Hemorrhoidectomy (Hemorrhoids)

Hemorrhoids are swollen veins in the anus. To some degree, everybody has them and they are a normal part of human anatomy. They are usually not symptomatic, and actually help in preventing leakage of gas or stool from the anus. It is when hemorrhoids become symptomatic that they need to be treated. Common symptoms include:

• Bleeding;
• Itching;
• Burning;
• Swelling;
• Pain;
• Anal masses; and/or
• Anal leakage or soiling.

Hemorrhoids are not cancer but symptoms of conditions other than hemorrhoids (including cancer) may mimic hemorrhoids, so it is important to have an evaluation by a physician. Hemorrhoids are often caused by pressure due to straining, pregnancy, or other factors. Hemorrhoidectomy is surgery to remove hemorrhoids. Not all hemorrhoids require surgical intervention, or are treated the same. Treatment options are dependent upon the underlying problem causing the hemorrhoids. Hemorrhoids can be internal or external:

• Internal hemorrhoids can occur in clusters around the anal canal wall. While usually painless, they may prolapse (protrude), bleed or discharge mucus. They occur above the level of nerve endings so they typically do not cause pain. They may cause an anal mass only if they prolapse. Internal hemorrhoids are classified by degrees I-IV, defined and treated by the degree of prolapse:
  • Grade I: No prolapse.
  • Grade II: Prolapse upon defecation but spontaneously reduce.
  • Grade III: Prolapse upon defecation and must be manually reduced.
  • Grade IV: Prolapsed and cannot be manually reduced.
• External hemorrhoids are at the anal opening. They become problematic when they thrombose (form a blood clot). This may appear as a hard, bluish lump that may cause severe pain. External hemorrhoids occur below the level of nerve endings; therefore treatment can be painful. They may accompany internal hemorrhoids.

Prevention of Hemorrhoids Finding the cause of your hemorrhoids is the first step to preventing them. It is much easier to prevent them than to treat them. Inability to rectify what is causing your hemorrhoids makes it much more likely that they will recur.

• Coughing, diarrhea and constipation are the main culprits in the formation of hemorrhoids.
• If your job requires you to spend most of the day seated, try to stand and walk five minutes for every hour and frequently shift position to alleviate pressure on the rectal area.
• Always exhale as you strain or lift. Don’t hold your breath.
• Do not delay or try to prevent a bowel movement when the urge is present.
• Regular exercise can help stimulate the bowels to move.
• Moistened tissues such as baby wipes are less irritating than using dry toilet paper after bowel movements. Lightly pat the rectal area dry.
• Keep the rectal area dry. Talcum or baby powders can help.
• Do not read or linger while on the toilet. If bowel movements take longer than five minutes, you are too constipated.

Prevention of hard stools and constipation is paramount in the prevention of hemorrhoids. To have soft, regular bowel movements:

• Drink at least 8 tall glasses of water a day.
• Maintain a high fiber diet. Fiber passes into the colon and can results in a larger, bulkier stool, which is soft and easier to pass. If you gradually work up to three fiber servings a day, you will find you can tolerate the fiber much better. Some high fiber sources include:
  • Whole grain (whole wheat) breads;
  • Bran cereals;
  • Vegetables—root (potatoes, carrots, turnips), leafy green (lettuce, celery, spinach), or cooked high residue (cabbage);
  • Fruit—cooked or stewed (prunes, applesauce) or fresh fruit (skin and pulp);
  • Bulking agents such as:
    • Food bran—available as wheat, oat or rice bran;
    • Psyllium bran—available as Metamucil, Konsyl, Effersyllium, Per Diem Fiber, or their generic equivalents. Although labeled a laxative, these aren’t really laxatives and are safe for everyday use.
    • Methylcellulose—available as Citrucel;
• Avoid narcotics (Vicodin, Percocet, oxycodone, codeine) as these medications increase constipation.

Sometimes a laxative is needed to stimulate more frequent bowel movements, but they are not a good long-term solution as it can damage the nerves of the colon. Osmotics (milk of magnesia, magnesium citrate, MiraLax, GoLytely) are safer than stimulants (Senokot, castor oil, Dulcolax, Ex Lax). Do not take any laxative product for more than seven days in a row. A bowel retraining program can be implemented for severe constipation. This includes a diet high in roughage (bran, leafy vegetables), six ounces of prune or apricot juice each morning, two large servings of stewed fruit each day, one heaping tablespoon of psyllium fiber twice a day. After a normal breakfast, set aside 15 minutes to sit on the toilet without straining to have a bowel movement. If no bowel movement occurs by the third day, you may use an enema and repeat this process.

Non-Surgical Treatment of Hemorrhoids Once hemorrhoids develop, non-surgical treatment includes relieving symptoms such as burning, pain and itching, as well as shrinking the hemorrhoids. Sitz baths are very useful in the treatment of hemorrhoids. You should soak the rectal area in hot water in a shallow bath for 20 minutes three to four times per day. This helps clean and relax the area. There are also topical medications can be used for aching, burning and itching. Anusol HC cream (hydrocortisone 1%) is very good for reducing the swelling, itching, and burning sensation. Anusol HC suppositories (hydrocortisone 1%) should be used for internal symptoms. Tucks pads are also useful for relieving symptoms. Make sure to gently cleanse the rectal area with warm water after each bowel movement. Avoid dry toilet paper or excessive wiping. Keep the area dry with talcum or other non-irritating powder. Use ibuprofen (Advil, Motrin) or Tylenol on a temporary basis to help treat pain. You should experience improvement of your hemorrhoids within days, but it may take two to four weeks of treatment for complete relief.

Surgical Removal of Hemorrhoids (Hemorrhoidectomy) Excision of thrombosed external hemorrhoids includes:

• Numbing the hemorrhoid with local anesthetic;
• Making a small incision to remove the blood clot; or
• Removal of hemorrhoid.

Removal of internal hemorrhoids may include:

• Banding—placing tight elastic bands around the base of the hemorrhoid to cut off blood supply, causing it to fall off within a week.
• Transanal Hemorrhoidal Dearterialization (THD) is an effective, minimally invasive surgical procedure for treating internal hemorrhoids. This surgery involves the use of a special proctoscope coupled with a Doppler transducer to allow for successful, targeted ligation of the arteries supplying blood to the hemorrhoids. This newer technique results in significantly less post-operative pain for patients.

Some bleeding is to be expected with all hemorrhoid procedures. Report any persistent bleeding, as well as increasing pain, fever or chills, or trouble urinating to your doctor immediately.