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Gastrointestinal

Haemorrhoids

Last revised in July 2021

Haemorrhoids (also known as piles) are abnormally swollen vascular mucosal cushions that are present in the anal canal.

Haemorrhoids: Summary

  • Haemorrhoids (also known as piles) are abnormally swollen vascular mucosal cushions in the anal canal.
  • Haemorrhoids are classed as external or internal, depending on their origin in relation to the dentate line. The dentate line is situated 2 cm from the anal verge and marks the transition between the upper and lower anal canal.
    • External haemorrhoids originate below the dentate line and are covered by modified squamous epithelium (anoderm), which is richly innervated with pain fibres. External haemorrhoids can therefore be itchy and painful.
    • Internal haemorrhoids arise above the dentate line and are covered by columnar epithelium, which have no pain fibres. Internal haemorrhoids are therefore not sensitive to touch, temperature, or pain (unless they become strangulated).
    • Internal haemorrhoids are further graded by degree of prolapse as: first degree (project into the lumen of the anal canal but do not prolapse), second degree (prolapse on straining but reduce spontaneously when straining is stopped), third degree (prolapse on straining and require manual reduction), and fourth degree (prolapsed and incarcerated and cannot be reduced). 
  • Factors which are thought to contribute to the development of haemorrhoids include:
    • Constipation.
    • Straining while trying to pass stools.
    • Ageing.
    • Heavy lifting.
    • Chronic cough.
    • Conditions that cause raised intra-abdominal pressure (such as pregnancy, childbirth, and space-occupying lesions).
  • Complications of haemorrhoids include ulceration; skin tags; maceration of the perianal skin; ischaemia, thrombosis, or gangrene; and rarely, perianal sepsis and anaemia from bleeding.
  • A thorough history and physical examination is important to confirm the diagnosis of haemorrhoids and to exclude serious underlying pathology (such as colorectal cancer).
    • Bright red, painless rectal bleeding is the most common symptom. It typically occurs with defecation and is seen as streaks on the toilet paper, in the toilet bowl, and/or outside of the stool (but not mixed with it).
    • Other possible symptoms include anal itching or irritation; a feeling of rectal fullness, of discomfort, or of incomplete evacuation on bowel movements; soiling; and anal pain (with prolapsed, strangulated internal haemorrhoids, or thrombosed external haemorrhoids). 
  • Management includes:
    • Ensuring stools are soft and easy to pass. 
    • Prescribing laxative treatment if the person is constipated.
    • Giving lifestyle advice to aid healing of the haemorrhoid, such as minimizing straining and maintaining good anal hygiene.
    • Offering symptomatic relief with simple analgesia and/or topical haemorrhoidal preparations.
  • Admission or referral should be arranged (using clinical judgement to determine the urgency) if:
    • The diagnosis is unclear or a serious pathology is suspected.
    • There are severe symptoms which cannot be managed in primary care.
    • The person does not respond to conservative treatment.
    • There are recurrent symptoms which do not respond to primary care treatment.
  • Secondary care treatments for haemorrhoids may be non-surgical or surgical, depending on the severity of symptoms and the degree of prolapse.
    • Non-surgical treatments include rubber band ligation, injection sclerotherapy, infrared coagulation/photocoagulation, and bipolar diathermy and direct-current electrotherapy.
    • Surgical treatments include haemorrhoidectomy, stapled haemorrhoidectomy, and haemorrhoidal artery ligation.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the primary care management of haemorrhoids.

This CKS topic does not cover the management of other perianal conditions or other causes of rectal bleeding.

There are separate CKS topics on Anal fissure, Constipation, Constipation in children, Gastrointestinal tract (lower) cancers - recognition and referral, and Pruritus ani. 

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2021 — reviewed. A literature search was conducted in June 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Updated advice on topical preparations for haemorrhoids which should be purchased over the counter in line with NHS Clinical Commissioners (2018). Re-positioning of the role of haemorrhoidal artery ligation in the treatment algorithm was also revised as repeat procedures are often needed.

