The
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"We treat people, not just problems." |
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John L.
Pfenninger, M.D. |
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Lori Oswald,
P.A.-C. |
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(989) 631-4545 |
Visit our Website at http://www.MPCenter.net
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PATIENT
EDUCATION INSTRUCTIONS |
Hemorrhoids are a very common problem. Many women have hemorrhoids secondary to
childbirth, but more men become symptomatic and actually need treatment.
Perhaps it is due to the heavy lifting that many of them do.
Hemorrhoids are nothing more than enlarged veins. When they occur in the lower
legs, we call them varicose veins. In the rectum they are called hemorrhoids or
"piles." There are multiple ways of taking care of hemorrhoids.
THE FIRST VISIT
In the past, most hemorrhoids were basically "tolerated" until they
became so bad that surgery was needed. Modern techniques have eliminated
surgical excision (cutting out) of hemorrhoids except in the most advanced
cases. You may have heard of the Baron ligation technique where a small
rubberband is actually put around the hemorrhoids. We have used this method for
many years. It is less painful than excision and can be carried out in the
office. Later, laser techniques were developed. Now, even more advanced
techniques are available using infrared coagulation, radiofrequency, and
low-dose electricity. These methods frequently provide excellent results with
less pain and less complications.
First let's describe the various TYPES OF HEMORRHOIDS.
Internal hemorrhoids: Just as you have light skin meeting the dark skin
around your lips, there is a similar "line" of tissue in the rectum
called the pectinate line. Internal hemorrhoids start above this line and are
easier to treat because they are in an area where there are no pain fibers. The
"line" is visible to the physician when the exam is done with a small
instrument called the anoscope. Internal hemorrhoids tend to bleed and can
"fall out."
External hemorrhoids: Hemorrhoids that start below the pectinate line.
These hemorrhoids are more difficult to treat because they start in an area
that does have pain fibers. They tend to get clots, which are very painful.
Mixed hemorrhoids: These hemorrhoids are actually a combination of the
above two types. Often, they can be treated, but they may be a little more
painful for a week or two after the treatment.
Thrombosed hemorrhoids: These are hemorrhoids which have developed a
small clot inside the vein. These clots don't cause any major problems. They
are not like clots in the leg which can be dangerous. Rather, these small
clots just cause severe pain. If you develop very severe discomfort with an
inability to even sit down, then you probably have a small clotted hemorrhoid.
Frequently you can feel a tender lump. These are quite easily treated in the
office by just removing the clot. Pain resolves in 12-24 hours. If left alone
they may cause pain for up to 1 week.
Prolapsed hemorrhoids: Many times a hemorrhoid will protrude through the
anal (rectal) area. Many people will call these "external
hemorrhoids", but that isn't technically a correct definition. The
hemorrhoid is classified from where it starts. Usually when these hemorrhoids
protrude out through the anal area, the base will be above the pectinate line
so they are actually an internal hemorrhoid. Sometimes these prolapsed
hemorrhoids will come down and then go back up. Other times, they will stay
down.
Skin tags: Often, even after the hemorrhoid or vein goes away, the skin
will have been stretched and will remain as a skin tag or an accumulation of loose,
stretched out skin. Many people are bothered by these since, although not
painful, they pose a real problem in keeping the area clean.
TREATMENTS
Each different type of hemorrhoid or problem requires a different type of
approach. Depending on the problem that you have, a particular instrument will
be used for the treatment. Below are the TYPES OF TREATMENTS that could
possibly be employed:
Hemorrhoidectomy: This is a surgical procedure where the hemorrhoids are
actually cut out with a knife or laser. It is reserved for only the most
advanced cases. This is usually done in the hospital operating room under
general anesthesia. Small accumulations of external hemorrhoids or tags can be
removed in the office. (Removing clots is also a simple 10-minute office
procedure.)
Rubberband ligation: This technique is still used frequently by many
physicians. It will treat many of the categories of internal hemorrhoids and
should cause no pain. It is also known as "Baron ligation."
