Haemorrhoids
Haemorrhoids - Summary
Haemorrhoids are abnormally swollen vascular mucosal cushions that are present in the anal canal.
Haemorrhoids are classed as internal or external, depending on their origin in relation to the dentate line:
The dentate line is situated 2 cm from the anal verge and marks the transition between the upper anal canal, which has no pain fibres, and the lower anal canal which is richly innervated with pain fibres.
Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated.
External haemorrhoids originate below the dentate line and can be itchy or painful.
People can have internal and external haemorrhoids at the same time.
Internal haemorrhoids are further graded as: first degree (project into the lumen of the anal canal but do not prolapse), second degree (prolapse on straining, then reduce spontaneously), third degree (prolapse on straining, and require manual reduction), and fourth degree (prolapsed and incarcerated, and cannot be reduced).
The causes of internal haemorrhoids are uncertain but may include:
Straining while trying to pass stools.
Ageing.
Raised intra-abdominal pressure.
Hereditary factors.
Complications of haemorrhoids include ulceration; skin tags; maceration of the perianal skin; ischaemia, thrombosis, or gangrene; perianal sepsis (rare), or anaemia from bleeding (rare).
Management includes:
Lifestyle advice to minimize constipation and straining.
Laxatives if the person is constipated.
Symptomatic relief with simple analgesia and/or topical haemorrhoidal preparations.
Referral for people who do not respond to conservative treatment, or in whom the diagnosis is uncertain.
Treatments available from specialists include:
Rubber band ligation.
Injection sclerotherapy.
Infrared coagulation/photocoagulation.
Bipolar diathermy and direct-current electrotherapy.
Haemorrhoidectomy.
Stapled haemorrhoidectomy.
Haemorrhoidal artery ligation.
Have I got the right topic?
This CKS topic covers the primary care management of haemorrhoids.
This CKS topic does not cover the management of other perianal conditions, or the treatment of other causes of rectal bleeding, or offer detailed surgical information.
There are separate CKS topics on Anal fissure, Constipation, and Pruritus ani.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.
Previous changes
March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.
April 2010 — minor update to the prescriptions. Issued in April 2010.
February to May 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
There are no major changes to the recommendations.
October 2005 — minor technical update. Issued in November 2005.
July 2005 — updated to incorporate the Referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence. Issued in July 2005.
December 2004 — reviewed. Validated in March 2005 and issued in April 2005.
September 2001 — reviewed. Validated in November 2001 and issued in April 2002.
September 1998 — rewritten.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 September 2012.
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2012.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2012.
Systematic reviews and meta-analyses
No new systematic reviews in the major journals since 1 September 2012
Primary evidence
No new randomized controlled trials published in the major journals since 1 September 2012.
New policies
No new national policies or guidelines since 1 September 2012.
New safety alerts
No new safety alerts since 1 September 2012.
Changes in product availability
No changes in product availability since 1 September 2012.
Goals and outcome measures
Goals
To relieve the symptoms of haemorrhoids
To prevent worsening of symptomatic haemorrhoids, including prolapse, where possible
To prevent recurrence of the symptoms of haemorrhoids
Background information
Definition
What are haemorrhoids?
Haemorrhoids are abnormally swollen vascular mucosal cushions that are present in the anal canal [Kaidar-Person et al, 2007].
In the anus there are three vascular mucosal cushions, whose function is to help maintain anal continence [Quijano and Abalos, 2005]. These are typically described as being present at the left lateral, right posterior, and right anterior positions (i.e. at 3, 7, and 11 o'clock) but there is considerable individual variation [Nisar and Scholefield, 2003; Kaidar-Person et al, 2007].
When these mucosal cushions become enlarged and symptomatic they are called haemorrhoids [Orkin et al, 1999].
Classification
How are they classified?
Haemorrhoids are classed as internal or external, depending on their origin in relation to the dentate line [Nisar and Scholefield, 2003; Studd, 2005; Kaidar-Person et al, 2007]:
The dentate line is situated 2 cm from the anal verge and marks the transition between the upper anal canal, which has no pain fibres, and the lower anal canal which is richly innervated with pain fibres.
Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated.
External haemorrhoids originate below the dentate line and can be itchy or painful.
People can have internal and external haemorrhoids at the same time.
Internal haemorrhoids are further graded as [Nisar and Scholefield, 2003]:
First degree (project into the lumen of the anal canal but do not prolapse).
Second degree (prolapse on straining, then reduce spontaneously).
Third degree (prolapse on straining, and require manual reduction).
Fourth degree (prolapsed and incarcerated, and cannot be reduced).
Causes
Why do they occur?
The causes of internal haemorrhoids are uncertain [American Gastroenterological Association, 2004a] but may include [Studd, 2005]:
Straining while trying to pass stools, which results in the anal vascular cushions becoming congested [Alonso-Coello and Castillejo, 2003; Studd, 2005].
Ageing, which causes weakening of the support structures and makes haemorrhoids more likely to prolapse [Studd, 2005].
Raised intra-abdominal pressure due to pregnancy, childbirth, ascites, or pelvic space-occupying lesions [Kaidar-Person et al, 2007].
Hereditary factors, possibly due to a congenital weakness of the venous walls [Reese et al, 2009].
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 precipitate the problem [Orkin et al, 1999; Cataldo et al, 2005]. Distension of the overlying perianal skin, and inflammation associated with the process of thrombosis, may cause severe pain [Alonso-Coello and Castillejo, 2003].
Prevalence
How common are they?
Estimates of prevalence vary widely, as anorectal symptoms are often wrongly attributed to haemorrhoids.
An analysis of three national data sources in the US (the National Health Interview Survey, which is based on self-reported disease; the National Hospitals Discharge Survey, which is based on randomly selected records from short-stay hospitals; and the National Disease and Therapeutic Index, which reports annual statistics from visits to the physician) found that [Johanson and Sonnenberg, 1990]:
Of the US population, 4.4% complained of haemorrhoids.
There was a peak in prevalence in people 45–65 years of age.
Morbidity statistics from general practice in England and Wales in 1970–1971 found that the prevalence of haemorrhoids increased with socioeconomic status [Johanson and Sonnenberg, 1990].
Prevalence is higher in pregnant women than in non-pregnant women of the same age [Quijano and Abalos, 2005].
Complications
What are the complications?
Complications of haemorrhoids include (and may be presenting features):
Ulceration from thrombosis of external haemorrhoids.
Skin tags from repeated episodes of haemorrhoid dilatation and thrombosis, causing enlargement of the overlying skin and problems with hygiene, and secondary irritation.
