Acute thrombosed external hemorrhoid
Adult with a sudden, painful lump at the anal verge
All Pathways
Colorectal SurgeryEmergency
Acute Thrombosed External Hemorrhoid Management (ASCRS 2024)
Acute Thrombosed External Hemorrhoid Management (ASCRS 2024): Acute thrombosed external hemorrhoid → Clinical assessment → Examination: confirm the diag...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Clinical assessment
History: onset, pain trend, bleeding, medicines and pregnancy
- Sudden painful, non-reducible lump at the anal verge
- Time since onset, and is the pain getting worse or settling?
- Anticoagulant or antiplatelet use; bleeding disorder
- Pregnancy (weeks), kidney disease, peptic ulcer or GI bleed, heart failure
- Fever, spreading redness, pus, cannot pass urine
- Bowel habit, constipation, rectal bleeding
03Action Examination: confirm the diagnosis
Tense, tender, bluish lump below the dentate line, covered by skin
- Look for skin ulceration, necrosis, bleeding or spreading redness
- Digital rectal exam if tolerated (not if neutropenic); anoscopy if possible
- Exclude perianal abscess (fluctuant, fever), fissure, prolapsed internal hemorrhoids
- Prolapsed, irreducible or strangulated internal hemorrhoids: surgical referral, not this pathway
04Warning Before treatment: check pregnancy, bleeding risk, age and special risks
These change drug and procedure choices below. IBD, portal hypertension, immunosuppression or past pelvic radiotherapy: prefer conservative care; get surgical advice before excision.
- Pregnancy: avoid NSAIDs, and never from 20 weeks; use paracetamol (acetaminophen)
- Anticoagulant, antiplatelet or bleeding disorder: higher bleeding risk with excision
- Child: a perianal lump is rarely a hemorrhoid; get paediatric surgical advice
05Decision Necrosis, infection, sepsis or strangulation?
Black skin, foul smell, pus, spreading cellulitis, fever or systemic illness, or strangulated prolapse. Immunosuppressed or neutropenic: low threshold for urgent surgical review.
- If Yes
06Warning Yes: urgent surgical review today
Possible necrotic thrombosis, abscess, necrotising infection or strangulated internal hemorrhoids. Do not treat as a simple thrombosis. Admit if septic; ongoing care under the surgical team.
- Sepsis or spreading cellulitis: IV antibiotics per local guideline and theatre for debridement
- Pain or redness spreading beyond the lump: consider Fournier gangrene
- Necrotic thrombosis: surgeon excises all dead tissue, often in theatre
07Action Care after excision
Wound care and pain relief. Abscess or necrotising infection: care as the surgical team directs. NSAID only if none of: pregnancy, kidney impairment, peptic ulcer or GI bleed, heart failure, anticoagulant or antiplatelet drug.
- Warm sitz baths from day 1; keep the wound clean
- Paracetamol (acetaminophen); NSAID only if safe (see above)
- Stool softener and fibre
- Return at once if heavy bleeding, fever, spreading pain or cannot pass urine
- Wound usually heals in 2 to 3 weeks
08Action Follow-up and prevention
Review in 2 to 4 weeks if not fully settled
- Check that the wound has healed or the lump has resolved
- Fibre and fluids; avoid straining and long toilet sitting
- Ongoing rectal bleeding or change in bowel habit: investigate (for example colonoscopy); do not assume hemorrhoids
- Recurrent thrombosis: refer to colorectal surgery
09Outcome Expected outcome
Excision: faster relief and fewer recurrences. Conservative: most settle in 1 to 3 weeks.
- Excision: symptoms settled in about 4 days in one series
- Conservative: median full resolution 8 days (range 1 to 45 days) in one series
- Recurrence in one series: 6% after excision vs 25% after conservative care
If No10Decision No: excision or conservative care?
Decide with the patient, based on time since onset, pain severity and local expertise. Excision helps most when done early (usually within 72 h) for severe pain. There is no fixed time limit.
- Early or severe pain
11Action Early or severe pain: excision of thrombosed external hemorrhoid
Faster pain relief and fewer recurrences. On an anticoagulant or antiplatelet: plan haemostasis, do not stop the drug without the prescriber, or choose conservative care. IBD, portal hypertension, immunosuppression or pelvic radiotherapy: surgical advice first.
