative → Rubber band ligation if persistent

Grade III

Prolapse Requiring Manual Reduction

Prolapse requires digital reduction after defecation.

Management: Rubber band ligation or surgical referral

Grade IV

Irreducible Prolapse

Permanently prolapsed haemorrhoids that cannot be reduced; risk of strangulation and thrombosis.

Management: Surgical referral — haemorrhoidectomy

Investigations

The investigation strategy depends on clinical presentation, patient age, and presence of red-flag features.

Essential Full blood count (FBC) Assess for iron-deficiency anaemia (low Hb, low MCV, low ferritin). All patients with recurrent or chronic rectal bleeding. MBS Item 65070.

Essential Iron studies Ferritin, serum iron, transferrin, transferrin saturation. Low ferritin (<30 µg/L) in setting of bleeding warrants colonoscopy. MBS Item 65145.

Available Proctoscopy / Anoscopy Primary care procedure where trained; visualises internal haemorrhoids and anal canal pathology. MBS Item 30230 (proctoscopy).

Available Flexible sigmoidoscopy First-line endoscopic evaluation for patients <50 with red-flag features or diagnostic uncertainty. Available at most public hospitals and some private GI practices. MBS Item 32222.

Referral Colonoscopy Required for: age ≥50 with new bleeding, iron-deficiency anaemia, change in bowel habit, family history of CRC <55 years. Public hospital wait: 30–90 days (Category 2). MBS Item 32224.

Specialist Endoanal ultrasound For assessment of sphincter integrity (recurrent fissures, suspected intersphincteric abscess). Limited availability — tertiary centres.

Available Faecal occult blood test (FOBt) iFOBT (immunochemical) used in the National Bowel Cancer Screening Program (NBCSP) from age 45. Should NOT replace endoscopic evaluation when symptomatic bleeding is present.

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When to investigate: In young patients (<45 years) with a typical history of haemorrhoids or fissure, no red flags, normal examination, and response to conservative therapy, investigations beyond FBC/iron studies are not routinely required. However, any atypical feature warrants lower GI endoscopy.

Risk Stratification & Severity Assessment

Acute Thrombosed External Haemorrhoid

Thrombosis of an external haemorrhoid typically presents within the first 48–72 hours as a painful, firm, blue-purple perianal lump. Risk stratification determines management pathway:

Low Severity

Small Thrombosis (<1 cm), >72 hrs

Resolving thrombus with mild discomfort; already recanalising.

Setting: GP — conservative management, sitz baths, analgesia

Moderate Severity

Moderate Thrombosis (1–2 cm), 24–72 hrs

Significant pain, visible tense nodule, impacting function.

Setting: GP/ED — consider excision within 72 hrs or conservative + strong analgesia

High Severity

Circumferential Thrombosis or Strangulation

Multiple thrombosed components, skin necrosis risk, excruciating pain, may have systemic features.

Setting: ED — urgent surgical review for excision under local or general anaesthesia

Anal Fissure — Acute vs Chronic

Feature	Acute Fissure (<6 weeks)	Chronic Fissure (≥6 weeks)
Appearance	Clean, linear mucosal tear	Deep ulcer with visible internal sphincter fibres, sentinel tag, hypertrophied papilla
Pain pattern	Brief, during defecation only	Severe, lasting hours post-defecation; may be constant
Spontaneous healing	50–60% within 6–8 weeks	Rare without targeted intervention
First-line Rx	Conservative measures	Topical GTN or diltiazem ± botulinum toxin

Conservative Management

Conservative management is the first-line approach for all grades of haemorrhoids and acute anal fissures. It should be trialled for a minimum of 4–6 weeks before escalation. The pillars of conservative therapy are:

1. Dietary Fibre Supplementation

Increased dietary fibre softens stool, reduces straining, and decreases intra-abdominal pressure. A systematic review (Cochrane, 2023) demonstrated that fibre supplementation significantly reduces bleeding and overall symptom scores in haemorrhoid patients. Target fibre intake: 25–30 g/day.

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Psyllium Husk (Ispaghula)

Metamucil® · Fybogel® · Bulk-forming laxative

Adult dose 3.5 g (1 sachet) PO BD, mixed in 250 mL water, taken with meals

Paediatric dose 6–12 years: 1.75–3.5 g PO BD; <6 years: seek specialist advice

Duration Ongoing — long-term use is safe and recommended

Renal adjustment None required

Key counselling Must be taken with adequate fluid (≥200 mL per dose); onset 12–72 hours. Bulk-forming — not a stimulant laxative.