Previous changes

December 2016 — minor update. The advice to give people about adverse effects of topical preparations has been updated in line with the manufacturer's Summary of Product Characteristics.

June 2016 to July 2016 — reviewed. A literature search was conducted in June 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made, but the topic has been restructured.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

April 2010 — minor update to the prescriptions. Issued in April 2010.

February to May 2008 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

October 2005 — minor technical update. Issued in November 2005.

July 2005 — updated to incorporate the Referral guidelines for suspected cancer published by the National Institute for Health and Care Excellence (NICE). Issued in July 2005.

December 2004 — reviewed. Validated in March 2005 and issued in April 2005.

September 2001 — reviewed. Validated in November 2001 and issued in April 2002.

September 1998 — rewritten.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 July 2021.

HTAs (Health Technology Assessments)

No new HTAs since 1 July 2021.

Economic appraisals

No new economic appraisals relevant to England since 1 July 2021.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 July 2021.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 July 2021.

New policies

No new national policies or guidelines since 1 July 2021.

New safety alerts

No new safety alerts since 1 July 2021.

Changes in product availability

No changes in product availability since 1 July 2021.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of haemorrhoids.
  • Manage a person with haemorrhoids in primary care by advising on measures to promote healing and prevent recurrence and by offering treatment for symptomatic relief.
  • Admit or refer a person with haemorrhoids to secondary care, where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What are haemorrhoids?

  • Haemorrhoids (also known as piles) are abnormally swollen vascular mucosal cushions in the anal canal.
    • In the anus, there are three vascular mucosal cushions which help maintain anal continence. These are typically described as being present at the left lateral, right posterior, and right anterior positions (that is, at 3, 7, and 11 o'clock), but there is considerable individual variation.     
    • When these mucosal cushions become enlarged and symptomatic, they are called haemorrhoids.
  • Haemorrhoids are classed as external or internal, depending on their origin in relation to the dentate line. The dentate line is situated 2 cm from the anal verge and marks the transition between the upper and lower anal canal.
    • External haemorrhoids originate below the dentate line and are covered by modified squamous epithelium (anoderm), which is richly innervated with pain fibres. External haemorrhoids can therefore be itchy and painful.
    • Internal haemorrhoids arise above the dentate line and are covered by columnar epithelium, which have no pain fibres. Internal haemorrhoids are therefore not sensitive to touch, temperature, or pain (unless they become strangulated).
    • Internal haemorrhoids are further graded by degree of prolapse (although these classifications do not always reflect the severity of the symptoms):
      • First degree (Grade 1) — haemorrhoids project into the lumen of the anal canal but do not prolapse.
      • Second degree (Grade 2) — haemorrhoids protrude beyond the anal canal on straining but spontaneously reduce when straining is stopped. 
      • Third degree (Grade 3) — haemorrhoids protrude outside the anal canal and reduce fully on manual pressure. 
      • Fourth degree (Grade 4) — haemorrhoids protrude outside the anal canal and cannot be reduced.
    • People can have internal and external haemorrhoids at the same time.

[Sandler, 2019; Sheikh, 2020; BMJ Best Practice, 2021]

How common is it?

  • The incidence of haemorrhoids is difficult to quantify accurately as only a small percentage of affected people seek medical attention.
    • Community-based studies in the UK reported that haemorrhoids affect 13–36% of the general population. However, it is likely that this estimation may be higher than the actual prevalence because the studies mainly relied on self-reporting, and many anorectal symptoms are often wrongly attributed to haemorrhoids [Lohsiriwat, 2012]. The 1-year prevalence is thought to be around 10% [Walsh, 2018].
    • An international study reported a prevalence of 11% in the general population [Sheikh, 2020].
      • In both sexes, the peak prevalence occurred between the ages of 45–65 years. 
      • In this study the authors reported that white people and people of higher socioeconomic status were affected more frequently than black people and people of lower socioeconomic status. This may reflect differences in health-seeking behaviour rather than a variation in prevalence [van Tol, 2019].

What are the complications?

