Haemorrhoidal disease (Guidelines)

Haemorrhoids are the most common diagnosis of perianal symptoms and a prevalence of up to 44% has been reported in the general population. Within this group, there are many patients with haemorrhoids that are asymptomatic and do not require any of the treatments below.

The majority of haemorrhoids are grade 1 and 2 on the Goligher classification system. According to the European Society of Coloproctologists (ESCP) and the American Society of Colorectal Surgeons (ASCRS) guidelines, conservative measures in primary care are the mainstay of treatment and are aimed at symptom relief and prevention of haemorrhoidal prolapse.

Symptom relief

There is no high-level evidence on the efficacy of commonly prescribed preparations but the following are options for the management of pain related to haemorrhoids:

• NSAIDs and non-opioid analgesics including paracetamol are recommended for pain.
• Topical preparations of combined anaesthetics, emollients and steroids are available but should be used with caution and for short periods (continuous use up to 1 week is reasonable) as there is no evidence of their efficacy and can cause allergies and sensitisation of the perianal skin.
• See resources: NHS Highland Formulary choices of medicinal products:
  
  • Compound haemorrhoidal preparations
  • Soothing haemorrhoidal preparations 
• There is strong evidence (level 1B) that titrating dietary fibre and fluid intake to pass regular, soft but formed stool significantly reduced PR bleeding. If necessary, bulk forming laxatives can be prescribed to achieve this. Regular formed motions will also help with seepage and faecal incontinence.
• Ideally patients should aim for a Type 4 stool on the Bristol Stool Chart (see resources).
• There are positions that make is easier to pass a stool, for example elvating the feet and leaning forward with your elbows on your thighs.

Prevention of prolapse

• General healthy lifestyle measures such as sufficient water intake, a healthy diet and exercise should be encouraged.
• Patients should also be counselled to avoid prolonged periods, spending less than 10 minutes on the toilet, and to avoid straining, as described above.

Special circumstances

• Symptomatic Grade 3 and 4 haemorrhoids require referral to the Colorectal team in addition to the conservative measures above for consideration of banding, haemorrhoidal artery ligation, haemorrhoidopexy or haemorrhoidectomy.
• Please discuss thrombosed, incarcerated haemorrhoids with the surgical team on call, especially in pregnancy and immunosuppressed patients.