Maceration of the perianal skin due to mucus discharge.
Ischaemia, thrombosis, or gangrene in fourth-degree internal haemorrhoids. Progressive venous engorgement and incarceration of the acutely inflamed haemorrhoid lead to thrombosis and infarction, and severe pain.
Perianal sepsis (rare).
Anaemia from bleeding (rare).
[Orkin et al, 1999; Nisar and Scholefield, 2003; American Gastroenterological Association, 2004a; Allen, 2007]
Prognosis
What is the prognosis?
The prognosis is usually excellent. Many symptomatic episodes settle with conservative measures [Reese et al, 2009].
Episodes tend to worsen with time, but only abut 10% of people eventually require surgery to alleviate their symptoms [Alonso-Coello and Castillejo, 2003].
Thrombosed external haemorrhoids (perianal haematomas): if not treated, the discomfort will gradually diminish in 2–4 weeks as the clot either spontaneously drains or is reabsorbed [Kann and Whitlow, 2004].
Diagnosis
Diagnosis of haemorrhoids
Diagnosis
How do I know my patient has it?
Most people with anorectal symptoms will ascribe their symptoms to haemorrhoids. A thorough history and physical examination is therefore necessary in order to rule out other diagnoses (see Differential diagnosis).
History
What history should I take?
History should include: the colour and character of bleeding, the relationship between symptoms and defecation, bowel symptoms (e.g. constipation, diarrhoea), presence of mucus, exacerbating factors, and factors related to the relief of symptoms. There may be a history of intermittent symptoms lasting from a few days to a few weeks.
Typical symptoms are:
Bleeding:
Painless bright red bleeding is the commonest symptom of internal haemorrhoids, and often occurs with defecation. The bleeding can vary from streaks on the toilet paper to blood dripping into the toilet. Blood is seen on the outside of the stool but is not mixed in with the stool.
In people with external haemorrhoids, bleeding may occur if the clot erodes through the skin. This is infrequent and when it happens, blood is often evident on underwear.
Anal itch:
Commonly occurs with internal haemorrhoids, due to prolapse of rectal mucosa causing chronic mucus discharge and irritation of the perianal skin. Soiling, which also occurs with prolapse, may cause anal itch.
Skin tags associated with external haemorrhoids may trap moisture and cause perianal irritation as well as interfering with anal hygiene
Prolapse:
Prolapse occurs with a bowel movement and is associated with an uncomfortable sensation of rectal fullness, incomplete evacuation, and a lump at the anal verge.
Pain:
Pain is rarely a significant symptom of internal haemorrhoids. Fourth-degree haemorrhoids may present with acute severe pain if strangulated: progressive venous engorgement and incarceration of the acutely inflamed haemorrhoid leads to thrombosis and infarction.
External haemorrhoids do not usually cause symptoms unless thrombosis occurs, in which case they present acutely as a severely painful perianal lump. The pain of a thrombosed haemorrhoid usually peaks 48–72 hours after onset, and is self-limiting in 7–10 days.
Rarely external haemorrhoids may dilate and become swollen and uncomfortable with straining.
Soiling:
Soiling may occur with third- or fourth-degree haemorrhoids as a result of impaired continence or mucus discharge.
Anal skin tags may cause problems in maintaining cleanliness.
Basis for recommendation
Basis for recommendation
Recommendations on what history should be taken to diagnose haemorrhoids are based on expert opinion from review articles [Orkin et al, 1999; Nisar and Scholefield, 2003; American Gastroenterological Association, 2004a; Studd, 2005; Allen, 2007; Kaidar-Person et al, 2007].
Examination
What examination should I perform?
Inspect the perianal area:
The perineum may appear normal if there is a non-prolapsed internal haemorrhoid.
The perineum may be macerated from chronic mucus discharge causing local irritation.
Straining may cause prolapsing haemorrhoids to appear at the anal verge. Bluish, soft bulging vessels covered by mucosa may be seen on examination if internal haemorrhoids have prolapsed.
If external haemorrhoids are asymptomatic, a bluish bulging of the blood vessel beneath the skin may be seen.
An acutely thrombosed external haemorrhoid is seen as a purplish, oedematous, tense, tender, subcutaneous perianal mass.
Check for the presence of skin tags which may persist after the resolution of thrombosis of an external haemorrhoid. They are common and should not be confused with external haemorrhoids as they do not contain dilated blood vessels. Less often, apparent skin tags may be the lower end of a prolapsing internal haemorrhoid. Skin tags are not always associated with haemorrhoids (e.g. a sentinel tag found distal to a chronic fissure) and they may be an isolated finding.
Perform a digital rectal examination — although internal haemorrhoids are not palpable it is important to check for other pathology, see Differential diagnosis.
Proctoscopy is supportive in making a diagnosis of haemorrhoids. Where the facilities or expertise are not available to perform this investigation in primary care, the person may need to be referred for assessment.
Haemorrhoids appear as pink swellings of the mucosa.
Even if haemorrhoids are seen this does not mean that other pathology is not present. Refer for further investigations to exclude malignancy in accordance with guidelines from the National Institute of Health and Clinical Excellence.
Serious pathology cannot be discounted at any age. Refer if there is doubt about the diagnosis or if there are recurrent symptoms.
Basis for recommendation
Basis for recommendation
Recommendations on the appropriate examination for a person with suspected haemorrhoids are based on expert opinion from review articles [Orkin et al, 1999; Alonso-Coello and Castillejo, 2003; Nisar and Scholefield, 2003; Allen, 2007; Acheson and Scholefield, 2008] and a text book [Friedman et al, 2002]. Referral recommendations are based on guidelines published from the National Institute for Health and Clinical Excellence [NICE, 2005a].
Differential diagnosis
What else might it be?
It is important to exclude other causes of rectal bleeding, particularly:
Colorectal or anal malignancy — see Referral. There may be a change in bowel habit, rectal bleeding, anaemia, and an abdominal or rectal mass.
Inflammatory bowel disease — change in bowel habit, rectal bleeding.
Diverticular disease — there may be constipation, diarrhoea, and painless rectal bleeding. See the CKS topic on Diverticular disease.
Adenomatous polyps — bleeding, diarrhoea, constipation, flatulence. Rarely a rectal mass may be palpable.
Anal fissure — a tear or ulcer in the lining of the anal canal immediately within the anal margin. Severe, sharp anal pain always occurs on defecation and bleeding may occur. A deep burning pain persists for several hours afterwards. A linear split may be seen at the anal margin. Digital rectal examination is not recommended as it is so painful. See the CKS topic on Anal fissure.
