The
“We treat people, not
just problems.”
John
L. Pfenninger, M.D.
(989) 631-4545
Visit our
website at: MPCenter.net
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.
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 rubber
band 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 do not 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.
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.)
Rubber band 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.
If we use infrared coagulation (IRC), 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. Do not 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 or Nuprin, etc.) approximately
an hour before coming to the office. You
might want to schedule the procedure later in the day so that you do not 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. Do not overdo it! You just need enough to keep the stool
soft. Remember to drink plenty of water.
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 with a flexible sigmoidoscopy or colonoscopy 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/colonoscopy)
or even more extensive testing should be done beginning at age 35. If you are 50 years of age or older, it
should be done now and every five years thereafter to screen for colon cancer.
Copyright, 2011.
John L. Pfenninger, M.D. jw02/11