  • Complications of haemorrhoids include:
    • Perianal thrombosis.
    • Incarceration of prolapsing haemorrhoidal tissue — the tissue is unable to be reduced into the anal canal, causing severe pain.
    • Ulceration — from thrombosis of external haemorrhoids.
    • Skin tags — from repeated episodes of haemorrhoid dilatation and thrombosis. This causes enlargement of the overlying skin, problems with hygiene, and secondary irritation.
    • Maceration of the perianal skin — due to mucus discharge.
    • Ischaemia, thrombosis, or gangrene in fourth degree internal haemorrhoids — progressive venous engorgement and incarceration of the acutely inflamed haemorrhoid leads to thrombosis, infarction, and severe pain.
    • Anal stenosis.
    • Perianal or pelvic sepsis (rare).
    • Anaemia from continuous or excessive bleeding (rare).

[van Tol, 2020; BMJ Best Practice, 2021]

What is the prognosis?

  • The prognosis of haemorrhoids is usually good. 
    • Many symptomatic episodes settle with conservative measures, with low rates of recurrence.
    • Residual or recurrent symptoms are more likely in people with continuing predisposing factors, such as constipation and straining while trying to pass stool [BMJ Best Practice, 2021].
    • About 10% of people will require surgery to alleviate their symptoms.
    • Recurrence rate after surgery is around 13% [Cocorullo, 2017].

What are the predisposing factors?

  • Factors which contribute to the development of haemorrhoids include:
    • Constipation.
    • Straining while trying to pass stools.
    • Ageing (weakening of the support structures makes haemorrhoids more likely to prolapse).
    • Conditions that cause raised intra-abdominal pressure (such as pregnancy, childbirth, ascites, or a pelvic mass).
    • Chronic cough.
    • Heavy lifting.
    • Exercising.
    • Hereditary factors (possibly due to a congenital weakness of the venous walls).
    • A low fibre diet.
  • These factors lead to increased pressure within the submucosal arteriovenous plexus and ultimately contribute to swelling of the cushions, laxity of the supporting connective tissue, and protrusion into and through the anal canal.
  • Women who experienced spontaneous pushing and slow delivery of the baby's head had fewer symptoms of haemorrhoids at 3 weeks postnatally.

[Ahlund, 2018; Ng, 2020; BMJ Best Practice, 2021]

Diagnosis of haemorrhoids

How should I diagnose haemorrhoids?

  • Take a history. 
    • Ask about symptoms, including the duration and severity, the relationship between symptoms and defecation, and any exacerbating or relieving factors. 
      • Bright red, painless rectal bleeding is the most common symptom of haemorrhoids. It typically occurs with defecation and is seen as streaks on the toilet paper, in the toilet bowl, and/or outside of the stool (but not mixed with it).
      • Anal itching or irritation may occur with prolapsing internal haemorrhoids (from prolapse-associated moisture, mucus secretion, and/or faecal incontinence) and with external haemorrhoids (from difficulty with perianal hygiene as a result of skin tags or extensive external haemorrhoids).
      • A feeling of rectal fullness, discomfort, or of incomplete evacuation on bowel movements may be present if prolapse occurs with straining and in people with large haemorrhoids.
      • Soiling (due to mucus discharge or impaired continence) may also occur.
      • Pain is not usually reported with internal haemorrhoids unless they prolapse and becomes strangulated, resulting in intense pain. External haemorrhoids are usually painless unless thrombosis occurs (the haemorrhoidal tissue becomes engorged and forms clots), resulting in an acutely painful mass in the rectum. 
      • A person with haemorrhoids may be asymptomatic, or there may be a history of intermittent symptoms lasting from a few days to a few weeks. 
      • In a symptomatic person, it may be difficult to determine whether symptoms are due to internal or external haemorrhoids, especially since people can have internal and external haemorrhoids at the same time.
    • Ask about a family history of, and the presence of 'red flag' symptoms for, anal or colorectal cancer. 
    • Ask about the presence of predisposing factors for haemorrhoids, such as constipation.
  • Examine the person. Ask them to lie comfortably in the left lateral position, the prone jack-knife position, or the lithotomy position. Offer the person the option of a chaperone.
    • Inspect the perianal area by gently spreading the buttocks.
      • The perineum may appear normal if there is a non-prolapsed internal haemorrhoid.
      • The perineum may be macerated from chronic mucus discharge causing local irritation.
      • If internal haemorrhoids have prolapsed, straining may cause them to appear at the anal verge, and bluish, soft bulging vessels covered by mucosa may be seen.
      • If external haemorrhoids are asymptomatic, a bluish bulging of the blood vessel beneath the skin may be seen.
      • An acutely thrombosed external haemorrhoid may present as a purplish, oedematous, tense, tender, subcutaneous perianal mass.
    • Check for the presence of skin tags or other anal pathology, such as fissures, fistulas, or perianal masses.
    • Perform a digital rectal examination (if this is possible without causing pain). 
      • Although internal haemorrhoids are not palpable, it is important to exclude differential diagnoses, such as a rectal prolapse.
    • A rigid anoscope, proctoscope, or rectoscope can be used to make a diagnosis of haemorrhoids, classify their severity, and exclude sinister pathology. Where the facilities or expertise are not available to perform this investigation in primary care, the person may need to be referred for assessment.
      • Haemorrhoids appear as pink swellings of the mucosa.
      • Even if haemorrhoids are seen, this does not mean that other pathology is not present. 
      • Serious pathology cannot be discounted at any age. Refer if there is doubt about the diagnosis.
  • Consider the need for further investigations.
    • Arrange a full blood count if there are signs of anaemia in a person that has experienced significant rectal bleeding. See the CKS topic on Anaemia - iron deficiency for more information.