Anorectal melanoma — there may be rectal bleeding, perianal pain, and a perianal mass.
Other differential diagnoses include:
Rectal prolapse — a protruding mass and possible faecal incontinence.
Condylomata acuminata (warts) — may resemble skin tags and bleed or cause irritation.
Perianal abscess — perianal pain, swelling, fever, marked tenderness, induration, redness, and fluctuation.
Anorectal fistula — may present with discharge, itchiness, intermittent swelling, bleeding, and pain. An external opening may be seen and a tract or cord may be palpable on digital rectal examination. Induration laterally or posteriorly suggests deep perianal or ischiorectal extension.
Perianal Crohn's disease — may present with abscesses or fistulas.
Other causes of pruritus ani (e.g. threadworms, contact dermatitis, inadequate hygiene).
Portal hypertension can cause varices of the anal canal which are distinct from haemorrhoids. Variceal bleeding is best treated by correction of the underlying portal hypertension.
Sexually transmitted disease (gonorrhoea, syphilis, chancroid) — pain, discharge, bleeding and systemic symptoms. There may be an ulcer of the perianal skin or anal canal, and proctitis.
Basis for recommendation
Basis for recommendation
Information on differential diagnosis are based on expert opinion from review articles [Orkin et al, 1999; Friedman et al, 2002; American Gastroenterological Association, 2004a; Kaidar-Person et al, 2007; Fleury, 2011; Rakinic, 2011; Zagrodnik, 2011; Ramji, 2012].
Management
Management
Scenario: Management: covers the management of a person with confirmed haemorrhoids.
Scenario: Management
Scenario: Management of haemorrhoids
Overview of management
How should I manage a person with haemorrhoids?
Identify people who need urgent referral for suspected malignancy or admitting for acute management of internal or external haemorrhoids.
Provide lifestyle advice to minimize constipation and straining.
Prescribe a laxative if the person is constipated.
Provide symptomatic relief.
Refer people who do not respond to conservative treatment, or in whom the diagnosis is uncertain.
Basis for recommendation
Basis for recommendation
The basis for each recommendation is discussed in the specific management section.
Referral
When should I refer?
Refer urgently:
People with suspected malignancy (see 'Red flags').
Consider admitting:
People with extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset for assessment, reduction or excision:
If diagnosed within 72 hours of the onset of pain, severely painful thrombosed external haemorrhoids are best managed by excision under local anaesthetic. This will usually require urgent referral.
For thrombosed haemorrhoids presenting more than 72 hours after the onset of pain, conservative measures are recommended (see Treatment). The pain improves after a few days as the tension in the distended vessels is reduced with lysis of the clot.
People with internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed (haemorrhoidectomy is likely to be needed).
People with perianal sepsis (rare).
Refer for non-urgent assessment and treatment:
People who need assessment where the facilities for proctoscopy do not exist in primary care.
People with first- or second-degree haemorrhoids (or third-degree haemorrhoids that are quite small) that do not respond to conservative treatment. A non-operative intervention (e.g. rubber band ligation, sclerotherapy, infra-red photocoagulation, bipolar diathermy and direct-current electrotherapy) or surgery (e.g. haemorrhoidectomy, stapled haemorrhoidectomy, haemorrhoidal artery ligation) may be beneficial.
People with fourth-degree haemorrhoids or third degree haemorrhoids that are either too large for non-operative measures or have not responded to them. Haemorrhoidectomy may be appropriate.
People with thrombosed haemorrhoids when bleeding is problematic, or there is chronic irritation or leakage.
People with large skin tags that need removing.
Refer for further investigations:
If the diagnosis is uncertain or if there are recurrent symptoms.
If another condition is suspected, particularly in younger people. For example when there is altered bowel habit (especially diarrhoea), weight loss, or abnormal blood counts.
'Red flags'
NICE referral guidelines for suspected cancer
Referral guidelines for suspected cancer, published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005b], recommend that people who present with symptoms and signs suggestive of colorectal or anal cancer (see Table 1) are urgently referred to a team specializing in the management of lower gastrointestinal tract cancer (depending on local arrangements).
Table 1. Guidelines for urgent referral of suspected lower gastrointestinal tract cancer.| Person | Symptoms and signs |
|---|---|
| 40 years of age and older | Rectal bleeding with a change in bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more. |
| 60 years of age and older | Rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms.A change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding. |
| Of any age | A right abdominal mass consistent with involvement of the large bowel.A palpable rectal mass (intraluminal and not pelvic; a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist). |
| Women (not menstruating) | Unexplained iron deficiency anaemia and haemoglobin 10 g/100 mL or less.* |
| Men of any age | Unexplained iron deficiency anaemia and haemoglobin 11 g/100 mL or less.* |
Basis for recommendation
Basis for recommendation
The basis for these recommendations is expert opinion in review articles [Nisar and Scholefield, 2003; American Gastroenterological Association, 2004a; Cataldo et al, 2005; Allen, 2007], a structured review [Reese et al, 2009], and the National Institute for Health and Clinical Excellence (NICE) guidance on when to refer for suspected malignancy [NICE, 2005a].
Feedback from expert reviewers recommends considering further investigations for people with recurrent symptoms or where there is doubt about the diagnosis.
Advice
What advice should I offer a person with haemorrhoids?
Provide lifestyle advice to minimize constipation and straining. Advise that lifestyle modifications are an integral part of treatment.
Increase daily fibre and fluid intake to promote soft, bulky, regular stools. This can help to relieve constipation and reduce straining.
Aim for a daily intake of 25–30 g of insoluble fibre (e.g. raw fruits and vegetables, cereals, or fibre supplements).
Consume 6–8 glasses of fluid daily, avoiding excessive caffeine intake.
Discourage straining during defecation which can exacerbate symptoms of haemorrhoids.
Advise the person about perianal hygiene as this may be helpful in symptomatic relief and prevention of perineal dermatitis.
Recommend careful perianal cleansing with moistened towelettes or baby wipes, and to pat (rather than rub) the area dry.
Basis for recommendation
Basis for recommendation
These recommendations are based on pragmatic advice and expert opinion [Nagle and Rolandelli, 1996; Hussain, 1999; Orkin et al, 1999; Alonso-Coello and Castillejo, 2003; Balasubramaniam and Kaiser, 2003; Nisar and Scholefield, 2003; Studd, 2005; Kaidar-Person et al, 2007].
Treatment
What treatment should I prescribe?
Prescribe a laxative if the person is constipated:
A bulk-forming laxative (e.g. ispaghula husk or sterculia) is the preferred choice.
