Haemorrhoids/Piles
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
- 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 laxative (or osmotic laxative or stool softener)
- 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)
Non-opioid analgesia for symptomatic relief
- For example, paracetamol. Avoid constipating codeine analgesia.
Referral
- In cases where there is significant rectal bleeding the patient should be referred for internal examination by a specialist.
Non-surgical haemorrhoid treatment*is commissioned where patients meet the criteria below:
• recurrent haemorrhoids
• persistent bleeding
• failure of documented conservative management techniques after at least 3 months
*Non-surgical treatment includes rubber band ligation, injection sclerotherapy or infra-red coagulation
Surgical haemorrhoid treatment*should only be considered for:
• Persistent grade 1 (rare) or 2 haemorrhoids that have not improved with non-operative measures
• Severe (grade 3 or grade 4), which combine internal/external haemorrhoids with persistent pain or bleeding
• Irreducible and large external haemorrhoids
*Surgical treatment includes stapled haemorrhoidoplasty, haemorrhoid artery ligation operation, radiofrequency ablation of haemorrhoids and excisional haemorrhoidectomy
For patients who meet the criteria for surgery, a shared decision-making process should be used to support the choice of intervention taking into account patient’s choice, severity of haemorrhoids and medical comorbidities
The removal of anal skin tags is not routinely commissioned by NHS Cornwall and Isles of Scilly Integrated Care Board.
Information required with referral
The referral letter and patient’s medical record need to clearly evidence how the above criteria are met, including details of
- 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.
Clinics
All referrals will be initially triaged by the Colorectal Surgery team and patients will be reviewed accordingly.
Resources
https://patient.info/doctor/haemorrhoids-piles-pro
Page Review Information
Review Date 6 May 2025 (partial update)
Next Review Date 6 May 2026
GP Sifter Dr L Lomas
Dr Laura Vines
Contributor Ms Melanie Feldman
Version 2.0