Haemorrhoidal Disease Across the Care Continuum: A Critical Narrative Review of Pathophysiological Mechanisms, Clinical Classification and Evidence-based Management

Abstract

Haemorrhoidal disease is among the most frequently encountered anorectal conditions in general practice, gastroenterology and colorectal surgery, yet the field remains unusually resistant to the forms of evidential consolidation achieved in comparable benign surgical domains. This critical narrative review examines the state of knowledge across the full care continuum, from mechanistic accounts of disease initiation through diagnostic classification to the comparative performance of conservative, office-based, ablative and operative interventions. Literature was identified through structured searching of MEDLINE via PubMed, Crossref Metadata Search and Semantic Scholar, supplemented by targeted retrieval of individual trials, consensus documents and guidelines named within retrieved sources, with a final search date of 9 June 2026. The synthesis is organised around mechanisms, measurement and management rather than around individual studies. Three interlocking problems are identified. First, the dominant sliding-anal-cushion model, although anatomically coherent and now supported by genetic evidence implicating smooth muscle, epithelial and connective tissue biology, has limited power to explain why symptomatic disease develops in some individuals and not others, and it has generated few testable predictions relevant to treatment selection. Second, the Goligher classification continues to serve simultaneously as a descriptive scheme, an eligibility criterion and an outcome, despite documented interobserver variability and weak correspondence with symptom burden, and the validated symptom scores and patient-reported outcome measures developed to replace it have not yet been consistently adopted in comparative trials. Third, the comparative evidence base is extensive but structurally weak, with recurrence defined inconsistently, follow-up frequently truncated before the interval at which prolapse recurs, and newer energy-based and endovascular techniques supported largely by uncontrolled series. Recurring findings that appear robust include the efficacy of fibre supplementation for bleeding, the trade-off between procedural invasiveness and durability, and the higher long-term recurrence of stapled haemorrhoidopexy relative to excisional surgery. Priorities for research include outcome standardisation, mechanistic stratification of patients, and adequately powered randomised comparison of the newer minimally invasive techniques against established office-based treatment.