Haemorrhoid Surgery

v1.0 January 2025

Policy:

This is a national Evidence Based Intervention policy formally adopted by Hertfordshire and West Essex Integrated Care Board. Please see https://ebi.aomrc.org.uk/

This procedure involves surgery for haemorrhoids (piles).

Criteria

Haemorrhoids are swellings that develop inside and outside the anus. The majority of haemorrhoids are not a sign of severe pathology and can be managed conservatively. Conservative management of haemorrhoids (especially lower grade haemorrhoids) include lifestyle changes e.g. avoiding straining, eating more fibre or drinking more water.

For patients who cannot be managed conservatively, depending on the size and severity of the haemorrhoids they may be suitable for outpatient therapy in the form of rubber band ligation or injection.

Surgical treatment should only be considered for: 

• Persistent grade 1 (rare) or 2 haemorrhoids that have not improved with non-operative measures.
  
  
• Severe (grade 3 or grade 4), which combine internal/external haemorrhoids with persistent pain or bleeding;
  
  
• Irreducible and large external haemorrhoids.
   

There are a variety of surgical options that are available to patients with severe haemorrhoid. These include: 

• Stapled haemorrhoidoplasty.
  
  
• Haemorrhoid artery ligation operation.
  
  
• Radiofrequency ablation of haemorrhoids.
  
  
• Excisional haemorrhoidectomy.  

For patients who meet the criteria for surgery, a shared decision-making process should be used to support the choice of intervention taking into account patient’s choice, severity of haemorrhoids and medical comorbidities.

This guidance is reflective of current known and approved interventions, however in the future, new surgical treatment options may be developed. Once the potential new techniques are shown to be safe and effective by NICE, they should be included in the consenting process.

In cases where there is significant rectal bleeding the patient should be examined internally by a specialist.

Rationale for Recommendation

Haemorrhoid surgery can lead to complications. Pain and bleeding are common, and pain may persist for several weeks. Urinary retention can occasionally occur and may require catheter insertion. Infection, iatrogenic fissuring (tear or cut in the anus), stenosis and incontinence (lack of control over bowel motions) are rare complications. Therefore, surgery should only be performed in cases of:

• Persistent grade 1 (rare) or grade 2 haemorrhoids that have not improved with dietary changes, rubber band ligation or injection;

  OR

• Grade 3 and 4 haemorrhoids;

  OR 

• Those with a symptomatic external component.
   

It is recommended that as part of the consultation process a shared decision making process is used to support the choice of intervention. The patients preferred treatment option will need to be considered alongside other factors such as general health status, severity of haemorrhoids and local availability.

Patient Information

Information for Patients
Surgery to treat haemorrhoids, commonly known as piles, should only be carried out for certain patients. There are many alternative and non-invasive treatments for treating haemorrhoids that should be considered before surgery.

What you can do about the condition
Haemorrhoids are swellings containing enlarged blood vessels found inside or around your bottom. In some cases, haemorrhoids are little more than a nuisance and you may not be too bothered by them. You might experience soreness, redness and swelling around the anus, bleeding when straining on the toilet, have blood in your poo or have a lump hanging down outside your anus which may need to be pushed back in after going to the toilet. 

You should talk to your doctor if you have these symptoms to ensure the underlying cause is haemorrhoids and not something more serious. If confirmed, you should make a shared decision about what’s best for you. If your haemorrhoids are becoming a problem, you should both consider the benefits, the risks and the alternatives to surgery and what will happen if you do nothing.
 

What are the BENEFITS of the intervention?
Surgery is effective for haemorrhoids that hang down and have to be pushed back or which remain permanently outside the anus. It can also be considered if you have tried alternatives first and they have not worked.
 

What are the RISKS?
When considering surgery, it is important to consider the significance of your symptoms, the benefits of surgery and the complications. The risks of haemorrhoid surgery may include infection, pain, bleeding, urinary retention, fissuring (a tear or cut in the anus), stenosis (narrowing of your anus) and in rare instances faecal incontinence (lack of control over bowel motions).
 

What are the ALTERNATIVES?
Often less severe haemorrhoids can be treated by simple measures including eating more fibre, drinking more water and avoiding straining on the toilet. Laxatives can be helpful to soften your stool. There are also other treatments that will help alleviate the symptoms of haemorrhoids, such as creams, ointments and suppositories. Some types of haemorrhoids can be treated without the need for surgery by specialist doctor in an outpatient clinics.
 

What if you do NOTHING?
Once a diagnosis of haemorrhoids has been made, doing nothing, isn’t likely to be harmful. Haemorrhoids often cause little more than discomfort and treatment should be tailored to your symptoms and based on a clinical assessment of the severity of condition.

Further information can be found at https://ebi.aomrc.org.uk/interventions/haemorrhoid-surgery/
This weblink was correct as of 27/11/2024.

References

1.   Watson AJM, Bruhn H, MacLeod K, et al. A pragmatic, multicentre, randomised controlled trial comparing stapled haemorrhoidopexy to traditional excisional surgery for haemorrhoidal disease (eTHoS): study protocol for a randomised controlled trial. Trials. 2014;15:439. doi:10.1186/1745-6215-15-439.

2.   Watson AJM, Hudson J, Wood J, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet (London, England). 2016;388(10058):2375-2385. doi:10.1016/S0140-6736(16)31803-7.

3.   Brown SR. Haemorrhoids: an update on management. Therapeutic Advances in Chronic Disease. 2017;8(10):141-147. doi:10.1177/2040622317713957.

4.   NHS website: Conditions – piles haemorrhoids

5.   Royal College of Surgeons and The Association of Coloproctology of Great Britain and Ireland (2017) Commissioning guide: Rectal Bleeding.

6.    Health Technol Assess. 2016 Nov;20(88):1-150. The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic Brown S et al.