- Local anaesthetic: lidocaine 1% (10 mg/mL) with adrenaline. Adult max 7 mg/kg, not over 500 mg
- Elliptical excision of the clot together with the overlying skin
- Do not only incise and drain the clot: more rebleeding and recurrence
- Leave the wound open; haemostasis with pressure or cautery
- Clinic or ED procedure by a trained clinician
- Pregnancy: excision under local anaesthetic is still an option
- Path rejoins step 07Shared downstream outcome
- Settling, late or patient choice
12Action Pain settling, late, or patient choice: conservative care
Most settle in 1 to 3 weeks. No NSAIDs in pregnancy, kidney impairment, peptic ulcer or GI bleed, heart failure, or with an anticoagulant or antiplatelet drug.
- Paracetamol (acetaminophen) regularly
- NSAID only if none of the conditions above apply
- Warm sitz baths several times a day
- Topical anaesthetic, for example lidocaine gel
- Topical nifedipine with lidocaine may speed resolution (off-label; compounded in Australia)
- Stool softener and fibre; avoid straining
13Decision Review in 2 to 3 days: improving?
Review sooner if pain gets worse, the lump grows, or bleeding or fever starts
- If Yes
14Action Yes, improving: continue conservative care
Continue until the pain and lump settle
- Same measures; stop topical treatment when symptoms settle
- Return if pain gets worse, bleeding, fever or pus
- Path rejoins step 08Shared downstream outcome
If No15Action No, not improving or worse: offer excision
Excision can still be offered after 72 h if severe symptoms persist. Same technique and local anaesthetic limits as early excision.
- Indications: persistent severe pain, growing clot, ulceration or bleeding
- Anticoagulant or antiplatelet: plan haemostasis; do not stop the drug without the prescriber
- IBD, portal hypertension, immunosuppression or pelvic radiotherapy: surgical advice first
- Fever, spreading redness or pus: urgent surgical review (abscess or infection)
- Path rejoins step 07Shared downstream outcome
Guideline Source
ASCRS Clinical Practice Guidelines for the Management of Hemorrhoids (Hawkins et al., Dis Colon Rectum 2024;67:614-623)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Evidence is low quality. No guideline sets a fixed time limit for excision; decide with the patient.
- Not for prolapsed, strangulated or thrombosed internal hemorrhoids, or for children: refer to surgery.
- Anticoagulant and antiplatelet management around excision is not covered by the source guidelines; follow local advice.
- Topical nifedipine and diltiazem are off-label and compounded in Australia.
Contraindicated Populations
Children (perianal lump: paediatric surgical advice)Pregnancy: avoid NSAIDs (never from 20 weeks)Anticoagulant, antiplatelet or bleeding disorder: bleeding plan before excisionStrangulated or thrombosed prolapsed internal hemorrhoidsIBD, portal hypertension, immunosuppression or pelvic radiotherapy: surgical advice before excision
Applicable Regions
USEUAU
AU: Paracetamol is the Australian name for acetaminophen. Topical nifedipine and diltiazem are not ARTG-registered topical products and need compounding; glyceryl trinitrate 0.2% ointment (Rectogesic) is ARTG-registered. NSAIDs are TGA pregnancy category C.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Acute Thrombosed External Hemorrhoid Management (ASCRS 2024)?
The Acute Thrombosed External Hemorrhoid Management (ASCRS 2024) is a emergency clinical algorithm for Colorectal Surgery. It provides a structured decision tree to guide clinical decision-making, based on ASCRS Clinical Practice Guidelines for the Management of Hemorrhoids (Hawkins et al., Dis Colon Rectum 2024;67:614-623).
What guideline is the Acute Thrombosed External Hemorrhoid Management (ASCRS 2024) based on?
This algorithm is based on ASCRS Clinical Practice Guidelines for the Management of Hemorrhoids (Hawkins et al., Dis Colon Rectum 2024;67:614-623) (DOI: 10.1097/DCR.0000000000003276).
What are the limitations of the Acute Thrombosed External Hemorrhoid Management (ASCRS 2024)?
Known limitations include: Evidence is low quality. No guideline sets a fixed time limit for excision; decide with the patient.; Not for prolapsed, strangulated or thrombosed internal hemorrhoids, or for children: refer to surgery.; Anticoagulant and antiplatelet management around excision is not covered by the source guidelines; follow local advice.; Topical nifedipine and diltiazem are off-label and compounded in Australia.. Individual patient factors may require deviation from these recommendations.
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