This guideline applies to situations where the diagnosis of haemorrhoids is likely or confirmed. If diagnostic uncertainty, please see the guideline on "Undiagnosed Rectal Bleeding".


Clinical features

Haemorrhoids produce symptoms due to prolapse or bleeding or both. When prolapse is present the mucosal lining of the anorectal junction can reach the outside leading to damp skin and/or mucous discharge, which can cause itch. Haemorrhoidal swelling can wax and wane and symptoms will vary accordingly. Large skin tags can be left when significant haemorrhoidal prolapse resolves.

Patients may exacerbate prolapse and bleeding by straining. If the underlying problem seems to be ineffective defaecation consider glycerine or bisacodyl suppositories with/without modest use of stool softeners such as fybogel and lactulose.

Patients frequently assume that any anorectal discomfort must be due to haemorrhoids. If there are symptoms of severe pain consider occult (intersphincteric) abscess, fissure in ano or a thrombosed haemorrhoid. Thrombosed haemorrhoids resolve spontaneously over 6 weeks (leaving a skin tag) and surgery is rarely appropriate.



On examination

Look for:

  • Local perineal irritation (due to chronic mucous discharge)
  • Bluish, bulging vessels covered in mucosa visible at anal verge on straining
  • Purple, swollen, acutely tender perianal lumps (thrombosed piles)
  • Fissure in ano - typically in the midline anteriorly or posteriorly in the lower third of the anal canal


Feel for:

  • Although internal haemorrhoids are difficult to palpate, digital rectal exam (DRE) is essential to rule out alternative pathology. If very painful, consider anal fissure or perianal sepsis.


Primary care management prior to referral

  • Dietary and lifestyle advice
    • Increase fluid (6-8 glasses/day) and insoluble fibre intake (25-30g/day)
    • Avoid excessive caffeine
    • Discourage straining, use glycerine or bisacodyl suppositories before breakfast as an alternative
    • Regular exercise
    • Feet-up position, see http://www.evidentlycochrane.net/feet-up-constipation/?
    • Good perianal hygiene, minimise use of perfumed toiletries and avoid wet wipes of any sort
    • Metanium or Vaseline as a barrier cream to minimise irritation
  • Bulk-forming laxatives
    • E.g. ispaghula husk / sterculia
    • Alternatives include lactulose or sodium docusate
  • Topical preparations for pain and symptom relief
    • Anaesthetic preparations, e.g. lidocaine ointment (for few days only)
    • Corticosteroids, e.g. scheriproct (up to 7 days)

RCHT 2WW Colorectal Form is available here

Referral criteria

Information required with referral

  • Patient’s symptoms
  • Findings of DRE
  • Details of prior therapeutic trials, including length of use of medications*

*Referrals will be cancelled if therapeutic trials are not of an appropriate period of time (12wks), unless over-riding concerns are detailed.



All referrals will be initially triaged by the Colorectal Surgery team and patients will be reviewed accordingly.




NHS Kernow CCG commissioning policy 2021-22



Review Date                         October 2021

Next Review Date                 October 2022

GP Sifter                               Dr Laura Vines

Contributor                            Ms Melanie Feldman

Version                                  2.0