Basis for recommendation

These recommendations are based on expert opinion in the European Society of Coloproctology guideline for haemorrhoidal disease [van Tol, 2020] and on expert opinion in review articles on haemorrhoids [Rubbini, 2019; BMJ Best Practice, 2021].

  • The symptoms of haemorrhoids are non-specific and may be seen in a number of anorectal diseases. A thorough history and physical examination is therefore important to confirm the diagnosis of haemorrhoids and to exclude serious underlying pathology (such as colorectal cancer) [RCS, 2017].

What else could it be?

  • Differential diagnoses of haemorrhoids include:
    • Adenomatous polyps — bleeding, diarrhoea, and constipation may be present. Rarely a rectal mass may be palpable.
    • Anal fissure — see the CKS topic on Anal fissure for more information. 
    • Anal or colorectal cancer — see the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for more information.
    • Anorectal fistula — may present with anal discharge, itch, intermittent swelling, bleeding, and pain. An external opening may be seen and a tract or cord may be palpable on digital rectal examination. Induration laterally or posteriorly suggests deep perianal or ischiorectal extension.
    • Anorectal melanoma — there may be rectal bleeding, perianal pain, and/or a perianal mass.
    • Condylomata acuminata (warts) — may resemble skin tags and bleed or cause irritation.
    • Diverticular disease — see the CKS topic on Diverticular disease.
    • Inflammatory bowel disease — see the CKS topics on Crohn's disease and Ulcerative colitis for more information.
    • Perianal abscess — which can cause perianal pain, swelling, fever, marked tenderness, induration, redness, and fluctuation.
    • Portal hypertension — can cause varices of the anal canal which are distinct from haemorrhoids. 
    • Pruritus ani and associated causes — see the CKS topics on Pruritus ani, Threadworm, and Dermatitis - contact for more information.
    • Rectal prolapse — a protruding mass and possible faecal incontinence.
    • Sexually transmitted infections (gonorrhoea, syphilis, or chancroid) — see the CKS topics on Gonorrhoea and Syphilis for more information.

Basis for recommendation

The information on the differential diagnoses of haemorrhoids is based on expert opinion in the Royal College of Surgeons (RCS) Commissioning guide: rectal bleeding [RCS, 2017], a review article [Ng, 2020], and a BMJ Best Practice review article on haemorrhoids [BMJ Best Practice, 2021].

Management

Scenario: Management

From age 16 years onwards.