Infrared coagulation (IRC): This procedure requires the application of
infrared light to the base of the hemorrhoid. This light is of the appropriate
wavelength to actually clot the hemorrhoid. There are usually 3 different areas
of hemorrhoids. One area or complex is treated at each office visit. The
infrared unit is applied four different times for 1.5 seconds to each complex.
Although the patient will occasionally feel a little warmth, there generally is
minimal pain or discomfort. The patient is allowed to return to work the same or
the next day. (Occasionally there will be a little bleeding between 4 and 10
days after treatment.) The patient then returns in approximately 1 month for
follow-up treatment. One to four visits may be needed.
BICAP: This method uses high-frequency electrical current to seal off
the hemorrhoid. The probe is applied for 2 seconds, 2 or 3 times. It can only
be used on internal hemorrhoids.
Radiofrequency surgery: With this unit, a very high frequency radio wave
is used to cut out external skin tags. The radiofrequency is the same as used
on your AM radio! The advantage to this technique is that it will prevent
bleeding frequently associated with excision of these tags. Also, very little
other tissue is damaged using this technique. It is similar to a laser procedure
and has actually replaced much laser surgery. Because this technique involves
removal of skin, the patient will be more tender for a longer period of time
(3-4 weeks) until the wound is healed.
PREPARATION FOR THE VISIT
If we use infrared coagulation (IRC), or the BICAP unit, or the rubber band
ligator, you do not have to lose any time from work. It might be best if you
could take it easy for a couple days after the procedure. Prior to coming in,
take one enema approximately an hour before the planned surgery. Hold the enema
for 5 to 10 minutes and then expel it. Fleets enemas, available without
prescription at the pharmacy, or tap water enemas are fine. After the
procedure, you may have some mild discomfort for several days. Expect some
weeping and some spotting of blood for up to several weeks. However, you should
be able to do most normal activities within a few days. Often little or no pain
medication is needed. Don’t be surprised if there is a little more bleeding
around 10-14 days after the procedure when the scab falls off.
Take four 200 mg ibuprofen (800 mg total – Advil, Motrin, Nuprin, etc.)
approximately an hour before coming to the office. You might want to schedule
the procedure later in the day so that you don't have to go back to work. Also,
you will find it much easier if you have soft stools. You may want to take a
stool softener such as Metamucil or Citrucel for a few days prior and
after the procedure. Don't overdo it! You just need enough to keep the stool
soft. Remember to drink plenty of water.
POST-SURGERY CARE
Whichever technique is used, it is very important that you maintain a high
bulk diet (a lot of fruits, vegetables, bran, etc.) so that your stool
remains soft. Drink at least 4-5 glasses of water per day. Many people feel
that sitz baths do the most good for discomfort. In this case, just sit
in a good hot bath for 20-30 minutes 3-4 times per day. It may help to apply an
ointment 2 or 3 times a day to keep the areas from rubbing together. Your
doctor may prescribe some Xylocaine or antibiotic ointment. Use them as
directed. Ice bags may also help relieve unexpected discomfort.
Complications: These include pain, bleeding, infection, return of the
hemorrhoids, and failure of the treatment itself so the hemorrhoids persist.
For any of these procedures, if you have extreme pain, more bleeding than you
expect, or develop fevers, chills, or sweats, call the office at once to
discuss with the doctor. Also call if you have difficulty urinating. You should
make a follow-up appointment in 4 weeks.
SPECIAL NOTE
Sometimes hemorrhoids can be caused by a tumor in the bowel. Your physician may
suggest screening you with a flexible sigmoidoscopy either prior to or after
treatment. Be sure to discuss this with the physician. If you have a family
history of colon cancer, this test (flexible sigmoidoscopy) or even more
extensive testing should be done beginning at age 35. If you are 50 years old
or older, it should be done now and every five years thereafter to screen for
colon cancer.