Lactulose (an osmotic laxative) or sodium docusate (a stimulant laxative with stool softening activity) are alternatives.
Stimulant laxatives without stool softening activity (e.g. senna) are less preferred as they do not soften stools and their stimulant effect may worsen haemorrhoid symptoms.
During pregnancy, avoid the use of stimulant laxatives (such as senna or sodium docusate).
For further information on the management of constipation, see the CKS topic on Constipation.
Provide symptomatic relief.
Prescribe an analgesic such as paracetamol for pain relief. Avoid opioid analgesics (e.g. codeine) which can cause constipation, and nonsteroidal anti-inflammatory drugs if rectal bleeding is present.
Consider topical haemorrhoidal preparations to provide short-term relief. Advise that they only provide symptomatic relief and do not cure haemorrhoids.
Basis for recommendation
Basis for recommendation
These recommendations are based on pragmatic advice and expert opinion [Balasubramaniam and Kaiser, 2003; Nisar and Scholefield, 2003; American Gastroenterological Association, 2004b; Kann and Whitlow, 2004; Studd, 2005; Kaidar-Person et al, 2007; BNF 64, 2012], and the results of a systematic review [Alonso-Coello et al, 2005].
Treatments not recommended
What treatments are not recommended?
The following treatments are not recommended for treating haemorrhoids:
Sitz bath (immersing the perineum and lower pelvis in warm or cold water).
Flavonoids.
Glyceryl trinitrate 0.2% ointment.
Basis for recommendation
Basis for recommendation
CKS does not recommended the following treatments as there is no good evidence to support their use:
Sitz baths: although a sitz bath has been recommended for relieving anal pain and maintaining anal hygiene [Kaidar-Person et al, 2007], a literature review found a lack of evidence supporting the use of sitz bath in the treatment of anorectal disorders [Tejirian and Abbas, 2005]. The issue of cold versus warm baths remains unanswered, and the optimal duration of the sitz bath is, as yet, undetermined.
Flavonoids: they are not licensed in UK for haemorrhoidal disease. One meta-analysis found evidence for their use in haemorrhoid disease to be variable between studies with flaws in the study design and considerable publication bias [Alonso-Coello et al, 2006].
Glyceryl trinitrate 0.2% ointment: it is licensed for the symptomatic relief of anal fissures but not for haemorrhoids. CKS could find no randomized controlled trials supporting its use in haemorrhoids.
Treatments in secondary care
What treatments are available in secondary care?
Non-surgical treatments
Rubber band ligation:
A band is applied to the base of the haemorrhoid. The strangulated haemorrhoid becomes necrotic and sloughs off. The underlying tissue undergoes fixation by fibrotic wound healing. Up to three haemorrhoids can be banded at one visit.
Minor complications include haemorrhoid thrombosis, band displacement, mild bleeding, and formation of mucosal ulcers.
Injection sclerotherapy:
Phenol in oil is injected into the submucosa of the rectum, around the pedicles of the haemorrhoids. It induces a fibrotic reaction which obliterates the haemorrhoidal vessels, causing atrophy of the haemorrhoids.
Provides short-term benefit in most people.
Complications: pelvic infection and impotence due to incorrectly sited injections (rare).
Infrared coagulation/photocoagulation:
This involves using infrared energy to produce an area of submucosal fibrosis leading to mucosal fixation and a reduction in the tendency to prolapse.
It may be as effective as rubber band ligation and injection sclerotherapy in the treatment of first- and second-degree haemorrhoids.
Bipolar diathermy and direct-current electrotherapy:
Causes coagulation and fibrosis after local application of heat.
Success rates are similar to those of infrared coagulation, and complication rates are low.
Surgical treatments
Haemorrhoidectomy:
Only symptomatic haemorrhoids are excised as this conserves the sensitive anoderm for continence.
Complications include post-operative urinary retention, secondary haemorrhage 7–10 days after the operation (from the vascular pedicle or from the edges of the wound), anal stricture, abscess, fistula, formation of skin tags, infection, pseudopolyps, and faecal incontinence.
Stapled haemorrhoidectomy:
A circular stapling gun is used to excise a doughnut of mucosa from the upper anal canal and lift the haemorrhoidal cushions back within the canal.
Although termed haemorrhoidectomy, it may more accurately be termed a haemorrhoidopexy as the haemorrhoids are not excised but relocated within the anal canal.
Retroperitoneal sepsis, rectal perforation, anovaginal fistula, and substantial haemorrhage are rare, but serious, complications.
Haemorrhoidal artery ligation:
Selective ligation of the arteries supplying blood to the haemorrhoids using a specially designed proctoscope with a Doppler-guided facility to identify the appropriate vessels.
A review concluded that there is insufficient evidence to judge the effectiveness of this technique, although the mean hospital stay was shorter than after closed haemorrhoidectomy, and there were fewer post-operative complications.
Basis for recommendation
Basis for recommendation
Information on non-surgical and surgical options to treat haemorrhoids in secondary care is based on expert opinion from review articles [Nisar and Scholefield, 2003; Cataldo et al, 2005; Kaidar-Person et al, 2007; Reese et al, 2009]
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Bulk-forming laxatives
Bulk-forming laxatives
Preferred products
Which bulk-forming laxatives are preferred for the management of haemorrhoids?
Bulk-forming laxatives containing ispaghula husk or sterculia are preferred for the management of haemorrhoids.
Table 1 shows the bulk-forming laxatives containing ispaghula husk or sterculia that are available in UK.
Table 1. Bulk-forming laxatives containing ispaghula husk or sterculia.| Ingredient | Formulation | Brand names |
|---|---|---|
| Ispaghula husk | Granules (gluten and sugar free) | Fibrelief® (orange or natural flavour), Fybogel® (plain, lemon, or orange flavour), Isogel®, Ispagel Orange® |
| Powder (gluten and sugar free) | Regulan® (orange or lemon/lime flavour) | |
| Sterculia | Granules (gluten free) | Normacol®, Normacol Plus® |
Basis for recommendation
This recommendation is based on a systematic review which found bulk-forming laxatives (such as ispaghula husk and sterculia) to produce a consistent beneficial effect for relieving symptoms and bleeding associated with symptomatic haemorrhoids [Alonso-Coello et al, 2005]. The systematic review did not identify any studies using other types of laxatives.
The bulk-forming laxative, methylcellulose, is less preferred:
Methylcellulose is a hydrophilic colloid which absorbs water causing it to swell to a soft gel of uniform consistency [ABPI Medicines Compendium, 2009].
CKS found no evidence to support its use for haemorrhoid conditions. Methylcellulose (Celevac®) is not licensed for this use, or for use in individuals who need to increase their daily fibre intake.