How should I manage a person with haemorrhoids?

  • Consider the need for admission or referral.
    • Consider admitting people with:
      • 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).
    • Refer using the suspected cancer pathway referral (for an appointment within 2 weeks) if anal or colorectal cancer is suspected. See the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for detailed information on when to suspect anal or colorectal cancer.
    • Refer to an appropriate specialist (using clinical judgement to determine the urgency) if another serious pathology, such as inflammatory bowel disease or a sexually transmitted infection, is suspected.
    • Refer for non-urgent assessment and management, people with:
      • Fourth degree haemorrhoids or third degree haemorrhoids which are too large for non-operative measures (haemorrhoidectomy may be needed).
      • Perianal haematoma (a blue or dark coloured swelling at the anal verge) if symptoms are for less than 24 hours duration for clot evaluation. 
      • Combined internal and external haemorrhoids with severe symptoms (surgery may be required).
      • Thrombosed haemorrhoids when bleeding is problematic, or there is chronic irritation or leakage.
      • Large skin tags (surgical excision may be required).
  • Ensure stools are soft and easy to pass.
    • If the person is constipated, see the CKS topics on Constipation and Constipation in children for information on management for adults and young people. 
    • If the person is not constipated:
      • Advise adequate dietary fibre intake by eating a balanced diet containing whole grains, fruits, and vegetables; this should be done gradually to minimize flatulence and bloating. 
      • Advise that adequate fluid intake is particularly important with an increased fibre diet to maintain soft, well-lubricated stools and to prevent intestinal obstruction.
  • Give lifestyle advice to aid healing of the haemorrhoid. 
    • Advise on the importance of correct anal hygiene. The anal region should be kept clean and dry to aid healing and reduce irritation and itching. Recommend careful perianal cleansing and to pat (rather than rub) the area dry.
    • Advise against 'stool withholding' and undue straining during bowel movements, both of which can worsen the condition.
  • Manage any symptoms.
    • Offer simple analgesia (such as paracetamol) for pain relief. Avoid opioid analgesics (such as codeine) as they can cause constipation, and avoid nonsteroidal anti-inflammatory drugs (NSAIDs) if rectal bleeding is present. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for prescribing information.
    • Consider recommending a topical haemorrhoidal preparation for symptomatic relief. See the section on Choice of topical preparations for more information. Note: haemorrhoidal conditions are a type of condition for which over the counter preparations should no longer be routinely prescribed [NHS England, 2018]. 
  • Advise the person that when the haemorrhoid has healed, they should continue with dietary and lifestyle measures to reduce the risk of recurrence.
  • Refer to secondary care for further investigation and management:
    • People who do not respond to conservative treatment.
    • People with recurrent symptoms who do not respond to primary care management.

What treatments are available in secondary care?

