Do I really need surgery for haemorrhoids?

When people are referred to a colorectal surgeon for haemorrhoids, the first question is almost always the same: "Am I going to need surgery?" The honest answer, for most people, is no. Most haemorrhoids respond well to simple dietary changes, topical treatments, or a brief in-rooms procedure that requires no anaesthetic and no hospital stay. Surgery is reserved for situations that cannot be managed any other way.

That said, there is also a risk in not doing anything. People who put off getting help sometimes end up living with symptoms that affect their daily life — bleeding, a lump coming down, constant discomfort, or embarrassing discharge — when there was an effective, minimally invasive solution available from early on. The goal of this page is to give you an honest overview of when treatment is needed, what the options actually involve, and when surgery makes real sense.

Haemorrhoids are cushions of blood vessel tissue that sit naturally inside the anal canal. Everyone has them — they are a normal part of your anatomy, helping to provide a soft seal and contributing to continence. They only become a problem when they enlarge, become congested, or start to slide down (prolapse), causing symptoms.

There are two types. Internal haemorrhoids develop inside the anal canal, above a boundary called the dentate line — a zone where the lining of the canal changes from insensitive to sensitive. Because they are in the insensitive zone, internal haemorrhoids are generally not painful. They most commonly cause bright red bleeding or prolapse (a lump coming down). External haemorrhoids develop outside that boundary, in the skin-covered area around the anus, and can be painful — especially if a blood clot forms inside one (called a thrombosed external haemorrhoid).

Internal haemorrhoids are graded by severity, and this grading is what guides the choice of treatment:

They bleed but do not come down (prolapse). Managed with dietary changes and topical treatments.

They prolapse when you strain to go, but slide back in on their own. Rubber band ligation (banding) is usually the first-line treatment.

They prolapse and need to be gently pushed back in with a finger. Banding may work for less severe cases; HALRAR, Rafaelo, or surgery are options if banding has not helped.

They are permanently prolapsed and cannot be pushed back in. Surgery is usually needed.

Not everyone with haemorrhoids has noticeable symptoms, and how bad your symptoms feel does not always match how severe the haemorrhoids look. The most common things people notice include:

• Bright red blood — typically on the toilet paper or in the bowl, separate from the stool itself (not mixed through it)
• A lump coming down — a feeling of tissue prolapsing after a bowel motion, or a lump you can feel or see around the anus
• Itch or discomfort around the anus — often caused by a small amount of mucous discharge from prolapsing internal haemorrhoids
• Pain — internal haemorrhoids are usually not painful because they are in the insensitive zone. If you have pain, it is more likely from an external thrombosed haemorrhoid (acute, sore) or from a related condition like an anal fissure
• Feeling like you have not fully emptied — a large prolapsing haemorrhoid can give this sensation
• Difficulty keeping the area clean — mucous discharge and skin tags can make perianal hygiene frustrating

Haemorrhoids are more common in people who:

• Eat a low-fibre diet and tend to pass hard, infrequent stools
• Spend a long time sitting on the toilet — reading, scrolling on a phone — which increases downward pressure on the anal cushions
• Strain to pass a bowel motion
• Are pregnant (due to increased pelvic pressure and changes in blood flow)
• Carry excess body weight
• Have chronic constipation or ongoing diarrhoea
• Have a family history of haemorrhoids

A quick note on myths: haemorrhoids are not caused by sitting on cold surfaces, eating spicy food, or most of the other things people commonly blame. Those ideas have been around for a long time but have no real evidence behind them.

Haemorrhoids themselves are rarely dangerous — but it is important not to assume that rectal bleeding or anal symptoms are definitely haemorrhoids without having them properly checked. Please see a doctor promptly if:

• The bleeding is heavy, persistent, or happening alongside a change in your bowel habits
• You are over 40 and have new rectal bleeding — bowel cancer needs to be excluded before symptoms are attributed to haemorrhoids
• Prolapsed tissue will not go back inside no matter what you try
• You develop sudden, severe anal pain — this may indicate a thrombosed haemorrhoid or another condition
• You have abdominal pain, unexplained weight loss, or a change in stool size or consistency alongside your anal symptoms

1. Dietary and lifestyle changes

The starting point for managing haemorrhoids is getting your bowel habits regular and gentle. A diet with 25–35 g of fibre per day, good hydration (1.5–2 litres of water), and not spending a long time sitting on the toilet all reduce the straining that aggravates haemorrhoids and allow them to settle. For Grade I and milder Grade II haemorrhoids, this approach alone is often enough. Fibre supplements like psyllium husks (Metamucil) are safe, effective, and worth trialling consistently for four to six weeks before concluding they have not worked — consistency matters more than the specific product.

