Try Googling hemorrhoids. In fact, just type the first three letters, “hem,” and you will soon discover the worldwide interest in the topic. The misspelled “hemroid” draws a staggering 48 million hits, and when spelled correctly, “hemorrhoid” finds an additional 5 million. Ahh, who could ever spell “hemorrhoid” anyways?
Internet privacy allows patients to learn more about topics they wouldn’t otherwise discuss. Let’s face it; some diseases—such as breast cancer—garner valued public attention. During breast cancer awareness month, The White House glows in pink, airlines paint ribbons on their fleet of planes and even staple items like Morton Salt advertise this coveted cause on millions of their cans. A similar awareness for anorectal disease? Simply doesn’t exist. Never will. So, the world turns to the privacy of the Internet for answers.
Patients usually present with anorectal pain or bleeding…or both. Often, a history of constipation or diarrhea can be elicited. Chronic, symptomatic hemorrhoids are typically associated with a protracted history of constipation and, sometimes, laxative abuse. Constipation may be defined as either straining during defecation or simply infrequent bowel movements. Internal hemorrhoids don’t cause severe pain and usually present with painless, bright red blood per rectum. Remember to rule out proximal colonic pathology in this circumstance. When patients present with predominant pain (often confirmed by an obvious lean to one side during the exam room interview), be sure your differential diagnosis includes thrombosed external hemorrhoid.
Thrombosed External Hemorrhoid
Typically, men will give a history “straining” while at the gym or lifting a heavy object. But men, remember, often have trouble putting two and two together, so you have to nag for this part of the history. You see, while male patients may describe themselves as Joe Six Pack, with constant probing, an “Oh yeah, I did help my buddy move a fridge up two flights of stairs…and come to think of it…(as if struck by a rare ray of genius)…that’s about the time my butt started hurtin’ me!” Go figure! Women, in general, are better historians. While heavy lifting and exercise are instigating factors, often a thrombosed external hemorrhoid in women is related to straining with defecation and vasalva. Prototypically, this is a peripartum mother.
Fiber, water, warm tub soaks, topical creams—these are the mainstays of initial therapy. Even the most aggressive colorectal surgeon would at least include these measures as part of the therapy plan. That’s right; even surgeons realize the importance of medical management! Treatment does have to be tailored and individualized. Mild hemorrhoidal disease is best treated with a bulking agent, ample water consumption and liberal use of tub soaks. The purpose of warm water is mainly to relax the sphincter mechanism, which can cause moderate to severe pain when it’s in spasm. Improving fiber consumption to 25-30 grams/day will help keep bowel movements soft and formed; eight to ten glasses of water is necessary to facilitate fiber’s action. Topical, steroid-based creams are also advocated and work by reducing pain, swelling, and edema.
The Society of Colon and Rectal Surgeons does not advocate use of Epsom salts, but so many patients ask about this that I thought to include this brief synopsis. Epsom salt is simply magnesium sulfate. The name derives from the town of Epsom, England, which has been renowned for its mineral-rich waters since Shakespeare’s day. Magnesium salts absorb through the skin, and the belief is that this reduces stress and “draws our toxins from the body.” OK. So, it’s voodoo. I am not aware of any clinical or scientific data that demonstrates a proven advantage to using Epsom salts with tub baths, however, I can’t say it’s harmful either! There may even be a placebo effect, as well. For this reason, I leave its use optional.
As always, treatment should be tailored.
General Guidelines follow:
Presenting problem: Bleeding internal hemorrhoids
Treatment: Banding if redundant and infrared coagulation (IRC) if hemorrhoidal cushion is relatively flat. Note: IRC is not indicated for external hemorrhoidal disease.
Presenting problem: Prolapse internal hemorrhoids
Treatment: Can still consider rubber band ligation. Newer techniques show promise, such as Doppler-guided hemorrhoid artery ligation. Procedure for prolapse hemorrhoids is an option, particularly when the external hemorrhoids aren’t involved.
Presenting problem: Thrombosed external hemorrhoids
Treatment: Complete excision (not lancing) versus conservative therapy
Presenting problem: Grade IV, incarcerated hemorrhoids with necrosis
Treatment: Standard surgical hemorrhoidectomy
By Sam Attalah, MD
Sam Atallah, MD, FASCRS, FACS is Director, Division of Colorectal SurgeryEndo-Surgical Center of Florida. is among the most well known colorectal surgeons in the world. He moved to Orlando in 2007 after completing training at Houston’s Texas Medical Center with Surgical Oncology training at MD Anderson Cancer Center where his training had earned him double-board certification in General Surgery and Colorectal Surgery. Two years to the day after completing fellowship training in colon & rectal surgery, Dr. Atallah performed the world’s first TAMIS operation in Winter Park, FL on June 30, 2009. This created a new approach to treating rectal cancers and polyps, that is now being practiced in more than 50 countries. Dr. Atallah pioneered robotic transanal surgery and was the first in the world to perform this technique. He is one of the leaders in advanced technology for rectal cancer surgery and has developed the technique of stereotactic navigation for transanal total mesorectal excision (taTME) — an important step forward in the evolution of computer-assisted surgery. Complex treatment of rectal cancer and surgical management of this disease through the new techniques of TAMIS and taTME represent Dr. Atallah’s principal interests in colorectal surgery and he is currently producing a textbook on these topics scheduled for 2019 publication by Springer Nature. He is also actively involved in the design and assessment of next-generation robotic systems that will be smaller, sleeker, and able to work in places and spaces never before imagined. To schedule an appointment or to refer a patient to Dr. Atallah, please call 407-384-7388.