What criteria should I use to decide whether to refer a patient with h

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

To determine whether to refer a patient with haemorrhoids for surgical intervention, consider the following criteria:

Urgent Referral/Admission Criteria:

Extremely painful, acutely thrombosed external haemorrhoids if the patient presents within 72 hours of onset, as reduction or excision may be needed .
Internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed, as haemorrhoidectomy may be needed .
Perianal haematoma if symptoms are less than 24 hours old, for clot evaluation .

Non-Urgent Referral for Assessment and Management (where surgery may be considered):

Fourth-degree haemorrhoids or third-degree haemorrhoids that are too large for non-operative measures, as haemorrhoidectomy may be needed .
Combined internal and external haemorrhoids with severe symptoms, as surgery may be required .
Thrombosed haemorrhoids when bleeding is problematic, or there is chronic irritation or leakage .
Large skin tags, as surgical excision may be required .
Patients who do not respond to conservative treatment .
Patients with recurrent symptoms who do not respond to primary care management .

What criteria should I use to decide whether to refer a patient with haemorrhoids for surgical intervention?