Haemorrhoids and anorectal problems: a patient guide for Australians

What haemorrhoids and anorectal problems are

Anorectal complaints are one of the most common reasons Australians see a GP — and one of the most frequently self-diagnosed. The umbrella covers several distinct conditions that share overlapping symptoms (bleeding, pain, itching, lumps) but have different causes and treatments. Sorting them out matters, because the management of each differs and a few of them carry serious consequences if missed.

Haemorrhoids are swollen cushions of blood vessels and supporting tissue inside and around the anal canal. Everyone has these cushions — they help with continence — but when they become engorged and start to bleed, prolapse, or thrombose, they become symptomatic. Internal haemorrhoids sit above the dentate line (the boundary between sensitive anal skin and insensitive rectal lining), so they produce painless bright-red bleeding, sometimes with prolapse. External haemorrhoids sit below the dentate line in sensitive skin — they only hurt when a clot forms inside one (a thrombosed external haemorrhoid), producing a sudden tender lump.

Anal fissures are small linear tears in the skin just inside the anus, usually triggered by a hard or large stool. They produce sharp, knife-like pain during a bowel motion that can last for hours afterwards, with a small streak of bright blood on the toilet paper. Most occur at the back of the anus (the posterior midline); fissures off to the side warrant investigation for less common causes including Crohn’s disease and infections.

Other conditions in this group include perianal abscess (a painful, fluctuant lump with throbbing pain and sometimes fever — needs prompt drainage), anal fistula (a chronic communication that follows some abscesses), pilonidal sinus (a hair-related condition at the base of the spine), pruritus ani (anal itch), rectal prolapse, and rarely anal cancer.

Australian guidance for general-practice management comes from Therapeutic Guidelines (eTG) and the Royal Australasian College of Surgeons colorectal resources, backed by HealthDirect and Better Health Channel for patient-facing information.

Why they happen

The common thread for haemorrhoids and fissures is chronic strain on the anal canal. The biggest contributors are:

• Constipation and straining — hard stools and prolonged time on the toilet engorge the anal cushions and damage the lining.
• Prolonged toilet sitting — scrolling through your phone on the toilet is a major modern driver. The position itself congests the anal vasculature when held too long.
• Pregnancy — pelvic pressure and progesterone-driven slow bowel motility make haemorrhoids common in pregnancy and after childbirth.
• Low fibre, low fluid intake — both promote constipation.
• Obesity — increased intra-abdominal pressure.
• Heavy lifting — Valsalva-style straining congests the anal vessels.
• Ageing — supporting tissue weakens over time.

Anal fissures typically begin with a single hard or bulky stool. The tear triggers spasm of the internal anal sphincter, which reduces blood flow to the area and impairs healing — explaining why fissures can become chronic and why treatment focuses on relaxing the sphincter.

How they’re diagnosed

A GP assessment for anorectal symptoms involves:

• History — pattern of bleeding (when, how much, what colour), pain (timing in relation to bowel motions, severity, duration), lumps, prolapse, itching, bowel habit, and importantly, alarm features (change in bowel habit lasting weeks, weight loss, dark blood, anaemia, family history of bowel cancer or inflammatory bowel disease).
• External examination — inspecting for skin tags, external haemorrhoids, thrombosed lumps, fissures (gentle traction at the back of the anus often reveals one), prolapse on bearing down, signs of Crohn’s perianal disease, or pilonidal pit.
• Digital rectal examination (DRE) — checking tone, masses, and any blood on the glove. A fissure may make full DRE too painful — that’s a diagnostic clue in itself.
• Anoscopy or proctoscopy — a short, simple in-clinic procedure that lets the GP visualise internal haemorrhoids and the fissure base directly.
• Blood tests when relevant — full blood count for anaemia, iron studies, inflammatory markers, faecal calprotectin if inflammatory bowel disease is on the differential.
• Colonoscopy — recommended when alarm features are present, when bleeding occurs at age 45 or older, or when there is a family history of bowel cancer. This is the test that excludes the dangerous mimics.

A common medical-legal trap is attributing rectal bleeding to haemorrhoids without examining and investigating properly. Per RACGP and eTG guidance, alarm features change the workup, not the symptom pattern.

Treatments — from fibre to surgery

First-line for haemorrhoids — conservative

These measures resolve the majority of haemorrhoids without anything more:

• Fibre 25 to 30 grams a day, increased gradually over a week or two to avoid bloating. Sources include vegetables, fruit, wholegrains, legumes, and psyllium husk supplementation if dietary intake falls short. Soft regular stools are the foundation of every other treatment.
• Fluids 1.5 to 2 litres a day — fibre without water becomes concrete.
• Toilet habits — go when you feel the urge (don’t delay), don’t strain, don’t sit on the toilet for prolonged periods. Leave the phone outside the bathroom.
• Footstool to squat — raising the knees above the hips on a small footstool straightens the anorectal angle and reduces straining. Cheap, simple, evidence-supported.
• Warm sitz baths — sitting in a shallow basin of warm water for 10 to 15 minutes twice daily relaxes the sphincter and soothes irritated tissue.
• Short-course topical preparations — over-the-counter creams or suppositories containing local anaesthetic, low-dose corticosteroid, or astringents (witch hazel) help symptoms for up to a week. Prolonged use can thin the skin and cause dependence, so they’re not long-term solutions (AMH).
• Stool softeners — psyllium, lactulose, or polyethylene glycol (PEG, sold as Movicol) where dietary measures aren’t enough.