2. Topical treatments

Over-the-counter creams and suppositories containing local anaesthetic or mild anti-inflammatories can reduce acute symptoms — particularly itch and discomfort. They do not treat the haemorrhoids themselves, but they are helpful for comfort while your dietary changes take effect. They are not a long-term solution.

3. Rubber band ligation (banding)

Banding is the most widely used in-rooms treatment for Grade I, II, and selected Grade III internal haemorrhoids. A small rubber band is placed around the base of the haemorrhoid using a short instrument called a proctoscope. The band cuts off the blood supply, and the tissue shrinks and falls away over seven to ten days. The whole thing takes a few minutes, requires no anaesthetic, and is done in the clinic. Most people feel a sense of pressure or fullness for 24–48 hours; severe pain is uncommon because internal haemorrhoids are in the insensitive zone. Banding usually settles symptoms after one or two sessions; occasionally a third session is needed.

4. Injection sclerotherapy

Sclerotherapy is an occasional in-rooms option in which a small amount of a sclerosing agent is injected into the base of the haemorrhoid to shrink it. It is suitable for some smaller Grade I–II internal haemorrhoids and can be useful in patients on blood thinners where banding is less suitable. Recovery is straightforward. It is not the first-line treatment for most patients, but it is occasionally used.

5. HALRAR — doppler-guided ligation with mucopexy

HALRAR is a day-surgery procedure under general anaesthetic. A Doppler probe is used to find and tie off the small arteries feeding the haemorrhoids, and a few internal stitches lift any prolapsing tissue back into position. There is no external wound, which means recovery is typically faster than a formal haemorrhoidectomy — usually about a week. It is most suitable for Grade II–III internal haemorrhoids, particularly when banding has not held or the haemorrhoids are bulkier than banding can address.

6. Rafaelo — radiofrequency ablation

Rafaelo is another day-surgery option for Grade II–III internal haemorrhoids. A small probe delivers radiofrequency energy to shrink each haemorrhoid from within. Like HALRAR, there is no external wound; recovery is typically 24–48 hours. Rafaelo is a newer technique than HALRAR, with more limited long-term data, but the early results are encouraging.

7. Haemorrhoidectomy (surgical removal)

Haemorrhoidectomy means surgically removing the haemorrhoids under a general or spinal anaesthetic. It is the most definitive treatment and, in published series, has the lowest long-term recurrence rate — but it also has the most involved recovery period. It is appropriate for Grade III haemorrhoids that have not responded to banding or to a day-surgery option, for Grade IV haemorrhoids, and for large external haemorrhoids or a combination of internal and external disease that needs formal excision.

Surgery is recommended when:

• You have Grade IV haemorrhoids — permanently prolapsed and unable to be pushed back in
• Grade III haemorrhoids have not responded to multiple banding sessions
• You have large external haemorrhoids or significant skin tags that are causing ongoing discomfort or hygiene problems, and that banding alone cannot address
• There is a combined internal-and-external haemorrhoid complex that needs formal excision
• You have an intensely painful thrombosed external haemorrhoid presenting within 72 hours — in this situation, surgical or bedside excision can provide fast, meaningful relief

It is worth being upfront about what recovery from haemorrhoidectomy involves. It is the most definitive treatment available, but the recovery is not trivial. The anal area has a rich nerve supply, and the wound is in an area that is active every time you have a bowel motion. Most people experience severe pain during the first week, needing regular paracetamol, anti-inflammatory medication, and sometimes short-term opioid pain relief. Sitz baths — sitting in a few centimetres of warm water three or four times a day, especially after going to the toilet — provide real relief and are not optional. Most people can return to desk work within two weeks and feel largely recovered by four to six weeks, though some people notice sensitivity for a little longer.

The upside is that, in published series, haemorrhoidectomy has the most durable long-term result of any haemorrhoid treatment, with lower recurrence than non-surgical options.