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

Consider admission for:

• Extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset (reduction or excision may be needed).
• Internal haemorrhoids which have prolapsed and become swollen, incarcerated, and thrombosed (haemorrhoidectomy may be needed).
• Perianal sepsis (a rare but life-threatening complication).
• Acute, profuse rectal bleeding.

Refer on the suspected colorectal pathway:

• aged 50 years and over with unexplained rectal bleeding.
• suspected anal cancer (unexplained anal mass or unexplained anal ulceration)

Consider referral on the suspected colorectal cancer pathway:

• aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings :

a. abdominal pain;

b. change in bowel habit;

c. weight loss;

d. iron-deficiency anaemia

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 Criteria

Refer for specialist assessment and treatment of haemorrhoids if:

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

Or

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

Or

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

Or

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 referral and specialist management of haemorrhoids in adults Commissioning Policy

Referrals submitted without this information may be returned.

Referral Instructions

e-Referral Service selection

• Specialty: GI and Liver (Medicine and Surgery)
• Clinic Type: Colorectal Surgery
• Service: DRSS-Northern-GI & Liver (Medicine & Surgery) -Devon ICB-15N

Referral Forms

DRSS referral template

Patient Information

MyHealth patient information - Haemorrhoids

Haemorrhoid clinical policy patient support information

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2020

Updated: May 2023