Prescribing issues
What issues should be considered when prescribing bulk-forming laxatives?
Bulk-forming laxatives relieve constipation by increasing faecal mass, which stimulates peristalsis. The full effect may take some days to develop.
They can relieve symptoms of non-prolapsing haemorrhoids, but may take 6 weeks for a significant improvement to be seen.
The use of bulk-forming laxatives is contraindicated in those with difficulty in swallowing, intestinal obstruction, or impaction.
They should be used with caution in debilitated individuals and those with intestinal narrowing or decreased motility.
They are of value in those with small, hard stools, but should not be required unless dietary fibre intake cannot be increased.
Bulk-forming laxatives are available in different formulations and in a variety of flavours. Careful choice of product might aid compliance.
[Nisar and Scholefield, 2003; ABPI Medicines Compendium, 2010d; ABPI Medicines Compendium, 2010a ; ABPI Medicines Compendium, 2011; BNF 64, 2012]
Pregnancy and breastfeeding
Which bulk-forming laxatives should be prescribed to a pregnant or breastfeeding woman?
The following bulk-forming laxatives are licensed for use during pregnancy and breastfeeding:
Ispaghula husk: Fybogel®.
Sterculia: Normacol®.
As they are not absorbed, they should not pose any harm to the fetus or to a breastfeeding baby.
[ABPI Medicines Compendium, 2010d; ABPI Medicines Compendium, 2010a]
Advice for patients
What advice should be given to patients about bulk-forming laxatives?
When prescribing bulk-forming laxatives such as ispaghula husk or sterculia:
Explain that these laxatives work by increasing faecal mass. Consequently, the full effect may take some days to develop.
Bulk-forming laxatives are not absorbed, and they produce their effect as a bulking agent by physical means alone.
Inform the person that bulk-forming laxatives can relieve symptoms of non-prolapsing haemorrhoids, but that it may take 6 weeks for a significant improvement to be seen.
Advise the person to ensure they have adequate fluid intake.
Warn that the preparation swells in contact with liquid and should be carefully swallowed with water. Once mixed with water, it should be taken immediately.
Bulk-forming laxatives should not be taken immediately before going to bed.
Inform the individual that adverse effects of bulk-forming laxatives are generally gastrointestinal in nature, including flatulence, abdominal distension, and more rarely, intestinal obstruction or impaction.
[Nisar and Scholefield, 2003; ABPI Medicines Compendium, 2010a; ABPI Medicines Compendium, 2010d; ABPI Medicines Compendium, 2011]
Adverse effects
What are the adverse effects of bulk-forming laxatives
Adverse effects associated with bulk-forming laxatives are generally mild.
A systematic review found gastrointestinal symptoms to be the most common adverse effects [Alonso-Coello et al, 2005].
Gastrointestinal symptoms typically start at the beginning of treatment. Bloating was the most common complaint. Adverse effects were generally not severe enough for participants to stop taking the treatment.
Reports of adverse effects were inconsistent between studies. Some studies reported a 50% incidence of bloating, while others observe no adverse effects.
Sodium docusate
Prescribing issues
What issues should be considered when prescribing sodium docusate?
Sodium docusate is a stimulant laxative with stool-softening activity.
It is licensed for use in the presence of haemorrhoids and anal fissure, to prevent hard, dry stools and reduce straining.
The manufacturer advises that treatment should be commenced with large doses, which should be decreased as the symptoms improve. In adults, up to 500 mg can be taken daily in divided doses.
Onset of action for oral preparations (capsules or oral solution) is within 1–2 days.
Because of its stimulant activity, it should not be used in those with abdominal pain, or when intestinal obstruction is present.
Use in pregnancy and breastfeeding:
Pregnancy: there are no adequate data. Although no increased risk of malformations has been observed, the use of a bulk-forming laxative or lactulose is preferred.
Breastfeeding: sodium docusate is excreted in breast milk. The manufacturer advises that it should be used with caution during lactation.
Adverse effects are rare. Sodium docusate may cause diarrhoea, nausea, abdominal cramps, or skin rash.
[Schaefer et al, 2007; ABPI Medicines Compendium, 2010b ; BNF 64, 2012]
Advice for patients
What advice should be given to patients about sodium docusate?
Explain that sodium docusate is a stimulant laxative with stool-softening activity. Remind the individual of the need for adequate fibre and fluid intake.
The onset of action is usually within 1–2 days.
Advise that the dose can be decreased as the condition improves.
The laxative should not be used if abdominal pain or intestinal obstruction is present.
Adverse effects are rare. Sodium docusate may cause diarrhoea, nausea, abdominal cramps, or skin rash.
Lactulose
Prescribing issues
What issues should be considered when prescribing lactulose?
Lactulose is an osmotic laxative which works by drawing more fluid into the bowel. This helps to soften the stool, allowing it to pass more easily.
Its use is contraindicated in people with galactosaemia and in cases of gastrointestinal obstruction.
The dose should be adjusted to the needs of the individual, to produce two or three formed stools each day.
Lactulose can be used in children and in women who are pregnant or lactating.
Onset of action is up to 48 hours.
Adverse effects include increased flatulence and abdominal discomfort that may occur during the first few days of treatment, and usually disappear under continued therapy. Diarrhoea may occur, especially when using higher doses.
[Schaefer et al, 2007; ABPI Medicines Compendium, 2012; BNF 64, 2012]
Advice for patients
What advice should be given to patients about lactulose?
Explain that lactulose is an osmotic laxative which can help to soften the stool, allowing it to pass more easily. Remind the individual of the need for adequate fibre and fluid intake.
Advise that the dose should be adjusted to the needs of the individual, to produce two or three formed stools each day.
The onset of action can be up to 48 hours.
Adverse effects include increased flatulence and abdominal discomfort that may occur during the first few days of treatment, and usually disappear under continued therapy. Diarrhoea may occur, especially when using higher doses.
Topical haemorrhoidal preparations
Products available
What topical haemorrhoidal preparations are available?
Table 1 shows examples of proprietary topical haemorrhoidal preparations available over-the-counter or on prescription in the UK.
