Hemorrhoids are vascular cushions which are part of the normal anatomy and are present at birth. Hemorrhoids line the anal canal and skin outside the anus in columns. They normally engorge with blood during bowel movements to cushion the anal canal and then quickly shrink at the completion of the movement. People may develop symptoms from their hemorrhoids if they enlarge, inflame or fail to shrink after bowel movements. Symptoms may include bleeding, discomfort, swelling, protrusion, and difficulty cleaning. Hemorrhoid symptoms are very common and affect approximately half of the adult population by the age of 50, with significantly more women affected than men.
While many activities have been implicated in causing hemorrhoid symptoms, and the exact mechanism of the problem is not completely understood, they generally occur from prolonged swelling and enlargement of the tissues. This is usually the result of straining, sitting on the commode for long periods of time, straining during labor and lifting heavy items. The connective tissues and vascular tone of the blood vessels in the hemorrhoids may also deteriorate with age and exacerbate symptoms.
While hemorrhoids can be an embarrassing condition, there is no reason to avoid seeking treatment when they cause discomfort, swelling or bleeding. Additionally, symptoms from hemorrhoids frequently overlap with those of other anal conditions such as fissures, fistulas, dermatitis and cancer. Thankfully, these conditions can typically be diagnosed with a simple office examination. While the majority of hemorrhoid patients can be managed non operatively and in the office, some cases can progressively worsen over time.
Internal hemorrhoids are located inside the anus. These hemorrhoids generally cause little discomfort, and in many cases, the patient is not aware of their existence unless the hemorrhoid bleeds during a bowel movement. This bleeding is noticeable as bright red blood on toilet tissue or in the toilet bowl. Blood may also be visible on the stool itself. Internal hemorrhoids may also prolapse out of the anus and cause a feeling of pressure. Straining during bowel movements may result in prolapsed internal hemorrhoids that recede back inside spontaneously or with gentle pressure. More advanced cases may become stuck outside.
External hemorrhoids are located just outside the anus at the anal verge. These also swell during bowel movements and straining. External hemorrhoids may cause moderate to severe discomfort, difficulty cleaning, swelling and occasional bleeding. In some cases this swelling may result in the formation of a blood clot in the hemorrhoid. While not a danger to the patient, this can be a very painful condition and is termed a thrombosed external hemorrhoid.
The first steps in managing hemorrhoid symptoms at home include dietary and bowel movement modification, soaks, and topical cream use. Patients should prevent hard bowel movements and straining with oral stool softeners such as Colace and fiber supplementation such as Metamucil, Citrucel, Benefiber or Konsyl. Soaking in warm water is typically helpful in reducing swelling. Topical therapy with hemorrhoid creams containing local anesthetics like Lidocaine can typically reduce pain and produce analgesia over the affected area. Patients should typically see results within hours to a couple of days. More severe cases should be evaluated and patients may be candidates for office treatment. Many office modalities have been used in treating hemorrhoids and include:
Injection sclerotherapy involves injecting a chemical sclerosing solution to cause fibrosis and fixation of the internal hemorrhoids. This results in shrinkage of the internal hemorrhoids. The treatment is useful for bleeding and small to moderate internal hemorrhoids. This treatment is safe, fast (less than 1 minute), and usually painless. It does not require anesthesia. Multiple hemorrhoids can be treated at one time. It can also be done safely in patients on anticoagulation.
Banding, also called rubber band ligation or RBL, involves placing small rubber bands around the base of the redundant internal hemorrhoid, causing ischemia and necrosis of that part of the hemorrhoid. The hemorrhoid tissue and band typically fall off in several days. It is useful for bleeding and prolapsing internal hemorrhoids. The resulting healing process causes fixation of the remaining hemorrhoid tissue. It is usually performed on one hemorrhoid at a time. Banding is routinely performed without anesthesia, is quick (less than 1 minute), safe and generally results in minimal discomfort. Occasionally pain medicines may be required afterwards.
Coagulation typically uses a handheld infrared laser to photo coagulate internal hemorrhoids. It is also known as infrared coagulation or IRC. The infrared light causes heating of the internal hemorrhoid tissues with resultant coagulation and shrinkage. Treatment is fast (less than 1 minute), usually painless and is done without anesthesia.
