• Refer urgently:
• People with suspected malignancy.
• Consider admitting:
• People with extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset for assessment, reduction or excision. Excision under local anaesthetic effectively relieves pain.
• 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.

In depth