PBS status ✔ PBS General Benefit

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Macrogol 3350 (Polyethylene Glycol)

Movicol® · Osmotic laxative

Adult dose 1–3 sachets PO daily; adjust to produce soft, formed stool

Paediatric dose 1–6 years: ½–1 sachet daily; 6–12 years: 1–2 sachets daily

Duration As needed for ongoing constipation management

Renal adjustment Use with caution in severe renal impairment (eGFR <30) — risk of electrolyte disturbance

PBS status ✘ Not PBS-listed for this indication (OTC; PBS-listed for faecal impaction in children)

2. Adequate Fluid Intake

Patients should aim for ≥1.5 L (approximately 8 glasses) of non-caffeinated fluid daily. Adequate hydration is essential for the efficacy of fibre supplementation; without sufficient water, bulk-forming agents can paradoxically worsen constipation.

3. Sitz Baths

Warm water sitz baths (plain water, 37–40°C, for 10–15 minutes, 2–3 times daily and after each bowel movement) provide analgesic and muscle-relaxant effects. They are particularly beneficial for:

Acute anal fissures — promote internal sphincter relaxation and improve mucosal blood flow
Thrombosed external haemorrhoids — reduce pain and oedema
Post-procedural care (e.g., after rubber band ligation or haemorrhoidectomy)

There is no evidence that adding antiseptics, salt, or other additives improves outcomes over plain warm water.

4. Topical Agents

For Haemorrhoids

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Hydrocortisone + Cinchocaine

Proctosedyl® · Rectal cream/ointment

Adult dose Apply to affected area BD and after each bowel movement (cream externally, ointment with applicator intrarectally)

Duration Maximum 5–7 days — prolonged corticosteroid use causes perianal skin atrophy, striae, and contact dermatitis

Renal/hepatic Minimal systemic absorption at recommended duration

PBS status ✔ PBS General Benefit

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Zinc Oxide + Bismuth Subgallate

Anusol® · Rectal cream/suppositories · Barrier + mild astringent

Adult dose Cream applied BD or suppository inserted PR BD and after defecation

Duration Up to 7 days; may be used longer if corticosteroid-free (Anusol plain formulation)

PBS status ⚠ OTC — Not PBS-listed

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Important: Combination haemorrhoidal preparations containing corticosteroids (e.g., Proctosedyl® HC, Scheriproct®) should be limited to 5–7 days maximum. Prolonged use leads to perianal skin atrophy, telangiectasia, and contact sensitisation. If symptoms persist beyond 7 days, review the diagnosis and consider escalation.

For Anal Fissures — Sphincter Relaxants

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Glyceryl Trinitrate (GTN) 0.4%

Rectogesic® · Rectal ointment · Nitric oxide donor

Adult dose 2.5 cm ribbon of ointment applied intra-anally BD (every 12 hours) with finger (gloved), gently massaged into the anal canal

Duration 8 weeks (minimum); reassess at 8 weeks

Key counselling Headache is the most common side effect (30–50% of patients); occurs within 30 min of application. Advise paracetamol 1 g PO pre-dose; start with half dose for first 3 days. Avoid concurrent PDE-5 inhibitors (sildenafil, tadalafil).

PBS status ✔ PBS General Benefit

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Diltiazem 2% Ointment

Compounded · Calcium-channel blocker (topical)

Adult dose 2.5 cm ribbon applied intra-anally BD; use a gloved finger or applicator

Duration 8 weeks; may continue up to 12 weeks if healing progressing

Key counselling Lower headache rate than GTN (~10%). Compounded formulation — not commercially available in Australia. Requires compounding pharmacy prescription. Less systemic absorption than GTN.