Table 1. Examples of proprietary topical haemorrhoidal preparations available in the UK.| Types of topical preparations | Localanaesthetic | Corticosteroid | Examples |
|---|---|---|---|
| Preparations containing astringent(s)* and/or lubricants | — | — | Anusol® cream/ointment/suppositories |
| Antiseptic | — | — | TCP® antiseptic ointment |
| With heparinoid | — | — | Anacal® rectal ointment/suppositories† |
| Local anaesthetic only | Lidocaine | — | Anodesyn® ointment/suppositories |
| Benzocaine | — | Lanacaine® cream | |
| Cinchocaine | — | Nupercainal® ointment† | |
| Local anaesthetic and astringent(s)* | Lidocaine | — | Germoloids® cream/ointment/suppositoriesHemocane® cream |
| Corticosteroid and astringent(s)* | — | Hydrocortisone acetate | Anusol HC Plus®†/Anusol HC® ointment/suppositories |
| Local anaesthetics and corticosteroid | Cinchocaine | Hydrocortisone | Proctosedyl® ointment/suppositories‡Uniroid-HC® ointment/suppositories‡ |
| Cinchocaine | Prednisolone hexanoate | Scheriproct® ointment/suppositories‡ | |
| Cinchocaine | Fluocortolone caproate/pivalate | Ultraproct® ointment/suppositories‡ | |
| Lidocaine | Hydrocortisone or hydrocortisone acetate | Germoloids HC® sprayPerinal® spray†Xyloproct® ointment‡ | |
| Pramocaine | Hydrocortisone acetate | Proctoform HC® foam‡ | |
| Local anaesthetics and corticosteroid with astringent(s)* | Pramocaine | Hydrocortisone acetate | Anugesic-HC® cream/suppositories‡ |
Preferred topical preparations
Which topical preparations are preferred for relieving haemorrhoids?
There is no evidence that any topical haemorrhoidal preparations is more effective than any other.
The choice of preparation should therefore be based on the risk of adverse reactions and the individual's preference.
Soothing preparations containing mild astringents or lubricants are usually preferred.
Topical preparations containing corticosteroid and/or local anaesthetic may be considered for treating perianal inflammation and pain. However, they should only be used in the short term as the risk of adverse effects increases with duration of use.
Preparations containing corticosteroids may ameliorate local perianal inflammation. However, there is no evidence to suggest they reduce haemorrhoidal swelling, bleeding, or protrusion [American Gastroenterological Association, 2004a]. Long-term use of corticosteroids should be avoided because they can cause thinning of the perianal skin [Kaidar-Person et al, 2007; BNF 64, 2012].
Preparations containing local anaesthetics are used to treat pain, but evidence for this is lacking. Preparations containing local anaesthetics should only be used for a few days as they may cause sensitization of the anal skin [BNF 64, 2012].
Prescribers should be aware that many proprietary products contain multiple ingredients (including corticosteroid and/or local anaesthetic) and that it is therefore prudent to always check the product information for these preparations. For further information, see Products available.
Basis for recommendation
These recommendations are based on pragmatic advice and expert opinion [Orkin et al, 1999; American Gastroenterological Association, 2004a; Kaidar-Person et al, 2007; BNF 64, 2012]
Topical products do not cure haemorrhoids as they do not affect the underlying pathological changes in the anal cushions [Nisar and Scholefield, 2003; Kann and Whitlow, 2004].
The evidence for their use is lacking, but the general consensus is that they may provide short-term symptomatic relief.
CKS found no randomized trials comparing soothing preparations with those containing corticosteroid and/or local anaesthetic.
Preferred products in pregnancy
Which topical haemorrhoidal preparations can be prescribed to a pregnant woman?
No topical haemorrhoidal preparations are licensed for use during pregnancy.
If treatment with a topical haemorrhoidal preparation is required, a soothing preparation containing mild astringents or lubricant may be considered.
The manufacturer's recommend that Anusol® cream, ointment, and suppositories (containing bismuth oxide, zinc oxide, balsam peru, bismuth subgallate) may be considered for use during pregnancy.
Basis for recommendation
This recommendation is pragmatic advice and also based on expert advice and recommendations from manufacturers of topical haemorrhoidal products.
Soothing preparations are generally recommended for symptomatic relief of haemorrhoids [BNF 64, 2012]. For further information, see Preferred topical preparations.
The potential risk of harms to the pregnant woman and/or fetus is likely to be less with simple, soothing products than with those containing ingredients such as corticosteroid, local anaesthetic, antiseptic, or analgesic.
Products containing corticosteroids and/or local anaesthetics are generally not recommended by the manufacturers for use during pregnancy, as there is inadequate safety evidence.
Anusol® cream, ointment and suppositories: whilst formal studies have not been conducted, there is no epidemiological evidence of adverse effects, either in the pregnant woman or fetus [ABPI Medicines Compendium, 2008a; ABPI Medicines Compendium, 2008b; ABPI Medicines Compendium, 2010c].
Prescribing issues
What issues should be considered when prescribing a topical preparation for haemorrhoids?
All topical haemorrhoidal preparations should be used in conjugation with symptomatic and lifestyle measures (for further information, see Advice and Treatment).
Be aware that many proprietary products contain multiple ingredients (with or without corticosteroids and/or local anaesthetics). Topical haemorrhoidal products are also available over-the-counter.
Before prescribing, check with the individual whether any over-the-counter preparations have been used.
For further information on product availability, see Products available.
The evidence for topical haemorrhoidal preparations is poor or lacking. The choice of preparation will be based on risk of adverse reactions and individual preference.
Bland, soothing (astringent) preparations (e.g. bismuth oxide, zinc oxide) are preferred to relieve local irritation and are less likely to cause skin sensitization (see Preferred topical preparations). These preparations should be applied morning and night, and after a bowel movement.
Anaesthetic-containing preparations (e.g. lidocaine, cinchocaine, benzocaine, pramocaine) may alleviate pain, burning, and itching. However, they should only be used for a few days because they may cause sensitization of the anal skin.
Exclude perianal thrush before prescribing.
Systematic absorption can occur through the rectal mucosa. Consequently, excessive application should be avoided, particularly in infants and children.
Choice of local anaesthetic: lidocaine is commonly used. Other local anaesthetics such as cinchocaine and pramocaine might be considered, but they are more likely to irritate.
Topical corticosteroids (e.g. hydrocortisone) may reduce inflammation and pain. Local infection (e.g. herpes simplex, perianal thrush) must be excluded before use. Short courses, of up to 7 days, should be used. Prolonged use may lead to skin atrophy, contact dermatitis, and skin sensitization.
[Nisar and Scholefield, 2003; American Gastroenterological Association, 2004a; BNF 64, 2012]
Advice for patients
What advice should be given to patients prescribed a topical haemorrhoidal preparation?
Emphasize that topical haemorrhoidal preparations should be used in conjugation with symptomatic treatment and lifestyle advice.
Explain that these preparations only provide symptomatic relief and do not cure the condition.
