“We treat people, not just problems.”
John L. Pfenninger, M.D.
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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