PBS status ⚠ Authority Required (compound)

5. Toilet Habit Modification

Patient education on appropriate toilet habits is a critical but often neglected component of management:

Avoid prolonged sitting on the toilet: Limit toilet time to <5 minutes. Do not use mobile phones or read on the toilet — this leads to prolonged straining and venous engorgement of haemorrhoidal cushions.
Avoid straining: Straining increases intra-abdominal pressure and worsens haemorrhoidal engorgement. Respond to the urge to defecate promptly (the gastrocolic reflex), and do not delay.
Optimal positioning: A squatting position or use of a footstool to elevate the knees above the hips straightens the anorectal angle and facilitates easier defecation with less straining.
Avoid forceful wiping: Use moist toilet paper, bidet, or gentle dabbing. Rough wiping exacerbates both fissures and external haemorrhoidal irritation.

6. Symptomatic Analgesia

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Paracetamol

Panadol® · First-line analgesic

Adult dose 1 g PO QID PRN (max 4 g/24 hrs; 2 g/24 hrs if hepatic impairment)

PBS status ✔ PBS General Benefit

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Ibuprofen

Nurofen® · NSAID — anti-inflammatory + analgesic

Adult dose 200–400 mg PO TDS with food (max 1.2 g/24 hrs OTC)

Duration Short course only (3–5 days); avoid in renal impairment, GI bleeding risk

PBS status ✔ PBS General Benefit

Directed / Pathogen-Specific Therapy

This section covers second-line and procedural interventions for haemorrhoids and fissures that persist despite optimal conservative management.

Second-Line Pharmacological Therapy for Anal Fissures

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Botulinum Toxin A (Botox®)

Botox® · Xeomin® · Neurotoxin — chemical sphincterotomy

Adult dose 20–50 units injected into the internal anal sphincter at 2–4 sites (bilateral, at the fissure edges); performed under local anaesthesia in specialist rooms

Efficacy Healing rates 60–80% at 8 weeks; recurrence 15–20% at 12 months

Key counselling Transient faecal incontinence (flatus) in 5–15% — usually resolves within 2–4 weeks. Avoid in patients with significant baseline sphincter weakness.

PBS status ✘ Not PBS-listed for anal fissure (Authority Required for other indications; cost ~0–400 out-of-pocket)

Procedural Interventions for Haemorrhoids

Procedure	Indication	Setting	Success Rate	Notes
Rubber Band Ligation (RBL)	Grade II–III haemorrhoids	Outpatient / GI specialist rooms	70–80% per session; up to 3 sessions at 4–6 week intervals	Most common office procedure. Band placed 2 cm above the dentate line. Mild discomfort, minor bleeding expected. Rare: severe bleeding, pelvic sepsis (present with fever + urinary retention — medical emergency)
Injection Sclerotherapy	Grade I–II haemorrhoids	Outpatient	70–80% for grade I; less effective for grade III	Phenol-in-almond-oil injected into submucosa. Lower recurrence rates than RBL for grade I. Useful in anticoagulated patients.
Haemorrhoidectomy (excisional)	Grade III–IV haemorrhoids, recurrent disease	Hospital — day case or overnight	>95% cure rate; lowest recurrence	Gold standard for advanced haemorrhoids. Open (Milligan-Morgan) or closed (Ferguson) technique. Post-operative pain is the main morbidity; 2–4 weeks recovery.
Haemorrhoidal Artery Ligation (HAL/THD)	Grade II–III haemorrhoids	Hospital — day case	85–90%	Doppler-guided ligation of haemorrhoidal arteries ± mucopexy. Less post-operative pain than excisional. Increasing availability in Australian tertiary centres.
Stapled Haemorrhoidopexy	Grade III haemorrhoids (circumferential)	Hospital	80–90%	Circular stapler resects prolapsing tissue and restores anatomy. Less pain than excisional but higher recurrence rate. Rare but serious: rectal perforation, retroperitoneal sepsis.

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Pelvic sepsis after rubber band ligation: Although rare (<1:1000), pelvic sepsis following RBL is a life-threatening emergency presenting with fever, urinary retention, severe perianal pain, and signs of systemic sepsis within 3–7 days post-procedure. Requires urgent surgical assessment and broad-spectrum IV antibiotics (as per eTG Antibiotic guidelines).

Surgical Interventions for Anal Fissures

Procedure	Indication	Success Rate	Key Risks
Lateral Internal Sphincterotomy (LIS)	Chronic fissure failing ≥8 weeks optimal medical therapy	90–95% healing; gold standard surgical treatment	Faecal incontinence (flatus 5–10%, solid stool <2%); most cases are minor and transient. Risk higher in women (thinner sphincter) and elderly.
Advancement Flap	Chronic fissure with risk factors for incontinence (multiparous women, elderly, pre-existing sphincter weakness)	80–90%	Sphincter-sparing option; avoids sphincterotomy risk. Longer operative time. Limited to specialist colorectal surgeons.