  • Secondary care treatments for haemorrhoids may be non-surgical or surgical, depending on the severity of symptoms and the degree of prolapse.
  • Non-surgical treatments include:
    • Rubber band ligation:
      • A band is applied to the base of the haemorrhoid. The strangulated haemorrhoid becomes necrotic and sloughs off. The underlying tissue undergoes fixation by fibrotic wound healing. Up to three haemorrhoids can be banded at one visit.
      • This is currently the best available outpatient treatment of haemorrhoids. About 2 in 10 people will require a second banding within 6 months for symptom control.
      • Minor complications include haemorrhoid thrombosis, band displacement, mild bleeding, and formation of mucosal ulcers.
    • Injection sclerotherapy:
      • Phenol in oil is injected into the submucosa of the rectum, around the pedicles of the haemorrhoids. It induces a fibrotic reaction which obliterates the haemorrhoidal vessels, causing atrophy of the haemorrhoids.
      • Provides short-term benefit in most people.
      • Complications include pelvic infection and erectile dysfunction due to incorrectly sited injections (rare).
    • Infrared coagulation/photocoagulation:
      • This involves using infrared energy to produce an area of submucosal fibrosis leading to mucosal fixation and a reduction in the tendency to prolapse.
      • It may be as effective as rubber band ligation and injection sclerotherapy in the treatment of first degree and second degree haemorrhoids.
    • Bipolar diathermy and direct-current electrotherapy:
      • Causes coagulation and fibrosis after local application of heat.
      • Success rates are similar to those of infrared coagulation, and complication rates are low.
  • Surgical treatments include:
    • Haemorrhoidectomy:
      • Only symptomatic haemorrhoids are excised as this conserves the sensitive anoderm for continence.
      • Complications include post-operative urinary retention, secondary haemorrhage 7–10 days after the operation (from the vascular pedicle or from the edges of the wound), anal stricture, abscess, fistula, formation of skin tags, infection, pseudopolyps, and faecal incontinence.
      • Surgical haemorrhoidectomy confers the best long-term effect with less than 20% symptom recurrence.
    • Stapled haemorrhoidectomy:
      • A circular stapling gun is used to excise a doughnut of mucosa from the upper anal canal and lift the haemorrhoidal cushions back within the canal.
      • Although termed haemorrhoidectomy, it is more accurately termed a haemorrhoidopexy as the haemorrhoids are not excised but relocated within the anal canal.
      • Retroperitoneal sepsis, rectal perforation, anovaginal fistula, and substantial haemorrhage are rare, but serious, complications.
    • Haemorrhoidal artery ligation:
      • Using a proctoscope, the haemorrhoidal arteries are ligated with sutures (above the dentate line) to remove the flow of blood to the haemorrhoids. For larger prolapsing haemorrhoids, an adjunctive mucosal plication procedure is done; the prolapsing mucosa is plicated up to the level of the dentate line where it is fixed by ligation of the plicating sutures (haemorrhoidopexy).
      • Recent evidence questions the efficacy of this when compared to conventional treatments. Frequent repeat procedures are required to achieve symptom improvement or cure and also reduce the cost-effectiveness of this treatment.

[Cocorullo, 2017; Rubbini, 2019; Ng, 2020; BMJ Best Practice, 2021]

Basis for recommendation

The recommendations on the management of haemorrhoids in primary care are based on expert opinion in the National Institute for Health and Care Excellence (NICE) interventional procedure guidelines Electrotherapy for the treatment of haemorrhoids [NICE, 2015], the Royal College of Surgeons (RCS) Commissioning guide: rectal bleeding [RCS, 2017], the European Society of ColoProctology Guideline for haemorrhoidal disease [van Tol, 2020], the World Journal of Gastrointestinal Surgery Classification and guidelines on haemorrhoidal disease [Rubbini, 2019], and the BMJ Best Practice review article on haemorrhoids [BMJ Best Practice, 2021].

Admission or referral
  • These recommendations are largely based on expert opinion in review articles on haemorrhoids:
    • The pain of a thrombosed haemorrhoid usually peaks 48–72 hours after onset and is self-limiting in 7–14 days. Admission is therefore generally recommended only for people who present within 72 hours of onset.
    • Expert opinion in a review article is that people with a perianal haematoma should be referred for clot evacuation if symptoms are less than 24 hours old.
Ensuring stools are soft and easy to pass and giving lifestyle advice
  • Expert opinion in guidelines and review articles is that all people with haemorrhoids should be offered information on lifestyle and dietary modifications, as most cases can be managed conservatively with advice to increase fibre and fluid intake, toilet training (to avoid straining), and maintain good anal hygiene.
  • Expert opinion is that passing hard stools increases shearing force on the anal cushions.
Offering a simple analgesia 
  • This recommendation is based on what CKS considers to be good clinical practice.
Considering a topical haemorrhoidal preparation
  • Although there is little evidence showing their benefit for prevention or long-term treatment of haemorrhoids, topical haemorrhoidal preparations are recommended in the European Society of ColoProctology Guideline for haemorrhoidal disease [van Tol, 2020], the World Journal of Gastrointestinal Surgery Classification and guidelines on haemorrhoidal disease [Rubbini, 2019], and the BMJ Best Practice review article on haemorrhoids [BMJ Best Practice, 2021]
  • The British National Formulary (BNF) states that preparations containing local anaesthetics and corticosteroids may give symptomatic relief by reducing perianal inflammation but do not effect swelling, protrusion, or bleeding [BNF, 2021].
Preventing recurrence
  • The risk of recurrence of haemorrhoids is highest in people with ongoing risk factors.
  • Expert opinion in the guideline is that after treatment of haemorrhoids, people should be advised to remain on a high fibre diet and good fluid intake to prevent recurrence.
Referring people who do not respond to conservative treatment or have persistent recurrent symptoms
  • This recommendation is based on expert opinion in the European Society of ColoProctology Guideline for haemorrhoidal disease [van Tol, 2020], the World Journal of Gastrointestinal Surgery Classification and guidelines on haemorrhoidal disease [Rubbini, 2019], and in the BMJ Best Practice review article on haemorrhoids [BMJ Best Practice, 2021].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical haemorrhoidal preparations

