Haemorrhoids — commonly called piles — are one of the conditions patients are most reluctant to discuss, yet they are remarkably common. Estimates suggest that around half the adult population will experience haemorrhoid symptoms at some point. Community pharmacists are frequently the first healthcare professional consulted, often because patients prefer the relative anonymity of a pharmacy counter conversation to booking a GP appointment.

What haemorrhoids are

Haemorrhoids are swollen blood vessels in and around the anus and lower rectum. They are classified by location:

• Internal haemorrhoids develop inside the rectum, above the dentate line. They are typically painless but can cause bleeding — bright red blood on toilet paper or in the bowl after a bowel movement.
• External haemorrhoids develop under the skin around the anus. They can be painful, especially if a blood clot forms within them (thrombosed haemorrhoid).

Common contributing factors include straining during bowel movements, chronic constipation, prolonged sitting (particularly on the toilet), pregnancy, obesity, heavy lifting and a low-fibre diet.

Over-the-counter treatment options

The pharmacist can recommend several OTC products depending on the predominant symptoms:

Creams and ointments

Hydrocortisone-containing products should not be used for more than seven days without medical advice. Prolonged use can thin the perianal skin and worsen symptoms.

Lidocaine-containing products provide localised pain relief and are particularly helpful for external haemorrhoids and thrombosed piles.

Suppositories

Suppositories (e.g. Anusol suppositories, Anusol HC suppositories) are preferred for internal haemorrhoids, as they deliver the active ingredients directly to the affected area inside the rectum. The pharmacist should explain correct insertion technique — the suppository should be inserted blunt end first, as this promotes retention.

Medicated wipes and sprays

Products such as Preparation H wipes and Anusol soothing and cleansing wipes provide gentle cleaning after bowel movements, which is more comfortable than dry toilet paper. These are particularly useful during acute flare-ups.

Lifestyle advice

Lifestyle modification is arguably more important than any OTC product for long-term haemorrhoid management. The pharmacist should cover:

Fibre intake: A high-fibre diet softens stools and reduces straining. Recommend at least 25–30 g of fibre daily from wholegrain cereals, fruits, vegetables, beans and pulses. If dietary fibre is insufficient, an OTC fibre supplement such as ispaghula husk (Fybogel) or sterculia (Normacol) can help.

Fluid intake: Adequate hydration (at least 6–8 glasses of water daily) is essential alongside increased fibre intake. Fibre without adequate fluid can worsen constipation.

Toilet habits: Advise against straining, reading on the toilet (which prolongs sitting time), and ignoring the urge to defecate (which leads to harder stools). The optimal position involves leaning forward with feet on a low stool, raising the knees above hip level — this straightens the anorectal angle and reduces straining.

Exercise: Regular physical activity promotes healthy bowel function. Even a daily 20–30 minute walk can make a meaningful difference.

Weight management: Excess body weight increases intra-abdominal pressure and contributes to haemorrhoid development.

Pregnancy and haemorrhoids

Haemorrhoids are extremely common during pregnancy, particularly in the third trimester, due to increased pelvic blood flow and pressure from the growing uterus. Management options are more limited:

• Simple soothing creams (e.g. Anusol without hydrocortisone) are considered safe in pregnancy
• Dietary fibre and adequate hydration are first-line
• Hydrocortisone-containing products should be avoided in the first trimester and used only briefly in later pregnancy, on pharmacist or medical advice
• Ice packs wrapped in a cloth can provide temporary relief from swelling and pain

Most pregnancy-related haemorrhoids resolve after delivery.

When to refer

The pharmacist should refer the patient to their GP if:

• Rectal bleeding persists despite treatment, or the blood is dark rather than bright red — dark blood may indicate a source higher in the gastrointestinal tract
• Symptoms do not improve after seven days of OTC treatment
• There is a palpable lump that is extremely painful, hard, or dark in colour — this may indicate a thrombosed external haemorrhoid that requires medical intervention
• The patient is over 50 and presenting with new rectal bleeding — bowel cancer screening thresholds mean that new bleeding in this age group warrants investigation
• There is associated change in bowel habit, unexplained weight loss, or persistent abdominal pain — these are red flags for colorectal pathology
• Symptoms are recurrent despite lifestyle modification — the patient may benefit from GP referral for banding, injection sclerotherapy or surgical assessment

The pharmacist should reassure the patient that haemorrhoids are common and treatable, while being clear that persistent or unusual symptoms need investigation. A sensitive, matter-of-fact approach reduces embarrassment and encourages patients to seek help early.

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