Procedural treatment for persistent haemorrhoids

When conservative care fails after about four to six weeks, your GP may refer you for:

• Rubber-band ligation — the most common procedure for grade I to III internal haemorrhoids. A small rubber band is placed at the base of the haemorrhoid in clinic, cutting off its blood supply so it shrinks and falls off. Quick, well tolerated, often needs two or three sessions for full resolution.
• Sclerotherapy or infrared coagulation — alternative office-based options.
• Stapled haemorrhoidopexy — a hospital procedure for grade III to IV haemorrhoids.
• Conventional haemorrhoidectomy — surgical excision for severe or refractory cases. Effective but the recovery is painful.

A thrombosed external haemorrhoid (sudden tender lump near the anus) is treated by simple incision under local anaesthetic within the first 48 to 72 hours for rapid pain relief. After that window, it’s left to resolve conservatively over a week or two, often leaving a small skin tag.

Treatment for anal fissures

Acute fissures (less than six weeks): stool-softening measures, sitz baths, topical anaesthetic or low-dose steroid for pain. Most heal in four to six weeks.

Chronic fissures (six weeks or longer): the sphincter spasm prevents healing. Treatment relaxes the sphincter to restore blood flow:

• Topical glyceryl trinitrate (GTN) 0.2% ointment (Rectogesic) — applied three times daily for six to eight weeks; PBS Authority Required (PBS). Heals about half of chronic fissures. Headache is a common side effect, affecting roughly a third of users.
• Topical diltiazem 2% — compounded by a pharmacy; comparable healing rate with fewer headaches; not PBS-listed for this indication.
• Botulinum toxin injection — specialist second-line option.
• Lateral internal sphincterotomy — surgical option for refractory cases; effective but carries a small (around 5%) risk of mild faecal incontinence.

Treatment for related conditions

• Perianal abscess — needs drainage, not just antibiotics. A small surgical incision releases the pus; antibiotics alone are inadequate.
• Anal fistula — surgical management with techniques chosen to preserve continence.
• Pilonidal sinus — surgical excision plus post-operative hair-removal habits.
• Pruritus ani — identify and treat the underlying cause (fungal infection, contact irritation, threadworm in children, faecal soiling, hygiene factors). Cotton underwear, gentle cleansing, barrier creams, and short-course mild topical steroid help.
• Rectal prolapse — surgical for full-thickness prolapse; bowel-habit optimisation for mucosal prolapse.

When to see your GP

See a GP within a week if you have:

• Any rectal bleeding aged 45 or older — and discuss bowel cancer screening, regardless of how typical your haemorrhoid symptoms look.
• Bleeding that’s persistent, recurrent, or not settling with two to four weeks of conservative care.
• Change in bowel habit lasting more than a few weeks.
• Severe pain on bowel motions suggesting a fissure that’s not improving.
• A palpable lump that doesn’t reduce or is growing.
• Recurrent abscesses — these need investigation for Crohn’s perianal disease.
• Family history of bowel cancer or inflammatory bowel disease with any new bowel symptoms.

Don’t be embarrassed — anorectal complaints are routine in general practice, and your GP examines them every day.

Red flags — seek urgent assessment

Go to your GP same-day, or to a hospital emergency department, for:

• Heavy rectal bleeding with dizziness, lightheadedness, or feeling faint
• Dark, tarry, or black stool — suggests upper gastrointestinal bleeding
• Severe pain with fever and a tender swelling — suggests an abscess that needs urgent drainage; rarely, severe perianal infection (Fournier’s gangrene) is a surgical emergency
• Rapidly progressive perianal swelling with fever and feeling systemically unwell
• Unexplained weight loss, persistent change in bowel habit, or anaemia with rectal bleeding — urgent investigation for colorectal cancer
• A new anal lump that’s hard, fixed, or ulcerated, especially with risk factors for anal cancer (HPV, HIV, smoking) — urgent specialist review

The most important point: rectal bleeding is never automatically haemorrhoids. In Australian general practice, the dominant medico-legal risk in this area is missing bowel cancer by assuming bleeding is haemorrhoidal. The National Bowel Cancer Screening Program offers a free faecal immunochemical test every two years from age 45, and the age was lowered from 50 to 45 in July 2024 because of rising rates of bowel cancer in younger adults. If you’re eligible, do the test — even if you think your bleeding is from haemorrhoids.

What this article is and is not

This is general health information based on current Australian clinical guidance — Therapeutic Guidelines, RACGP resources, the Australian Medicines Handbook, Royal Australasian College of Surgeons materials, and the National Bowel Cancer Screening Program. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about your own symptoms — including whether to investigate, which treatments are appropriate, and when to consider procedures or surgery — are made with your GP.

For Australian consumer-friendly information: HealthDirect — Haemorrhoids · HealthDirect — Anal fissure · Better Health Channel — Haemorrhoids · Continence Foundation of Australia.

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Sources cited

1. Therapeutic Guidelines (eTG) — Gastrointestinal: Haemorrhoids and anal fissure
2. RACGP — Anorectal complaints clinical resources
3. Australian Medicines Handbook (AMH)
4. National Bowel Cancer Screening Program — age lowered to 45
5. Royal Australasian College of Surgeons — Colorectal
6. HealthDirect — Haemorrhoids
7. HealthDirect — Anal fissure
8. Better Health Channel — Haemorrhoids
9. Continence Foundation of Australia
10. PBS — Topical preparations for anorectal conditions