Which topical haemorrhoidal preparations are available and which should I prescribe?

  • Haemorrhoidal preparations usually contain multiple ingredients, including astringent, lubricants, antiseptic, local anaesthetic, and/or corticosteroids. 
    • There is no evidence that any topical haemorrhoidal preparations is more effective than another. The choice of preparation should therefore be based on the risk of adverse effects and the person's symptoms and preference.
      • Preparations containing mild astringents or lubricants relieve local irritation and are less likely to cause skin sensitization.
      • Preparations containing local anaesthetics may alleviate pain, burning, and itching, but can cause sensitization of the anal skin. Lidocaine is the preferred topical anaesthetic because others, including tetracaine, cinchocaine (dibucaine), and pramocaine (pramoxine), are more irritant.
      • Preparations containing corticosteroids may reduce inflammation and pain, but prolonged use may lead to skin atrophy, contact dermatitis, and skin sensitization. Local infection (for example herpes simplex infection or perianal thrush) must be excluded before use.
  • Haemorrhoidal preparations are available over the counter or on prescription, however in 2018 NHS Clinical Commissioners recommended that these preparations should not be routinely prescribed for haemorrhoids.
  • They include creams and ointments (generally used for external haemorrhoids) and suppositories (generally used for internal haemorrhoids).
    • Examples of proprietary topical haemorrhoidal preparations available in the UK are listed below. A complete list of the available haemorrhoidal preparations are available in the British National Formulary (BNF) [BNF, 2021].
      • Anusol® cream/ointment/suppositories: contains astringent(s) and an emollient.
      • Anacal® rectal ointment/suppositories: contains a heparinoid.
      • Anodesyn® ointment/suppositories: contains a local anaesthetic (lidocaine).
      • Germoloids® cream/ointment/suppositories: contains a local anaesthetic (lidocaine) and astringent(s).
      • Anusol HC Plus®/Anusol HC® ointment/suppositories: contains a corticosteroid (hydrocortisone acetate) and astringent(s).
      • Proctosedyl® ointment/suppositories: contains a local anaesthetic (cinchocaine) and a corticosteroid (hydrocortisone).
      • Anugesic-HC® cream/suppositories: contains a local anaesthetic (pramocaine), a corticosteroid (hydrocortisone acetate), and an astringent.
    • No topical haemorrhoidal preparations are licensed for use during pregnancy or breastfeeding. However, the potential risk of harms to the pregnant woman and/or fetus is likely to be less with simple, soothing products than with those containing corticosteroid and/or local anaesthetic (which are generally not recommended by the manufacturers for use during pregnancy due to inadequate safety evidence). 
    • For detailed information on the different haemorrhoidal preparations, see the manufacturer's Summary of Product Characteristics (SPC, available on www.medicines.org.uk/emc).

If a topical haemorrhoidal preparation is prescribed or recommended, advise the person on the safe use of the preparation.

[BNF, 2021]

What should I advise on the safe use of topical haemorrhoidal preparations?