Give advice regarding the safe use of these products:
Bland, soothing (astringent) preparations (e.g. bismuth oxide, zinc oxide):
Explain that these preparations relieve local irritation and are less likely to cause skin sensitization.
They should be applied morning and night, and after a bowel movement.
Anaesthetic-containing preparations (e.g. lidocaine, cinchocaine, benzocaine, pramocaine):
These may alleviate pain, burning, and itching but should only be used for a few days because they may cause sensitization of the anal skin.
Avoid excessive application to minimize systematic absorption.
Topical corticosteroids (e.g. hydrocortisone):
These may reduce inflammation and pain. They should only be used for up to 7 days as prolonged use may lead to skin atrophy, contact dermatitis, and skin sensitization.
If a topical haemorrhoidal preparation is prescribed, advise the individual to avoid using other over-the-counter topical haemorrhoidal preparations as they may contain similar ingredients (including corticosteroid and/or local anaesthetic). They should seek advice from a pharmacist before buying such products.
Adverse effects
What are the adverse effects of topical haemorrhoidal preparations?
Transient burning on application may be encountered, especially if the anoderm is not intact.
Ingredients in proprietary haemorrhoidal preparations which are known to cause adverse effects are:
Local anaesthetics: skin sensitization has been associated with the use of local anaesthetics [BNF 64, 2012]. This can be minimized by limiting use to a few days [BNF 64, 2012].
Case reports of contact dermatitis associated with local anaesthetics in haemorrhoidal preparations have been documented [van Ketel, 1983; Lee, 1998; Lodi et al, 1999].
Corticosteroids: prolonged use of corticosteroids can cause atrophy of the anal skin [American Gastroenterological Association, 2004a; BNF 64, 2012]. These should not be used for more than 7 days.
Evidence
Evidence
Supporting evidence
Laxatives
Evidence on laxatives for the treatment of haemorrhoids
Evidence from a systematic review suggests bulk-forming laxatives produce a consistent beneficial effect, relieving the symptoms and bleeding associated with symptomatic haemorrhoids. A non-significant trend toward increased mild adverse events has been reported. The review found no studies using other types of laxatives.
A Cochrane review identified seven randomized controlled trials (RCTs) (n = 378) that met the eligibility criteria (out of 206 articles found). These studies compared the use of bulk-forming laxative with placebo [Alonso-Coello et al, 2005]. None studied other types of laxatives.
Six RCTs using a parallel group design, and one with a crossover design, were included. All compared bulk-forming laxatives with placebo.
Types of bulk-forming laxative studied: ispaghula husk (three trials, n = 41, n = 28, and n = 67), plantago ovata or psyllium (two trials, n = 52 and n = 50), sterculia (one trial, n = 40) and unprocessed wheat bran (one trial, n = 92).
Outcome:
The pooled analysis for overall improvement showed a 53% reduction in the risk of not improving or of not being asymptomatic (RR 0.47, 95% CI 0.32 to 0.68).
Bleeding: four studies reported bleeding as an individual outcome. All showed either a trend or a significant difference in favour of the bulk-forming laxative group. The pooled analysis showed a 50% relative risk reduction in the bulk-forming laxative arm (RR 0.50, 95% CI 0.28 to 0.89). A fifth study found a significant benefit in the bulk-forming laxative group compared with placebo, but only from day 15–30 (5.5 +/– 3.2 bleeding episodes versus 3.1 +/– 2.7) and from day 30–45 (5.5 +/– 2.9 bleeding episodes versus 1.1 +/– 1.4).
Prolapse: the pooled analysis of three studies showed a non-significant difference between bulk-forming laxative and placebo for persistent prolapse (RR 0.79, 95% CI 0.37 to 1.67).
Pain: a pooled estimate from two studies evaluating pain or discomfort found a non-significant trend in favour of bulk-forming laxative (RR 0.33, 95% CI 0.07 to 1.65).
Itch: two studies that evaluated itching did not find a significant difference between the groups (RR 0.71, 95% CI 0.24 to 2.10).
Recurrence or need for further treatment: one study compared bulk-forming laxative with placebo on the number of recurrences in the long term. In those with third degree haemorrhoids treated with rubber band ligation, the study reported less overall recurrence in the bulk-forming laxative group (15% versus 45%) at 18 months (RR 0.34, 95% CI 0.15 to 0.77). Follow up found fewer recurrent protrusions in the bulk-forming laxative group (10% vs. 38%). The number of rubber band ligations required until disappearance of symptoms was lower in the bulk-forming laxative group (median 2, range 1–4 versus median 3, range 1–5).
Adverse effects:
Results showed a non-significant trend toward increases in mild adverse events in the bulk-forming laxative group (RR 6.0, 95% CI 0.57 to 64.8).
Gastrointestinal adverse effects were inconsistent. Some studies reported a 50% incidence of bloating, versus 0% for placebo, but two of the studies did not observe any adverse effects.
Authors' comments: moderate study quality and publication bias are potential limitations to this systematic review. However, the authors concluded that the inferences drawn from the trials were moderately strong. In addition, in an attempt to minimize publication bias, authors, experts and the pharmaceutical industry were contacted to locate unpublished studies.
Proprietary haemorrhoidal preparations
Evidence on proprietary haemorrhoidal preparations for treatment of haemorrhoids
Despite the many products marketed, CKS found little evidence to support the effectiveness of proprietary haemorrhoidal preparations in treating haemorrhoids. Two small studies reported improvement of symptoms but these were small studies and their designs were methodologically weak.
CKS found two trials investigating the use of proprietary haemorrhoid preparations.
Anacal® rectal ointment (containing heparinoid, prednisolone and oxypolyethoxydodecane) vs. placebo:
One randomized controlled study (n = 68 women from one postnatal ward in UK) reported higher pain relief with Anacal® ointment than placebo within 3 days of treatment (74% vs. 30% respectively reported relief of pain in those with moderate to severe pain) [Ledward, 1980]. However, no information was given if the groups were matched. It is uncertain if the study was double-blind.
The formulation of Anacal® used contained 5% prednisolone which is not found in the current product marketed in UK.
Proctosedyl® vs. Uniroid®:
One UK primary care study (n = 89 adults) found no statistically significant difference between the suppository and ointment formulations of Proctosedyl® and Uniroid® in the treatment of second-degree haemorrhoids after 3 weeks of treatment [Smith and Moodie, 1988].
However, there are several limitations to this study, which was an open-label comparison of the different formulations (no placebo control, randomization procedure unknown). Although the authors reported a good response to treatments (> 90% of participants reported controlled of symptoms within 3 weeks), no information was given regarding the magnitude of improvement. No statistical significance was found due to the small number of participants involved. No adverse events were reported.