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Atypical fissures — investigate further: Fissures that are off-midline (lateral), multiple, deep, or non-healing despite optimal therapy should prompt evaluation for Crohn's disease (ileocolonoscopy), HIV testing, tuberculosis, or anal malignancy. Do not proceed to sphincterotomy without excluding underlying systemic disease.

Monitoring

Follow-Up Schedule

2 weeks

Telephone or telehealth review for symptom progress with conservative therapy. Assess compliance with fibre, fluids, sitz baths, and toilet habit modification. Re-evaluate bleeding — any new red flags?

6 weeks

In-practice review. For fissures: reassess pain and healing. If no improvement with GTN/diltiazem, consider switching to diltiazem (if started on GTN and headache-limited) or initiating botulinum toxin discussion. For haemorrhoids: assess response to conservative ± topical therapy. Consider referral for grade II–III persistent symptoms.

8–12 weeks

Definitive review. Chronic fissure: if not healing after 8 weeks of optimal topical therapy, refer to colorectal surgery for consideration of botulinum toxin or LIS. Haemorrhoids: persistent grade III–IV symptoms require surgical referral. Document iron studies and FBC if bleeding has been chronic.

3–6 months post-procedure

Post-intervention follow-up. After RBL: check for recurrence and need for repeat sessions (up to 3 sessions at 4–6 weekly intervals). After LIS: assess healing and continence. After haemorrhoidectomy: wound healing, recurrence, and symptom resolution.

Monitoring Parameters

Parameter	When	Action
FBC + iron studies	Baseline if recurrent bleeding; repeat at 3 months	If Hb falling or ferritin low → urgent colonoscopy regardless of suspected haemorrhoidal source
Symptom diary	Throughout treatment	Bleeding episodes, pain severity (VAS 0–10), bowel frequency, stool consistency (Bristol chart)
Anal examination	6–8 weeks post-topical therapy; post-procedure	Fissure healing, haemorrhoid grade progression, exclude new pathology
Continence assessment	Post-LIS or post-haemorrhoidectomy	Wexner incontinence score; physiotherapy referral if faecal incontinence develops

Special Populations

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Pregnancy

Prevalence: Haemorrhoids affect 25–35% of pregnant women, most commonly in the third trimester and postpartum period, due to progesterone-mediated venous relaxation, increased pelvic blood volume, and constipation.
Conservative management is first-line: Dietary fibre, fluids, sitz baths, and toilet habit modification are safe and should be initiated early.
Safe medications: Psyllium (B category), paracetamol, hydrocortisone-based rectal preparations (short course ≤5 days). Lactulose 15 mL BD is a safe osmotic laxative in pregnancy.
Avoid: GTN 0.4% ointment (hypotension risk; not recommended in pregnancy). Diltiazem topical — limited safety data; avoid unless specialist-directed. NSAIDs (especially in the third trimester — risk of premature ductus arteriosus closure). Stimulant laxatives (senna, bisacodyl) for prolonged use.
Procedures: Rubber band ligation should be deferred until postpartum. Acutely thrombosed external haemorrhoids may be excised under local anaesthesia if severely symptomatic.
Postpartum: Most pregnancy-related haemorrhoids improve significantly within 6–8 weeks post-delivery. Persistent symptoms should be managed as per standard guidelines.

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Paediatrics

Haemorrhoids are rare in children. Rectal bleeding in children is more commonly due to anal fissure, Meckel's diverticulum, intussusception, juvenile polyps, or inflammatory bowel disease.
Anal fissures are the most common cause of rectal bleeding in infancy and childhood, almost always related to constipation.
Treatment: Address underlying constipation with dietary fibre, adequate fluids, and osmotic laxatives (macrogol 3350 — first-line in paediatrics). Topical GTN and diltiazem are not recommended in children. Barrier cream (zinc oxide, petroleum jelly) applied perianally before defecation reduces pain.
Red flags in children: Chronic diarrhoea, bloody diarrhoea, weight loss, perianal fistula or skin tags → refer for investigation of inflammatory bowel disease. Consider child protection evaluation if perianal injury is unexplained.

