HEMORRHOIDS!!!
Did you know you were born with hemorrhoids? What? Yes, you read that right. A hemorrhoid is a vascular cushion inside the anal canal and rectum. There are two different types, Internal and external.
I would estimate that 75% of my referrals for anorectal complaints are for hemorrhoids. Of those, only about 25% are actually hemorrhoids. The truth is that most people don’t really know what a hemorrhoid is or looks like (although google images and a hand-held mirror have educated some brave souls). Patients often assume that anything that is irritating down there must be due to hemorrhoids.
Internal hemorrhoids: They don’t hurt. Yes, you read that right. Internal hemorrhoids don’t truly cause pain. They are technically above the dentate line so there are no pain sensors. Internal hemorrhoid symptoms present as itching, pressure, seepage, bleeding, protrusion and difficulty cleaning. If you have severe pain and burning, then an internal hemorrhoid is probably not the issue.
What causes a symptomatic internal hemorrhoid? Spicy foods and foods like garlic, onions and tomatoes are very irritating to the digestive tract, so this can cause some irritation and bleeding. The main culprit is poor bowel habits. If you take your phone or a book in the bathroom to have a bowel movement, then you are at risk. Prolonged toilet time will cause increased pressure and congestion of the hemorrhoids. Hard stool and straining and even diarrhea can lead to symptoms.
Treatment: I only offer surgery to patients who have made an effort to correct their bowel habits. This is because hemorrhoids can come back after surgery and hemorrhoid surgery is often extremely painful. If bowel habits are corrected and toileting behaviors are corrected, most of the time symptoms will resolve and people won’t need surgery. With the exception of grade 4 hemorrhoids (non-reducible), most patients can avoid surgery altogether. If surgery is indicated, your surgeon will choose the best approach based on size and status of your health.
Fiber: psyllium husk, in my opinion, is just the best. It is a bulking agent- fluffs the stool up nicely when water intake is adequate. There are other supplements but I really think this works the best. Adults need about 25-35 g of fiber per day and the majority of us don’t get to that number. 64 oz of water is also recommended but that is often a tough goal as well. Fiber supplementation can help fluff up the stool so less pressure and force is needed to have a BM. This will decrease trauma to the anal canal and help with hemorrhoid symptoms.
External Hemorrhoids: Now these are the ones that do hurt. An external hemorrhoid is also a vascular bundle right at the edge of the anal opening. Straining, constipation, diarrhea, pregnancy and heavy lifting can cause external hemorrhoid symptoms. The most painful is a thrombosed external hemorrhoid. An acute increase in intraabdominal pressure (i.e. bearing down to have a bowel movement or lifting something heavy) can cause a vein in the hemorrhoid to tear leading to a quickly growing clot. That clot has nowhere to expand other than that tiny little hemorrhoidal compartment. So you get this often scary looking purple, large lump at the edge of the anal opening. Boy do those hurt!
Treatment: Most colorectal surgeons recommend hemorrhoid surgery within the first 72 hours of the thrombosis. After that, we will tell you to treat it with sitz baths (Epsom salt and water), witch hazel, topical creams, fiber and stool softeners. Why not surgery? Well, the maximum pain occurs in the first 72 hours, after that the pain will decrease and be manageable. The swelling will often take weeks to resolve while your body works to absorb that clot. Removing the hemorrhoid surgically after 72 hours will lead to surgical pain, which is just as, if not more painful than the hemorrhoid.
The after effect of a thrombosed hemorrhoid is often a skin tag. Those are those floppy redundant skin folds that people seem to be the most self-conscious about. I see these in women who have been pregnant or in patients who have had a history of thrombosed external hemorrhoids. More reason to love your children! These tags can only be removed surgically. There is no rubber band or laser that will treat them. Sorry…
Most of the time I will offer excision if the patient complains of irritation and problems keeping their anal area clean. Be warned however, that that a perfectly smooth anus is likely never going to happen again. Scarring will occur from surgery! As long as that is kept in mind, then most people will be satisfied with the result.
When should you see a doctor? Rectal bleeding for me is always a concern. Most of the time it is benign but with colorectal cancer rates increasing in young people these days, I think that it is always better to be safe than sorry. When a patient younger than 45 without a colorectal cancer family history comes in for rectal bleeding, I will perform anoscopy in the office. An anoscope is a small lighted tube-like tool that is inserted into the anus. I can see part of the rectum and the entire anal canal. If there is no obvious hemorrhoid or other thing that can cause bleeding, I will always recommend a more thorough exam such as a colonoscopy. SO if you have rectal bleeding that is persistent without pain, see us sooner than later!