In addition to a corticosteroid and a local anaesthetic, the preparations used in the study also contained an antibiotic which is not found in the current products marketed in UK.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of haemorrhoids.
Search dates
December 2007 – September 2012
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp hemorrhoids/ or hemorrhoid$.tw. or haemorrhoid$.tw. or piles.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Guidelines International Network
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
Institute for Clinical Systems Improvement
National Health and Medical Research Council (Australia)
Royal Australian College of General Practitioners
British Columbia Medical Association
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Patient experiences
Patient.co.uk - Patient Support Groups
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
References
ABPI Medicines Compendium (2008a) Summary of product characteristics for Anusol suppositories. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2008b) Summary of product characteristics for Anusol ointment. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2009) Summary of product characteristics for Celevac tablets 500mg. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010a) Summary of product characteristics for Normacol. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010b) Summary of product characteristics for Dioctyl 100 mg capsules. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010c) Summary of product characteristics for Anusol cream. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2010d) Summary of product characteristics for Fybogel Orange. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2011) Summary of product characteristics for Regulan orange flavour. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2012) Summary of product characteristics for Duphalac. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
Acheson, A.G. and Scholefield, J.H. (2008) Management of haemorrhoids. British Medical Journal 336(7640), 380-383. [Free Full-text]
Allen, S. (2007) Haemorrhoids and anal fissures. Pharmaceutical Journal 279(7461), 79-82.
Alonso-Coello, P. and Castillejo, M.M. (2003) Office evaluation and treatment of hemorrhoids. Journal of Family Practice 52(5), 366-374. [Free Full-text]
Alonso-Coello, P., Guyatt, G., Heels-Ansdell, D. et al. (2005) Laxatives for the treatment of hemorrhoids (Cochrane Review). The Cochrane Library.Issue 4.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Alonso-Coello, P., Zhou, Q., Martinez-Zapata, M.J. et al. (2006) Meta-analysis of flavonoids for the treatment of haemorrhoids. British Journal of Surgery 93(8), 909-920. [Abstract]
American Gastroenterological Association (2004a) American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 126(5), 1463-1473. [Free Full-text]
American Gastroenterological Association (2004b) American Gastroenterological Association medical position statement: diagnosis and treatment of hemorrhoids. Gastroenterology 126(5), 1461-1462. [Abstract] [Free Full-text]
Balasubramaniam, S. and Kaiser, A.M. (2003) Management options for symptomatic hemorrhoids. Current Gastroenterology Reports 5(5), 431-437. [Abstract]
BNF 64 (2012) British National Formulary. 64th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Cataldo, P., Ellis, C.N., Gregorcyk, S. et al. (2005) Practice parameters for the treatment of hemorrhoids (revised). Diseases of the Colon & Rectum 48(2), 189-194.
Chemist & Druggist (Ed.) (2012) Guide to OTC medicines & diagnostics for pharmacists & pharmacy assistants. 31st edn. Tonbridge: CMP United Business Media.
Fleury, A. (2011) Perianal granuloma. Electronic Medicines Compendium..WebMD.www.emedicine.com [Free Full-text]
Friedman, S.L., McQuaid, R. and Grendell, J.H. (2002)
Hussain, J.N. (1999) Hemorrhoids. Primary Care: Clinics in Office Practice 26(1), 35-51. [Abstract]
Johanson, J.F. and Sonnenberg, A. (1990) The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 98(2), 380-386. [Abstract]
Kaidar-Person, O., Person, B. and Wexner, S.D. (2007) Hemorrhoidal disease: a comprehensive review. Journal of the American College of Surgeons 204(1), 102-117. [Free Full-text]
Kann, B.R. and Whitlow, C.B. (2004) Hemorrhoids: diagnosis and management. Techniques in Gastrointestinal Endoscopy 6(1), 6-11.
Ledward, R.S. (1980) The management of puerperal haemorrhoids. A double-blind clinical trial of Anacal rectal ointment. Practitioner 224(1344), 660-661.
Lee, A.Y. (1998) Allergic contact dermatitis from dibucaine in Proctosedyl ointment without cross-sensitivity. Contact Dermatitis 39(5), 261.
Lodi, A., Ambonati, M., Coassini, A. et al. (1999) Contact allergy to 'caines' caused by anti-hemorrhoidal ointments. Contact Dermatitis 41(4), 221-222.
Nagle, D. and Rolandelli, R.H. (1996) Primary care office management of perianal and anal disease. Primary Care 23(3), 609-620. [Abstract]
NICE (2005a) Referral for suspected cancer (NICE guideline). .Clinical guideline 27.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2005b) Referral guidelines for suspected cancer: quick reference guide. .Clinical guideline 27.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Nisar, P.J. and Scholefield, J.H. (2003) Managing haemorrhoids. British Medical Journal 327(7419), 847-851. [Free Full-text]
Orkin, B.A, Schwartz, A.M. and Orkin, M. (1999) Hemorrhoids: what the dermatologist should know. Journal of the American Academy of Dermatology 41(3 Pt 1), 449-456. [Abstract]
Quijano, C.E. and Abalos, E. (2005) Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium (Cochrane Review). The Cochrane Library.Issue 3.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Rakinic, J. (2011) Rectal prolapse. emedicine..WebMD.www.emedicine.com [Free Full-text]
Ramji, A. (2012) Villous adenoma. emedicine..WebMD.www.emedicine.com [Free Full-text]
Reese, G.E., von Roon, A.C. and Tekkis, P.P. (2009) Haemorrhoids. Clincial Evidence..BMJ Publishing Group. [Free Full-text]
Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.
Smith, R.B. and Moodie, J. (1988) Comparative efficacy and tolerability of two ointment and suppository preparations ('Uniroid' and Proctosedyl') in the treatment of second degree haemorrhoids in general practice. Current Medical Research and Opinion 11(1), 34-40. [Abstract]
Studd, P. (2005) Haemorrhoids: prevention and treatment. Nursing in Practice 25(Nov-Dec), 50-53.
Tejirian, T. and Abbas, M.A. (2005) Sitz bath: where is the evidence? Scientific basis of a common practice. Diseases of the Colon & Rectum 48(12), 2336-2340. [Abstract]
van Ketel, W.G. (1983) Contact allergy to different antihaemorrhoidal anaesthetics. Contact Dermatitis 9(6), 512-513.
Zagrodnik, D.F. (2011) Fistula-in-ano. emedicine..WebMD.www.emedicine.com [Free Full-text]