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Other
General Surgery
Referral Guidelines
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Home | Guideline Alphabetical | Guidelines by Specialty | Clinical Guidelines | Treatment Guidelines |
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VA/DOD Guidelines | MEDCOM Guidelines | Provider Resources | Madigan Army Medical Center |
General Surgery
Hemorrhoids
Diagnosis/Definition
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Engorgement of a cushion of perianal venous plexus noted on external or endoscopic anal examination.
They may cause bleeding, itching or pain.
Initial Diagnosis and Management
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Patients suspected of having hemorrhoids should undergo a visual and digital examination. Those patients in the defined demographic should be inquired as to most recent endoscopic evaluation.
Hemorrhoids are graded as follows:
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First degree: anal cushions are present above the dentate line.
Second degree: cushions may prolapse below the dentate, but reduce spontaneously.
Third degree: prolapsed cushions must be manually reduced.
Fourth degree: nonreducible cushions.
First and second-degree hemorrhoids should be treated with stool softeners and bulking agents (e.g. psyllium).
Third and fourth degree hemorrhoids usually require surgical intervention.
Ongoing Management and Objectives
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Symptom relief is the main objective.
More aggressive stool softening may be tried if necessary.
Indications for Specialty Care Referral
Patients with third and fourth degree hemorrhoids or those patients with uncontrollable symptoms despite aggressive medical management should be referred to the General Surgery Clinic.
Criteria for Return to Primary Care
If an operation is not indicated, the patient will return to primary care for follow-up. If an operation is undertaken, the patient will return to primary care about one month post-operatively.
Last Review for this Guideline:
October 2007
Referral Guidelines require review every three years.
For more information about the guidelines, or if you are interested in making changes or new submissions please contact: The Clinical Guidelines Administrator.
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