  • If a topical haemorrhoidal preparation is prescribed or recommended, advise the person:
    • On how to use it:
      • Generally, haemorrhoidal preparation should be used in the morning and night, and after a bowel movement. See the manufacturer's Summary of Product Characteristics (SPC) of the recommended product (available on www.medicines.org.uk/emc) for detailed information on how to use the product. 
      • Anaesthetic-containing preparations should only be used for a few days because they may cause sensitization of the anal skin.
      • Corticosteroid-containing preparations should be used for no longer than 7 days because prolonged use may lead to skin atrophy, contact dermatitis, and skin sensitization. Excessive application should be avoided, as systematic absorption can occur through the rectal mucosa. 
    • That local adverse effects may occur on application, such as burning, erythema, exfoliation, or irritation (frequency unknown). 
    • That they should seek advice from a pharmacist before buying over the counter topical haemorrhoidal preparations as they may contain similar ingredients to the one prescribed (including corticosteroid and/or local anaesthetic).

[BNF, 2021]

Supporting evidence

This CKS topic is largely based on expert opinion in guidelines and review articles on haemorrhoids. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of haemorrhoids.

Search dates

July 2016 - June 2021

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp hemorrhoids/
  • (hemorrhoid$ or haemorrhoid$).ti,ab,tw. or piles.ti,ab,tw.
  • exp hemorrhoids/ diagnosis* adverse effect* surgery* therapy*

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Ahlund, S., Rådestad, I., Zwedberg, S., et al. (2018) Haemorrhoids - a neglected problem faced by women after birth. Sexual & Reproductive Healthcare 18, 30-36. [Abstract]
  • BMJ Best Practice (2021) Haemorrhoids. BMJ Best Practice. https://bestpractice.bmj.com [Free Full-text]
  • BNF (2021) British National Formulary. BMJ Group and Pharmaceutical Press. https://bnf.nice.org.uk
  • Cocorullo, G., Tutino, R., Falco, N., et al. (2017) The non-surgical management for hemorrhoidal disease. A systematic review. G Chir 38(1), 5-14. [Free Full-text]
  • Lohsiriwat, V. (2012) Hemorrhoids: from basic pathophysiology to clinical management. World Journal of Gastroenterology 18(17), 2009-2017. [Abstract]
  • Ng, K.S., Holzgang, M. and Young, C. (2020) Still a case of "no pain, no gain"? An updated and critical review of the pathogenesis, diagnosis, and management options for hemorrhoids in 2020. Annals Coloproctology 36(3), 133-147. [Free Full-text]
  • NHS England (2018) Conditions for which over the counter items should not routinely be prescribed in primary care: guidance for CCGs. NHS England. http://www.england.nhs.uk [Free Full-text]
  • NICE (2015) Electrotherapy for the treatment of haemorrhoids. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • RCS (2017) Commissioning guide: rectal bleeding. Royal College of Surgeons. https://www.acpgbi.org.uk [Free Full-text]
  • Rubbini, M. and Ascanelli, S. (2019) Classification and guidelines of hemorrhoidal disease: present and future. World Journal of Gastrointestinal Surgery 11(3), 117-121. [Free Full-text]
  • Sandler, R.S. and Peery, A.F. (2019) Rethinking what we know about hemorrhoids. Clinical Gastroenterology and Hepatology 17(1), 8-15. [Free Full-text]
  • Sheikh, P., Régnier, C., Goron, F. and Salmat, G. (2020) The prevalence, characteristics and treatment of hemorrhoidal disease: results of an international web-based survey. Journal of Comparative Effectiveness Research 9(17), 1219-1232. [Free Full-text]
  • van Tol, R.R.V., Kimman, M.L., Breukink, S.O., et al. (2019) Experiences of patients with haemorrhoidal disease – a qualitative study. Journal of Coloproctology 39(1), 41-47. [Free Full-text]
  • van Tol, R.R., Watson, A.J.M., Jongen, J., et al. (2020) European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Disease 22(6), 650-662. [Free Full-text]
  • Walsh, C.J., Delaney, S. and Rowlands, A. (2018) Rectal bleeding in general practice: new guidance on commissioning. British Journal of General Practitioners 68(676), 514-515.
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