Haemorrhoids – how we should treat them? What works and what doesn’t? Assoc Prof Jane Smith

Robina Journal Club 28/2/14 facilitated by Assoc Prof Jane Smith


Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician. 2011;84(2):204-10. Epub 2011/07/20.

The topic of Haemorrhoids was chosen after a GP registrar asked about how should we treat them and the pros and cons of different topical treatments for piles.

A search through MIMs showed that one of my favourite formulas had been deleted.

A subsequent search made me realise that although it appears an apparently simple and straightforward area, it was worthy of a journal club  to discuss issues

The article chosen summarised evidence highly relevant to general practice patients  from Cochrane reviews and National Guideline clearing house.

What did “we” learn?

It is estimated that about 4.4% of adults have piles, more commonly over the age of 45 years.

Some of us did not understand the correct definition of internal and external haemorrhoids, as depending on originating above or below the dentate line, suggesting that internal haemorrhoids are unlikely to be innervated and cause pain.

Take home messages:

Rectal bleeding needs appropriate investigations (colonoscopy) if young and no obvious local cause, and even if obvious source (of bleeding) found colonoscopy is indicated in those over 40  depending on whether risk factors are present (family history, iron deficiency anaemia , and colonoscopy previous 10 years) as specified in article.

There is good quality evidence that fibre supplements (psyllium, sterculia or bran) will reduce bleeding, pain, prolapse and itching.

Although we all prescribe topical preparations (such as steroids, anaesthetics, antiseptics)  there is no evidence from RCTs about their effects.

Sitz baths although popular have not been found to provide any benefit in trials

There is evidence about topical nifedipine with local anaesthetic, causing more pain relief for thrombosed piles than topical local anaesthetics, although incision or excision of thrombus within 72 hours gives the most rapid relief.

If conservative management fails to relieve, then rubber band ligation appears the best option, although it is suggested that warfarin and anti-platelet agents such as aspirin need to be stopped.

If all else fails excisional haemorrhoidectomy operation is indicated for the most severe variety (grades 3 and 4). Although this results in the most pain post operatively topical metronidazole, diltiazem, and topical nitroglycerin all reduce this pain.

To read the full paper, click on the link below:

Hemorrhoids AmFP