Haemorrhoids (piles) are abnormally swollen vascular mucosal cushions that are present in the anal canal. They are classed as external or internal, depending on their origin in relation to the dentate line.
Bright-red, painless rectal bleeding with defecation is the most common symptom.
Pain is rarely felt with haemorrhoids unless a pile has strangulated +/- thrombosed.
DC & RC 27/11/25
Who to refer:
Haemorrhoids are extremely common and affect a large proportion of the general population at some point in their lives. As such, most haemorrhoidal symptoms do not warrant referral. The proportion of patients who may benefit from surgical intervention is extremely small. All referrals are carefully triaged. If it is felt that secondary care review is not required, then the patient will not be offered an appointment, but will be provided with written advice.
Those that may benefit include
- Patients with significant Anaemia where other causes have been excluded
- Patients with severe or distressing daily problems that pervasively interfere with quality of life over a long period of time, after exhaustion of all conservative measures outlined in the Primary Care Management section.
Abnormal perianal lesions where there is diagnostic uncertainty should be referred as Urgent Suspicion of Cancer (patient should be counselled that this referral is for diagnosis rather than treatment of haemorrhoids per se)
See Colorectal Cancer guidelines for advice about referral of patients with concerning new rectal bleeding, such patients are managed using the qFIT pathway.
Please note that acute haemorrhoid conditions such as thrombosis, whilst giving significant symptoms in the short term, often self-resolve by the time patients are seen in a routine OPD clinic and an interval review in Primary Care should be considered prior to outpatient referral. Acute haemorrhoids rarely need to be reviewed as an emergency in the surgical assessment unless there is concern of sepsis or necrosis (via flow centre).
How to refer:
Via Sci Gateway
WGH/SJH>General Surgery – Colorectal>LI Basic Colorectal Referral
Treatment in Primary Care
Thorough assessment:
Risk factors include constipation, prolonged straining and time on the toilet, increased abdominal pressure as in ascites or during pregnancy and childbirth, heavy lifting, chronic cough and ageing.
Exclude red flags.
Perform a PR examination to visualise external piles. Local perineal irritation may be seen if chronic mucous discharge is present. Patients should have a digital rectal examination to exclude any other pathology.
Self help measures to advise patients
Aim to pass stools of a soft, “toothpaste-like” consistency.
Increase daily intake of fibre. Avoid dehydration. Aim for 1.5-2 litres’ fluid per day.
Get more exercise.
Don’t put off going to the toilet until later. Avoid straining to pass a stool. Avoid sitting on the toilet for too long and limit the time to 5 minutes.
Review of medications with GP or Pharmacist to check if any are causing constipation.
Medications
Laxatives
Bulking supplements (e.g. Ispaghula Husk) for mild symptoms. Stool softeners (such as Lactulose) are helpful. Consider adding in another laxative, such as Macrogol, if constipation needs treated.
Topical anaesthetics and steroids
Anaesthetic preparations (creams, ointments, foams sprays or suppositories) may alleviate pain, burning and itching. These should normally only be used for up to 7 days, as they may cause irritation of the anal skin with longer use. Intermittent use is usually tolerated.
Steroid preparations (usually in combination with local anaesthetic) can help if there is inflammation around the piles. This may help ease itch and pain. Again, these should not normally be used for longer than a week at a time.
Most medications are to be used morning and night and after opening the bowels. Topical preparations that come with an applicator and suppositories are better at treating “internal piles”.
Other treatments
Most piles do not require treatment beyond what is described above. A very small proportion of people will eventually need surgery. Being extremely common, many haemorrhoidal symptoms will recur without addressing the lifestyle factors above. Even despite this, current evidence suggests a high recurrence rate following surgery. Moreover, the complications / side effect profile of the surgical procedures can unfortunately be more problematic than the underlying haemorrhoidal symptoms.
Rubber band ligation
Small rubber bands are placed at the base of the pile. This cuts off the blood supply to the pile which then dies and drops off after a few days. Banding can be performed in clinic, endoscopy and theatre. Has a low success rate and may require multiple sittings. Risks include severe pain, bleeding/transfusions/reoperation, vasovagal episodes, displaced bands and recurrence.
Haemorrhoidal Artery Ligation Operation (HALO)
This procedure is used for patients with bleeding/anaemia as the predominant symptoms and treats third/forth degree and external disease poorly. This is done under general anaesthetic, usually as a day case procedure. Risks include severe pain, bleeding/transfusions/reoperation, recurrence of bleeding/symptoms and theoretical risks of ischaemia.
Haemorrhoidectomy
Traditional haemorrhoidectomy is used for large haemorrhoids, with significant external components or where the above has failed. This is done under general anaesthetic, usually as a day case procedure. Associated with more significant side effects including severe pain that can be long lasting, urinary retention, bleeding/transfusions/reoperation/delayed haemorrhage, infection/abscess/fistula, skin tags, anal stenosis, incontinence (temporary/permanent), recurrence of symptoms.
The following treatments are not currently offered in NHS Lothian – injection sclerotherapy, infrared coagulation/photocoagulation, and bipolar diathermy and direct-current electrotherapy.
