• Present as bright red PR bleed separate from (and usually after) normal brown stool. If painless and normal PR examination, patient can be discharged with outpatient flexible sigmoidoscopy arranged.

• Exceptions are painful piles. These can represent external/prolapsed piles and thrombosed external piles. Prescribe analgesia and consider admission.

• Presents with pain on defecation. Can occur with or without small amounts of bright red PR bleeding.

  • Prescribe stool softener.

  • Analgesia.

  • Treatment:

    • First choice: Glyceryl trinitrate 0.4% rectal ointment, 2.5cm every 12 hours until pain stops. Max duration 8 weeks

      • Second choice if GTN if not effective or not tolerated: Diltiazem 2% ointment, apply twice daily until pain stops. Max duration 8 weeks

• Arrange outpatient follow up.

Caused by infection of one or more (hair containing) subcutaneous sinuses in the natal cleft. Presents as a painful swelling between the buttocks, with or without offensive discharge.

• May require admission for incision and drainage.

• Prescribe analgesia and IV fluids.

• NBM.

Present with dull throbbing pain and local inflammation. May be signs of sepsis particularly with ischiorectal abscess.

• May require admission for incision and drainage.

• Prescribe analgesia and IV fluids.

• NBM.

• Consider IV antibiotics if systemically unwell or diabetic (see Eolas)

Localised (usually) bacterial infection:

• Requires incision and drainage. This can be performed under local anaesthetic in A+E/SAU if appropriate.

• More extensive abscesses will require admission for GA.

• Antibiotics are not required as long as the infection is localised and the patient is not immunocompromised.

• If inflammation is extensive, spreading or if the patient is systemically unwell consider IV antibiotics. See Antimicrobial MicroGuide - Adult for appropriate treatment.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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