Haemorrhoids and anal lesions

Overview

Haemorrhoids, also known as piles, are swellings that contain enlarged blood vessels that are found inside or around the rectum and anus. Most haemorrhoids are mild and sometimes don't even cause symptoms. When there are symptoms, these usually include: 

• Bleeding after passing a stool (the blood will be bright red), 
• Itchy bottom,
• A lump hanging down outside of the anus, which may need to be pushed back in after passing a stool,
• Pain

Conservative Management in Primary Care

Patients with symptoms of Haemorrhoids should be conservatively managed initially as it is reasonable to use a period of ‘treat, watch and wait’. See 'Before Referral' section below.

Who to Refer

Please see Red Flag section below for indications for 2WW referral for anal lesions.

For non-2WW conditions please see advice below:

Haemorrhoids

Most haemorrhoids can be successfully treated in primary care using conservative treatments and lifestyle measures (see 'Before Referral' section below). Treatment of haemorrhoids in secondary care is not routinely funded by the CCG and is subject to the Surgical Treatment of Haemorrhoids Policy - Criteria Based Access. This requires that the patient must meet the specific criteria for treatment in order for the referral to be processed. Referrals that do not meet criteria may be returned by the referral service or the provider.

The mainstay of treatment in patients who need referral is banding and patients who are referred should be warned that this is the likely treatment that will be offered and is usually done on the first outpatient visit. The procedure can be painful and cause bleeding so it is advisable that they have someone to take them home after their procedure.

If a patient is taking oral anti-coagulants then these should be stopped prior to their outpatient appointment if possible to avoid them having to return for a second clinic visit.

Anal Skin Tags

Please note that the removal of anal skin tags is not commissioned unless exceptional funding is approved. Please see the Anal Skin Tag Removal Exceptional Funding Request Policy.

If there is suspected malignancy (anal mass or unexplained ulceration) then please use the 2WW pathway (see Red Flags below).

Perianal cysts and abscesses

Perianal abscesses will often present acutely and need surgical admission for incision and drainage.

Perianal abscess | The BMJ

If a cyst is recurrently discharging or a fistula has formed then a referral to the colorectal surgeons can be made (no funding required). Simple asymptomatic perianal cysts that have not been infected and do not discharge will not be removed routinely and fall under the Benign Skin Lesion Prior Approval Policy unless there is an anal mass or unexplained ulceration (see 2WW criteria below).

Pilonidal sinus disease

See CKS guidelines on management of pilonidal sinus.

Patients with an asymptomatic sinus can be managed with a 'watch and wait' approach, and reassurance that treatment is not necessary.

Patients with a discharging pilonidal sinus should be referred to a colorectal surgeon (no funding policy is applicable) or if an abscess has formed then the patient will need surgical admission for incision and drainage.

Anal warts

See CKS guideline on management of ano-genital warts.

Treatment, if required, should be managed by the Sexual health clinic.

Anal Fissures

Please see the Anal Fissure page

Red flags

• Anal mass or unexplained anal ulceration.
• Rectal or abdominal mass
• Aged under 50 with rectal bleeding and associated symptoms (abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia)
• Aged 50 and over with unexplained rectal bleeding.

See Lower GI - USC (2WW) for full criteria and how to refer.

If 2WW criteria are not met but there are symptoms such as persistent rectal bleeding that may not be due to haemorrhoids then consider non-2WW endoscopy.

Thrombosed and prolapsed piles

CKS guidelines recommend consideration of admission for acutely thrombosed piles. However local clinicians advise that this is rarely necessary.

Please see suggested approach below from Mrs Anne Pullyblank (consultant colorectal surgeon at NBT)

Before Referral

Before referral for haemorrhoids

If no red flags then haemorrhoids should be managed in primary care initially as it is reasonable to use a period of treat, watch and wait.

Lifestyle advice

Patients should be advised that making lifestyle changes to reduce the strain on the blood vessels in and around the anus is recommended. These can include:

• gradually increasing the amount of fibre in their diet – good sources of fibre include fruit, vegetables, wholegrain rice, wholewheat pasta and bread, seeds, nuts and oats
• drinking plenty of fluid - particularly water, but avoiding or cutting down on caffeine and alcohol
• not delaying going to the toilet – ignoring the urge to empty bowels can make stools harder and drier, which can lead to straining when the patient does go to the toilet
• avoiding medication that causes constipation – such as painkillers that contain codeine
• losing weight if they are overweight
• exercising regularly – this can help prevent constipation, reduce blood pressure and help lose weight.

Please also see the Self Care page of Remedy for a downloadable patient leaflet on gut health and link to the Medicines for Self-Care which includes Haemorrhoid treatments.

Topical creams and suppositories

Topical treatments that the patient applies directly to their anus can be bought from a pharmacy or prescribed by a GP.

Laxatives

Laxatives can be bought from a pharmacy or prescribed by a GP if constipation is a contributing factor.

Investigations

Consider investigations if indicated:

• FBC/ ferritin - if persistent or heavy bleeding from haemorrhoids
• Faecal calprotectin - if IBD is suspected 

Referral

Referral for haemorrhoids

If above conservative treatment have not been effective (over a period of at least 3 months), and other criteria are met, then consider a referral for treatment of haemorrhoids via eRS. Please ensure evidence from primary care records indicating how criteria are met are included in the referral.

See the Surgical Treatment of Haemorrhoids Policy - Criteria Based Access for details.

Referral for other anal conditions

Please see the 'Who to Refer' section above.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.