Haemorrhoids
Please refer to the BNF or SPC for licenced indications, doses, contraindications and other
prescribing information.
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Haemorrhoids are abnormally swollen vascular mucosal cushions that are present in the
anal canal. Internal haemorrhoids arise above the dentate line and may not cause
symptoms. External haemorrhoids originate below the dentate line and can be itchy and
painful. People can have internal and external haemorrhoids at the same time.
Symptoms:
Itching, burning, pain, swelling and discomfort in the perianal area and anal canal and
rectal bleeding (bright red blood) after passing a stool.
Precipitating factors: the causes of haemorrhoids are uncertain.
 Straining whilst trying to pass stools may result in the anal vascular cushions
becoming congested
 Ageing – causes weakening of the support structures and makes haemorrhoids more
likely to prolapse
 Raised intra abdominal pressure due to pregnancy, childbirth, ascites, or pelvic
space occupying lesions
 Hereditary factors - possibly due to congenital weakness of the vascular walls
 External haemorrhoids become symptomatic as a result of thrombosis. A difficult
bowel movement and straining, prolonged sitting or travel, heavy lifting, or labour and
delivery may exacerbate the problem. Distension of the overlying perianal skin, and
inflammation associated with the process of thrombosis may cause severe pain
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Criteria for INCLUSION
Treat Patients who can give an verbal history of symptoms of haemorrhoids
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Criteria for EXCLUSION
Patients <18 years
When bleeding is problematic or recurrent or there is chronic irritation or leakage
Abdominal pain / vomiting
Pregnant or breastfeeding women
Patients taking anticoagulants
Patients with anaemia
Patients with alarm symptoms
o Patients aged 60 years and over with rectal bleeding or change in bowel
habit
o Patients of any age with rectal bleeding and change in bowel habit
---------------------------------------------------------------------------------------------------------------------------Action for excluded patients and non-complying patients
Refer to GP*
--------------------------------------------------------------------------------------------------------------------------------Action for patients who are included for treatment
Advice
 Provide lifestyle advice to minimise constipation and straining
 Avoid taking OTC medicines which may have a constipating effect e.g.
codeine
 Drink plenty of fluids (not tea or coffee or alcohol)
 Eat more fibre, found in wholemeal foods, fruit and fresh vegetables, this can
help to relieve constipation and reduce straining
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Taking prescribed medication with recognised constipating effects (supply and
provide a laxative (see MAS protocol for constipation) but advise to make a non
urgent appointment with GP)
Try not to strain during defecation which can exacerbate the symptoms of
haemorrhoids
Regular exercise improves bowel habits
Try not to put off going to the toilet when you need to go
Losing weight (if appropriate)
Advise on perianal hygiene this may be helpful with symptomatic relief. Clean
the perianal area with moistened towelettes or baby wipes, and pat (not rub)
the area dry
Haemorrhoid preparations only provide symptomatic relief and do not cure
haemorrhoids
If treatment fails to be effective within one week contact GP
Alert patients to the alarm symptoms of bowel cancer
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Treatment choice from the formulary
Anusol ®cream
23g
Anusol ® suppositories
24
Anusol HC® ointment
15g
Anusol HC® Suppositories
12
Cream should be used to treat external haemorrhoids, suppositories used to treat
internal haemorrhoids. If both are present at the same time, both products can be
recommended.
Advise patient that the maximum use for treatment is 1 week if there are no signs of
improvement to visit the GP
Supply
One treatment course in twelve months.
Provide a laxative if the patient is constipated; a bulk forming laxative is the preferred
choice. (See MAS protocol for constipation).
More than one product may be supplied if required for the treatment course, e.g.
haemorrhoid preparation(s) and laxative. Only one consultation fee may be claimed for
the consultation.
-------------------------------------------------------------------------------------------------------------------------------Routine referral to GP*
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Where 1 week duration of treatment fails
Patients <18 years
Suspected drug induced constipation (prescribed medicines)
When bleeding is problematic or recurrent or there is chronic irritation or leakage
Associated abdominal pain/vomiting
Pregnant or breast-feeding women
 Patient taking anticoagulants
 Patients with anaemia
--------------------------------------------------------------------------------------------------------------------Referral to GP within 24 hours*
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Patients with alarm symptoms
o Patients aged 60 years and over with rectal bleeding or change in bowel
habit
o Patients of any age with rectal bleeding and change in bowel habit
-----------------------------------------------------------------------------------------------------------Emergency referral to A&E
N/A
-----------------------------------------------------------------------------------------------------------* The pharmacist should complete a referral note for the patient to hand to the surgery
detailing why the patient was unable to be treated under the MAS.
Version 1.0 29/10/14