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Gastrointestinal & Hepatic System

Haemorrhoids and Anal Fissures

Haemorrhoids are swollen, engorged venous cushions in the anorectal region (internal or external). Anal fissures are linear tears or cracks in the lining of the distal anal canal. Both are common causes of rectal bleeding and anal pain.

Also known as: Piles, Anal Tear

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Referral and warning signs

When to refer

Refer to specialist (Colorectal Surgeon/Gastroenterologist) if: Severe or persistent symptoms despite conservative management. Need for office-based procedures (banding, sclerotherapy) or surgery (haemorrhoidectomy, sphincterotomy). Thrombosed haemorrhoid requiring excision. Chronic anal fissure refractory to medical therapy. Diagnostic uncertainty / suspicion of underlying pathology (IBD, malignancy).

Red flags

  • Significant rectal bleeding (more than streaks on paper/stool)
  • Change in bowel habit
  • Unintentional weight loss
  • Severe persistent pain
  • Signs suggesting malignancy on DRE/anoscopy
  • Associated systemic symptoms (fever)
  • Failure to heal fissure after 6-8 weeks of medical therapy

Signs and symptoms

  • Haemorrhoids:
  • - Painless rectal bleeding: Bright red blood, typically seen on toilet paper, coating stool, or dripping into toilet bowl after defecation.
  • - Anal itching (pruritus ani).
  • - Sensation of anal fullness or incomplete evacuation.
  • - Prolapse: Internal haemorrhoids may protrude outside the anus during defecation, may reduce spontaneously or require manual reduction.
  • - Pain: Usually only present if haemorrhoid becomes thrombosed (external) or strangulated (prolapsed internal).
  • - Mucous discharge.
  • Anal Fissure:
  • - Severe anal pain: Sharp, tearing, or burning pain DURING and especially AFTER defecation, can last minutes to hours.
  • - Rectal bleeding: Usually small amount of bright red blood on toilet paper or surface of stool.
  • - Anal spasm.
  • - Sentinel pile/tag may be visible externally at the distal end of a chronic fissure.

Risk factors

  • Constipation and straining during defecation (common to both)
  • Chronic diarrhoea
  • Pregnancy and childbirth
  • Prolonged sitting (e.g., on toilet)
  • Obesity
  • Low-fibre diet
  • Heavy lifting
  • Portal hypertension (less common cause of haemorrhoids)
  • Anal intercourse (risk factor for fissures)
  • Inflammatory bowel disease (Crohn's disease can cause atypical fissures)

Diagnosis

Clinical assessment

Diagnosis based on history (bleeding pattern, pain characteristics) and careful inspection of the perianal area and digital rectal examination (DRE). - External Haemorrhoids/Thrombosed Haemorrhoids/Sentinel Tag: Visible on inspection. - Anal Fissure: Often visible by gently parting the buttocks, typically in posterior midline. DRE may be very painful and deferred. - Internal Haemorrhoids: Usually not palpable on DRE unless thrombosed. Require anoscopy or proctoscopy for visualization and grading. Differential diagnosis: Rectal cancer/polyps, Inflammatory Bowel Disease (IBD), Anal abscess/fistula, Pruritus ani from other causes, Condylomata acuminata, STI-related proctitis/ulcers.

Investigations

  • Visual Inspection.
  • Digital Rectal Examination (DRE) - may be deferred if severe fissure pain.
  • Anoscopy/Proctoscopy: Essential for visualizing internal haemorrhoids and distal rectum.
  • Sigmoidoscopy/Colonoscopy: Indicated if bleeding source uncertain, change in bowel habit, age >40-50, family history CRC, or other alarm features, to rule out proximal pathology.

Diagnostic criteria

Clinical diagnosis based on characteristic symptoms and findings on external inspection and/or anoscopy/proctoscopy.

Management

Non-pharmacological management

  • Lifestyle and Dietary Measures (Foundation for both):
  • - Increase dietary fibre intake (goal 20-35g/day).
  • - Increase fluid intake.
  • - Avoid straining during defecation.
  • - Limit time spent sitting on the toilet.
  • - Regular exercise.
  • Sitz Baths: Soaking anal area in warm water for 10-15 minutes, 2-3 times daily and after bowel movements. Provides symptomatic relief, especially for fissures.
  • Local Hygiene: Keep anal area clean and dry. Avoid harsh soaps/wipes.
  • Haemorrhoid specific:
  • - Management of prolapse: Gentle manual reduction if needed.
  • - Office-based procedures (for symptomatic internal haemorrhoids refractory to conservative measures): Rubber band ligation, Sclerotherapy, Infrared coagulation (Specialist).
  • - Surgical Haemorrhoidectomy: For large, symptomatic external haemorrhoids, thrombosed external haemorrhoids causing severe pain, or internal haemorrhoids refractory to office procedures (Specialist).
  • Anal Fissure specific:
  • - Avoid constipation (primary goal).
  • - Surgical Lateral Internal Sphincterotomy: For chronic fissures refractory to medical therapy (Specialist - risk of incontinence).

Pharmacological treatment

  • Topical Preparations (Symptomatic relief):
  • - Anorectal creams/ointments/suppositories containing local anaesthetics (e.g., Lidocaine), vasoconstrictors (e.g., Phenylephrine), astringents, protectants, +/- corticosteroids (e.g., Hydrocortisone). Examples: Anusol, Proctosedyl, Scheriproct, Bismuth subgallate compound. Use for limited duration (1-2 weeks).
  • Stool Softeners / Laxatives: If constipation present (Bulk-forming or Osmotic preferred - see Constipation GI015).
  • Analgesics: Oral Paracetamol or NSAIDs for pain.
  • Anal Fissure specific medical therapy (Aim to relax internal anal sphincter):
  • - Topical Glyceryl Trinitrate (GTN) 0.2-0.4% ointment applied BID-TID (Headache is common side effect).
  • - Topical Calcium Channel Blockers (e.g., Diltiazem 2% cream) applied BID-TID.
  • - Botulinum toxin injection (Specialist).
  • Thrombosed External Haemorrhoid: Excision under local anaesthesia within 48-72 hours of onset can provide rapid pain relief (if expertise available).
  • If signs of secondary infection (rare): Consider topical or systemic antibiotics (e.g., Metronidazole).

Monitoring

Monitor symptom relief (pain, bleeding). Monitor bowel habits. Assess healing of fissure. Monitor for recurrence.

Complications

  • Haemorrhoids: Thrombosis, Strangulation (prolapsed internal), Anaemia (chronic blood loss), Skin tags, Perianal infection/abscess (rare).
  • Anal Fissure: Chronic fissure formation, Sentinel pile, Anal stenosis (rare), Abscess/fistula (rare).

Prevention

  • Prevent constipation (high fibre diet, fluids, exercise).
  • Avoid straining during defecation.
  • Avoid prolonged sitting on toilet.

Patient education

  • Explanation of haemorrhoids/fissures and common causes.
  • Importance of dietary/lifestyle changes (fibre, fluids, avoiding straining).
  • Correct use of topical medications and Sitz baths.
  • Reassurance that bleeding is usually minor but needs evaluation if significant/persistent.
  • When to seek further medical attention.
  • Information on procedural/surgical options if conservative measures fail.

Uganda-specific notes

Very common conditions, often related to diet. Conservative management with lifestyle advice, Sitz baths, and topical agents is first-line. Ensure bleeding is not attributed to haemorrhoids without excluding other causes, especially in older patients. Access to specialist procedures limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.4.2

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