Surgical Removal of Piles

What is surgical removal of piles?

Piles or haemorrhoids are swellings that develop inside and around the back passage (anus). Symptoms range from temporary and mild, to persistent and painful. In many cases, piles are small and symptoms settle down without treatment.

Surgical removal of piles (haemorrhoidectomy) can be used for third or fourth degree haemorrhoids, or for piles that are large and cannot be pushed back inside the anus (irreducible). It is usually carried out under general anaesthetic, which means the patient will be asleep during the procedure and won't feel any pain while it is carried out.

Patient eligibility for the treatment option varies by haemorrhoid severity or grade one to four. Internal haemorrhoids are classified by the degree that the internal piles that protrude (prolapse) out of the back passage (anus) which helps determine management:

• grade one: no prolapse
• grade two: prolapse that goes back in on its own
• grade three: prolapse that must be pushed back in by the patient
• grade four: prolapse that cannot be pushed back in by the patient (often very painful).

Not normally funded treatment or procedure:

Haemorrhoidectomy for grades one or two are not normally funded by the patient’s local NHS commissioning organisation. This is because treatment of bleeding haemorrhiods depends on the degree of prolapse and severity of symptoms. A procedure in which the haemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the haemorrhoid (rubber band ligation) is currently the best available outpatient treatment for haemorrhoids with up to 80% of patients satisfied with short term outcomes.

Patient eligibility criteria:

Haemorrhoidectomy for grades three or four will be funded if the patient meets one or more of the
following criteria:

• recurrent grade three or grade four combined with persistent pain or bleeding OR
• irreducible and large external haemorrhoids.

This is because removing the piles or haemorrhoidal tissue by cutting it away (excisional haemorrhoidectomy) is more effective than which the haemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the haemorrhoid (rubber band ligation) in the long term and is the treatment of choice for recurrent grade two haemorrhoids and grade three/four haemorrhoids.

The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

Advice and further guidance:

Preventing and treating haemorrhoids:

Haemorrhoid symptoms often settle down after a few days without needing treatment. Haemorrhoids that occur during pregnancy often get better after giving birth. Making lifestyle changes to reduce the strain on the blood vessels in and around the patients anus is often recommended.

These can include:
• gradually increasing the amount of fibre in the patients diet – good sources of fibre include fruit, vegetables, wholegrain rice, wholewheat pasta and bread, pulses and beans, seeds, nuts and oats
• drinking plenty of fluid – particularly water, but avoiding or cutting down on caffeine and alcohol
• not delaying going to the toilet – ignoring the urge to empty the bowels can make the patients stools harder and drier, which can lead to straining when the patient does go to the toilet
• avoiding medication that causes constipation – such as painkillers that contain codeine
• losing weight if the patient is overweight
• exercising regularly – this can help prevent constipation, reduce the patients blood pressure, and help with weight loss.

These measures can also reduce the risk of haemorrhoids returning or even developing in the first place. Medication that is applied directly to the patients back passage (topical treatments) or tablets bought from a pharmacy or prescribed by the patients GP may ease the symptoms and make it easier to pass stools.

For more information search for ‘haemorrhoids’ at www.nhs.uk

Treatment policy for patients covered by NHS Solihull, Birmingham CrossCity and Birmingham South Central Clinical Commissioning Groups.

Download the pdf leaflet here

Download the Treatment Policy Detail here.

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