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Elderly (≥65 years)

Higher prevalence of haemorrhoids due to cumulative connective tissue deterioration, chronic constipation, polypharmacy (anticholinergics, opioids, calcium-channel blockers, iron supplements).
Increased colonoscopy threshold: All patients ≥50 with new rectal bleeding should undergo colonoscopy per RACGP red-book; lower threshold in elderly given higher CRC incidence.
Medication considerations: GTN ointment — increased hypotension and headache risk in elderly; consider diltiazem 2% as preferred first-line topical for fissures. Review polypharmacy for constipating agents.
Surgical caution: Lateral internal sphincterotomy carries higher risk of faecal incontinence in elderly patients due to pre-existing sphincter weakness. Advancement flap may be preferred. Assess baseline continence before any procedural intervention.
Bleeding assessment: Iron-deficiency anaemia in the elderly should always be investigated for colorectal malignancy, even in the presence of known haemorrhoids.

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Renal Impairment

Constipation is more prevalent in CKD due to phosphate binders (calcium carbonate, sevelamer), iron supplements, and reduced fluid intake (in patients on fluid restriction).
Safe laxatives: Psyllium, lactulose, macrogol 3350 (monitor electrolytes in severe CKD, eGFR <30). Avoid magnesium-containing laxatives in severe renal impairment (hypermagnesaemia risk).
Topical GTN/diltiazem: No dose adjustment required; minimal systemic absorption. Safe in renal impairment.
Avoid ibuprofen — risk of AKI. Paracetamol preferred for analgesia (no dose adjustment unless concurrent hepatic disease).

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Hepatic Impairment

Portal hypertension: Rectal varices may mimic haemorrhoids in patients with portal hypertension (cirrhosis). Differentiation is critical — biopsy or injection of haemorrhoids in portal hypertensive patients carries life-threatening haemorrhage risk.
Topical agents: GTN and diltiazem — no dose adjustment for topical use. Short-course hydrocortisone rectal preparations are safe.
Paracetamol: Reduce maximum dose to 2 g/24 hrs in significant hepatic impairment.
Procedural risk: Coagulopathy must be corrected before any invasive procedure. Rubber band ligation and surgery in patients with cirrhosis and coagulopathy carry elevated bleeding risk — MDT discussion required.

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Immunocompromised

HIV/AIDS: Atypical and non-healing fissures are common. Consider CMV, HSV, and syphilis as causes of perianal ulceration. CD4 count determines investigation urgency.
Transplant recipients and immunosuppressed patients: Poor wound healing, increased infection risk with procedural interventions. Sphincterotomy and haemorrhoidectomy should be avoided where possible; medical management preferred. If surgery is required, ensure optimisation of immunosuppression and prophylactic antibiotics.
Corticosteroid caution: Perianal corticosteroid preparations should be used at the lowest effective dose and shortest duration in immunocompromised patients due to increased risk of perianal fungal superinfection.

Referral for Procedures

Referral to a gastroenterologist or colorectal surgeon is indicated when persistent symptomatic haemorrhoids or fissures fail optimal conservative therapy. The decision to refer should consider symptom severity, impact on quality of life, response to medical treatment, and patient preference.

Indications for Gastroenterology Referral

Rectal bleeding requiring colonoscopic evaluation (age ≥50, iron-deficiency anaemia, change in bowel habit, family history CRC)
Internal haemorrhoids amenable to rubber band ligation or injection sclerotherapy
Diagnostic uncertainty — atypical fissures or lesions requiring biopsy
Suspected inflammatory bowel disease presenting as perianal disease

Indications for Colorectal Surgery Referral

Grade III–IV haemorrhoids failing conservative and office-based treatments
Thrombosed external haemorrhoid presenting >72 hours or with extensive circumferential involvement
Chronic anal fissure (>8 weeks) failing topical GTN or diltiazem therapy
Recurrent fissures after initial healing
Suspected fistula-in-ano, intersphincteric or perianal abscess
Atypical fissures (off-midline, multiple, suspicious morphology) requiring biopsy
Patients with significant faecal incontinence symptoms who may benefit from advancement flap rather than sphincterotomy

Referral Priority (Recommended Timeframes)

Routine

Chronic Haemorrhoids / Fissures

Symptomatic, stable, no red flags. Managed conservatively for ≥6 weeks. Awaiting outpatient assessment.

