Haemorrhoids
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Haemorrhoids (piles) are abnormally enlarged vascular mucosal cushions that are present in the anal canal
- They can be external or internal and people can have both at the same time
- External haemorrhoids can be itchy and painful
- Pain (dull, rather than sharp) may be experienced upon defecation
- Some rectal bleeding may be evident
- Internal haemorrhoids are further graded by degree of prolapse:
- First degree (Grade 1) do not prolapse
- Second degree (Grade 2) protrude on straining but spontaneously reduce when straining is stopped
- Third degree (Grade 3) protrude but can be manually reduced
- Fourth degree (Grade 4) protrude outside the anal canal and cannot be reduced
Referral criteria
- Probably prudent to refer if unclear diagnosis, particularly a first-time sufferer of internal haemorrhoids
- Internal haemorrhoids that have prolapsed (those requiring manual reduction or that cannot be reduced)
- Severe pain (constant or upon defecation)
- Presence of ulceration
- Maceration or secondary infection of the perianal skin due to mucus discharge and scratching. Perianal sepsis is a rare, but potentially very serious complication
- Bleeding (small amount of fresh red blood is less urgent than a large amount or dark coloured blood mixed in with stool)
- Suspected anaemia from continuous or excessive bleeding
- Lasting a few weeks despite pharmacological measures
Time frame to resolution
- Many symptomatic episodes settle with conservative measures and have low recurrence rates. Recurrence is more likely in people who have continuing predisposing factors including constipation and pregnancy. A small proportion of people will require surgery to alleviate their symptoms
- OTC products containing hydrocortisone will be capped at a maximum of 7 days' use prior to seeking medical attention
Management strategy
Non-pharmacological advice
- Advise about perianal hygiene as this may provide symptomatic relief and prevent perineal dermatitis
- Recommend careful perianal cleansing with moist wipes, and to gently pat the area dry
- Provide lifestyle advice to minimize constipation and straining (see under 'Constipation' heading for further information)
Pharmacological advice
- You may wish to consider recommending an OTC product containing a local anaesthetic or hydrocortisone as they have some evidence of effectiveness in other similar conditions. Choice of preparation should be based on patient preference and the risk of adverse effects (for example, local anaesthetics can cause sensitization and long-term use of topical corticosteroids can cause skin atrophy, contact dermatitis and sensitization. OTC products containing topical corticosteroids tend to be capped at a maximum of 7 days' use without seeking medical advice)
- Check the product license to ensure it is licensed for the type of haemorrhoids requiring treatment. For example, suppositories are indicated for internal haemorrhoids, ointments and creams may be for both types, and spray formulations are typically for external use only
- Explain how to use the product (particularly for suppositories or internal cream/ointment)
- Consider a bulk-forming laxative (preferred choice) to treat underlying constipation, if applicable
- Offer simple analgesia such as paracetamol for relief of pain (if required)
- Pregnancy: there are one or two topical OTC haemorrhoid products licensed for use in pregnancy but the evidence-base for these is lacking/dubious. It may be prudent to refer the patient to their doctor in the first instance if they want/require a haemorrhoid product and/or the diagnosis is unclear. Discuss non-pharmacological measures. Also, for constipation in pregnancy, see the Constipation entry