Questionnaire/history:

Bright red, painless rectal bleeding?

Anal itching or irritation?

Feeling of rectal fullness, discomfort or of incomplete evacuation?

Soiling due to mucus discharge or impaired continence?

Pain (if piles strangulated or thrombosed)?

Red flags for rectal or bowel cancer?

Past medical history?

Current medication?

Known drug allergies?

Examination:

Maybe normal if non-prolapsed internal haemorrhoid

External haemorrhoids (originated below the dentate line covered by modified squamous epithelium, can be itchy and painful)?

Purplish, oedematous, tense, tender, subcutaneous perianal mass (acutely thrombosed external haemorrhoid)?

Internal haemorrhoids (arise above the dentate line covered by columnar epithelium, which have no pain fibres and so are NOT sensitive to touch, temperature or pain (unless they become strangulated)?

First degree (grade 1): project into the lumen of the anal canal but do not prolapse

Second degree (grade 2): protrude beyond the anal canal on straining but spontaneously reduce when straining is stopped

Third degree (grade 3): protrude outside the anal canal and reduce fully on manual pressure

Fourth degree (grade 4): protrude outside the anal canal and cannot be reduced

Management:

Advised:

Adequate fluid intake and increased fibre diet to maintain soft, well-lubricated stools and to prevent intestinal obstruction

Importance of correct anal hygiene with keeping the anal region clean and drying

Considering cleansing with moistened towelettes or baby wipes

No 'stool withholding' and undue straining during bowel movement

Paracetamol if required

Topical haemorrhoid preparations

Urgent referral if:

Extremely painful, acutely thrombosed external piles who present within 72 hours of onset

Internal haemorrhoids that have prolapsed and become swollen, incarcerated and thrombosed

Resource(s):

CKS 2021