Target: within 30 days (Category 3)

Semi-urgent

Failed Conservative Therapy

Persistent symptoms after 8 weeks of optimal management; significant impact on quality of life; grade III haemorrhoids; chronic fissure.

Target: within 30 days (Category 2)

Urgent

Complications / Red Flags

Strangulated grade IV haemorrhoid, extensive thrombosis, suspected pelvic sepsis, iron-deficiency anaemia, new rectal bleeding age ≥50.

Target: within 7 days (Category 1)

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Telehealth triaging: Many Australian colorectal surgery practices offer virtual consultation for triaging referral urgency. GPs in rural and remote areas should utilise Healthdirect Video Call or state-based telehealth platforms to expedite specialist assessment and reduce patient travel burden.

Preparing the Patient for Referral

1

Document Conservative Measures

Record compliance with fibre supplementation, fluid intake, sitz baths, topical agents, and toilet habit modification — including doses, duration, and response.

2

Investigations Pre-referral

FBC and iron studies (to exclude/confirm anaemia). Arrange colonoscopy if red-flag features are present (do not wait for specialist appointment). Proctoscopy findings if available.

3

Examination Findings

Document DRE findings, external appearance (fissure, haemorrhoid grade, skin tags), and any concerns regarding atypical features.

4

Patient Counselling

Explain the procedure options (RBL, sclerotherapy, LIS, haemorrhoidectomy) with their benefits and risks. Set expectations for post-procedural recovery. Address patient anxiety regarding bleeding and surgical intervention.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander peoples experience a significantly higher burden of gastrointestinal disease, including anorectal conditions, compared with the non-Indigenous Australian population. The AIHW reports that Indigenous Australians have higher rates of constipation, haemorrhoidal disease, and perianal sepsis, often presenting at a later stage due to barriers in healthcare access. Culturally safe, community-centred approaches are essential for effective management.

Healthcare Access

Many Aboriginal and Torres Strait Islander people live in remote or very remote areas where access to GPs, let alone gastroenterologists or colorectal surgeons, is limited. Royal Flying Doctor Service (RFDS) and visiting specialist clinics are the primary means of accessing procedural care. Telehealth should be utilised to bridge the gap where possible.

Cultural Safety

Anorectal examination and discussion of perianal symptoms can be a source of significant cultural discomfort and embarrassment. Clinicians should ensure same-sex health practitioners are available for examination where possible. Health workers and liaison officers should be involved in consultations to facilitate trust and understanding. Use plain language and visual aids when explaining diagnoses and treatments.

Constipation & Diet

Remote communities often face food insecurity, with limited access to fresh fruit, vegetables, and fibre-rich foods. "Discretionary" foods high in fat and low in fibre are frequently more accessible and affordable. Community nutrition programs (e.g., Good Tucker) and health promotion through Aboriginal Community Controlled Health Organisations (ACCHOs) are vital for addressing the fibre gap. Psyllium supplementation should be provided through community pharmacies or health centres where dietary intervention alone is insufficient.

Bowel Cancer Screening

Aboriginal and Torres Strait Islander peoples have lower participation rates in the National Bowel Cancer Screening Program (NBCSP) (~27% vs ~43% non-Indigenous). Higher colorectal cancer incidence, later-stage diagnosis, and poorer survival rates are well documented. Proactive opportunistic screening and GP-facilitated iFOBT completion should be integrated into routine healthcare encounters for patients aged 45–74, particularly when presenting with rectal bleeding.

Traditional Medicine

Some patients may use traditional bush medicines alongside Western treatments. Clinicians should enquire about traditional medicine use in a respectful, non-judgemental manner. Ensure there are no harmful interactions with prescribed medications (e.g., GTN ointment and concurrent herbal vasodilators). Integrative approaches that respect cultural practices while ensuring safety are preferred.

Remote Pharmacy Access

PBS-listed medications may be less accessible in remote communities. The Section 100 (S100) Aboriginal Health Worker supply program and Remote Area Aboriginal Health Services can provide essential medications, including topical agents and laxatives. Ensure prescriptions are filled through accessible channels, and consider multi-dose dispensing where adherence is a concern.

📚 References

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