Destruction of the internal hemorrhoid tissue may also be achieved with the use of varying forms of electric current diathermy. Several methods have been described including bipolar and direct current. Electric diathermy is not as widely used by colon and rectal surgeons as other faster treatment methods. Treatment times can vary from a couple to fifteen minutes per hemorrhoid depending on the type of treatment.
Excision of external hemorrhoids can be done safely and comfortably in the office in appropriately selected patients. Local anesthetic is used prior to removal of the hemorrhoid which generally lasts less than five minutes. External thrombosed hemorrhoids represent a special case where timely removal cans shorten recovery and recurrence.
We have found that the majority of patients can be treated without surgery. Our approach at Saleeby and Wessels is to offer time proven office procedures which are the most effective, least painful and least costly available. This is done with the aim of leading to a significant improvement in symptoms while avoiding the recovery time typically associated with surgery. Along this approach, our experience has found injection sclerotherapy, rubber band ligation and excision when indicated, to be among the easiest, most convenient and most cost effective methods. While the majority of hemorrhoid patients are candidates, these procedures are typically offered to the appropriate patients after an office evaluation.
Surgery is commonly performed in cases of hemorrhoids which have failed non operative techniques or are of advanced degree or severity. Most cases are performed as outpatient surgery where the patients are sent home following the procedure. They all require anesthesia, and many are performed under heavy sedation and local anesthetic. Recovery times can vary but most require from one to two weeks off of work. Newer local anesthetics such as Exparel have greatly reduced post operative pain as compared to only a few years ago. Several techniques are available for the appropriately selected patients.
Excisional hemorrhoidectomy, involves cutting and removing the hemorrhoid tissue. It is the time proven method of treating advanced hemorrhoid disease surgically. The hemorrhoid tissue is typically excised, including the internal and external parts, and the wound closed with suture. The surgery is appropriate for all forms of hemorrhoid disease including cases with other conditions like fissures, fistulas and skin tags. While almost all patients require 1-2 weeks recovery as well as oral pain medications, patients experience the lowest rate of recurrent symptoms. Additionally, newer local anesthetics like Exparel, now routinely used, can remain active for up to 2 days. The most common complications include bleeding, infection and urinary retention.
Stapled hemorrhoidpexy is otherwise known as the procedure for prolapsed hemorrhoids or PPH. It involves removing a ring of internal hemorrhoid tissue with a cutting stapler device. It is typically used for appropriately selected patients with symptomatic internal hemorrhoids. Recovery times and pain levels are usually less when compared to excisional surgery. However, the recurrence of symptoms is more common. Pain medication is usually required. The most common complication is bleeding. Rarely, prolonged pain from the staples may necessitate removal.
Hemorrhoid dearterialization and pexy is also known as trans anal hemorrhoid deartertiazation or THD. It involves using a Doppler sound probe to identify and ligate the arteries feeding the internal hemorrhoids. The internal hemorrhoids are then suspended higher in the anal canal with stitches. It is a surgical treatment which is non excisional, meaning no tissue is removed. Subsequently, recovery is among the shortest of surgical procedures for hemorrhoids. Because the technique is newer, long term results are less available.
The Saleeby and Wessels Proctology Approach
Our primary approach is to put our patients first in everything that we do, striving to create a comfortable and proactive environment for recovery. We understand that dealing with hemorrhoids can feel embarrassing or stressful, but we can help to alleviate these feelings by providing a comfortable and stress-free visit to our medical office. It is important to seek care from Board Certified Colon and Rectal Surgeons trained in multiple office and surgical techniques when diagnosing and treating hemorrhoids. As Board Certified Colon and Rectal surgeons, we provide specialized hemorrhoid care, and are able to offer several non surgical and surgical treatment options to our patients. We do so in a timely fashion in order to maximize the benefit for our patients. We believe in utilizing the least invasive treatment approach that is likely to be successful. In fact, about 90 percent of our patients are treated in our office. We also offer the latest in surgical modalities for hemorrhoid sufferers who fail non operative treatment.