Haemorrhoids Management

Scope

This guidance covers recurrent haemorrhoids with associated persistent pain or bleeding.

Haemorrhoids (piles) are enlarged blood vessels found inside or around the rectum or anus.

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral letter.

Referral Criteria

Referral for specialist assessment and treatment of haemorrhoids is not routinely commissioned in Devon. Referral will only be funded if:

The haemorrhoids are prolapsed and incarcerated, and cannot be reduced (fourth degree haemorrhoids)

The haemorrhoids are recurrent and associated with persistent bleeding and /or pain

And

There is failure of documented conservative management techniques after at least three months

Out of scope

Suspected cancer and acute, profuse rectal bleeding

Assessment

Signs and Symptoms

Haemorrhoids are often mild and sometimes asymptomatic, when symptoms are present, they include:

bleeding after passing a stool
itching around the anus
prolapse of the haemorrhoid which may need to be pushed back in after defecation

History and Examination

Haemorrhoids are classified as internal or external; internal haemorrhoids are graded as follows:

First-degree: project into the lumen of the anal canal but do not prolapse
Second-degree: prolapse on straining, then reduce spontaneously
Third-degree: prolapse on straining and require manual reduction
Fourth-degree: prolapsed and incarcerated, and cannot be reduced

Red Flags

If patients present with the following an urgent referral should take place for suspected malignancy:

Suspected cancer
Acute, profuse rectal bleeding

Management

Conservative management techniques include:

dietary and lifestyle advice (increase fluid and insoluble fibre intake, discourage straining)
bulk forming laxative (or osmotic laxative or stool softener) See Formulary 1.6 Laxatives
non-opioid analgesia and/or topical haemorrhoid preparations for symptomatic relief. See Formulary 1.7 Local preparations for anal and rectal disorders

Referral

Referral Criteria

Refer for specialist assessment and treatment of haemorrhoids if:

The haemorrhoids are prolapsed and incarcerated, and cannot be reduced (fourth degree haemorrhoids)

The haemorrhoids are recurrent and associated with persistent bleeding and / or pain

And

There is failure of documented conservative management techniques after at least three months.

Conservative management techniques include:

dietary and lifestyle advice (increase fluid and insoluble fibre intake, discourage straining)
bulk forming laxative (or osmotic laxative or stool softener)
non-opioid analgesia and/or topical haemorrhoid preparations for symptomatic relief

Referrals submitted without this information may be returned.

Non-surgical treatment

Commissioned if:

Recurrent haemorrhoids

And

Persistent bleeding and / or pain (significant discomfort)

And

Failure of documented management techniques after at least three months.

Surgical treatment

Commissioned if:

Fourth-degree haemorrhoids

Third-degree haemorrhoids associated with persistent bleeding and / or pain (significant discomfort) that have not responded to non-surgical treatment in line with the above policy statement, or which are too large for non-surgical measures

Second-degree haemorrhoids associated with persistent bleeding and / or pain that have not responded to non-surgical treatment in line with the above policy statement.

The removal of anal skin tags is not routinely commissioned in Devon.

NHS Devon CCG The referral and specialist management of haemorrhoids in adults Commissioning Policy

Referrals submitted without this information may be returned.