Wednesday, January 16, 2008

Hemorrhoids














If you haven't seen it yet, take 7 minutes of your life to watch the Glenn Beck post-op hemorrhoid surgery video. Now, I generally frown upon making light of anyone's perception of physical pain. There's a neurologic component to pain that is very real and should never be minimized. However. This rambling, incoherent diatribe is absolutely ridiculous. And amusing. It's funny, doctors see patients like this all the time. They're the patients who torture family members with incessant personal illness stories, the lady who calls you every week because she's "concerned" about her hernia incision (looks fine), the guy who lugubriously asks "am I gonnna make it, doc" as you take him back for gallbladder surgery. These are the people who think the world has cursed them with incurable illness and suffering and, god willing, they may just pull through. Almost universally, what they suffer from is something routine and non-life threatening (hemorrhoids, hernia, gallbladder, etc.) They take weeks off from work. They call for multiple refills of pain meds. They even make Youtube videos while unshaven and zonked out on painkillers. Patience and empathy are the keys. Eventually, they "heal" and, as a surgeon, you dont have to see them anymore. Thank god I'm not primary care.

Hemorrhoid surgery is literally a pain in the ass. Think about it. You're subjecting yourself to sharp objects being used around your anus. That's going to hurt, right? Perhaps even for days afterwards.

Here's the deal with hemorrhoids. They're basically vascular plexi underneath the anal mucosa. Importantly, hemorrhoids are not innately pathologic. Everyone has hemorrhoids. They actually function to provide some resting anal pressure and also have a sensory function to help differentiate between gas and stool. (Therefore allowing one to cut a little cheese without soiling oneself). They cause problems only when engorged or swollen. They come in two flavors: internal and external. The picture above helps delineate the difference. Presentation is different for each one.

Internal hemorrhoids cause painless bleeding. Their location above the dentate line renders them insensate. Usually patients are treated conservatively for as long as possible (stool softeners, metamucil, etc). Surgical intervention is indicated for refractory bleeding. In the past this meant either rubber band ligation or formal hemorrhoidectomy. Nowadays, more surgeons are using the PPH hemorrhoidopexy device. This is a stapler that resuspends the anal mucosa and essentially cuts off the blood supply to the hemorrhoidal plexus. The benefit is that is allows you to treat multiple hemorrhoid bundles simultaneously, with much less post-operative pain.

External hemorrhoids are right at the anal verge. These babies are well innervated and when thrombosed, cause significant pain. I suspect a thrombosed external hemorrhoid was what brought Mr Beck to a surgeon. After surgery, you're going to be sore as hell for several days. I hate these cases because patients aren't always pleased with how they feel afterwards. The key thing to to properly prepare the patient for what is going to happen and how they're going to feel after. As always, patient expectations are associated with patient satisfaction.

Also, a lot of patients present with combined internal and external hemorrhoids. When conservative measures fail, operative intervention can include PPH along with concommitant excision of the external component. You don't want this. You're going to be sore as hell and you're going to curse your surgeon. Plan on seven days of discomfort and some bloody spotting on the toilet paper, but it should get better.

How do you avoid complications of hemorrhoids? The best evidence we have seems to suggest that chronic constipation and straining at stool contribute to engorgement of the vascular plexi. If you're going every three days, that's a problem. Mix in a little prune juice or metamucil if you can. And when you do go, if your legs are going numb by the time you're finished, you've probably been sitting there too long. You shouldn't be able to finish the NY Times crossword puzzle during a BM session. Sit down, do your business and get off the toilet. Just a little public service announcement from your friendly anal specialist.

20 comments:

Anonymous said...

Great post.

I try to avoid hemorrhoid surgery as much as possible, because you are right, no matter how much you tell the patient about the pain after surgery, it's never enough preparation. Even with PPH, the patients "feel funny" down there and are not perfectly satisfied. And I hate to admit it, but reimbursement is not worth the weeks of postoperative hand-holding that is required.

rlbates said...

I like the advise on "prevention". The US Sam cereal with flax seed is also helpful with constipation.

sterileeye said...

Self-pity is a virtue...

It seems to me that the patients with the most serious diseases often are the ones who complain the least. And vice versa.

Anonymous said...

Varicose veins, inguinodynia, hemorrhoids, mastodynia, sports hernias - I tell patients who push for hemorrhoid surgery that every patient I have met who has had hemorrhoid surgery in the past (by myself or others) has uniformily said "I would never do that again".

cheryl said...

So, what is the most Painful post op surgery? Multiple L spinal fusion? Total knees? Radical hysts.? What is the surgery that you do expect patients to call you post op and take weeks or many months to heal or for the pain to become tolerable? One thing I know for sure is Lap Gallbladder is the EASIEST post op surgery I have ever had. I have had 8 surgeries and with that GB I was back to work full time at 3 days post op. On the other hand, it was a total knee that kicked my butt. But I dont think I expected my surgeon to hold my hand through it either. But no doubt about it, it was a painful one.

make mine trauma said...

Here's a story to illustrate why you should not try to treat hemorrhoids on your own.......
http://intraoporate.blogspot.com/2008/01/reading-bongis-post-this-evening-i-am.html

Anonymous said...

Hm. I had the surgery you're talking about and honestly, the pain wasn't nearly as bad as you make out. I guess I got lucky.

And the pont about not taking your time with your business is a good one. It's what caused mine and they haven't recurred since I quit using the throne as a reading platform.

Anonymous said...

I am going to have the hemorrhoid op the day after tomorrow. I can't leave it anymore. It's too painful. I've been trying to avoid it. I use cream, tables ( Daflon ), I took a hot bath. But it didn't help much. I hate hospital. I feel so nervous.

:(

..............

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Anonymous said...

I got hemorroids recently, after a crazy diet I tried. It hardly ever hurts, but when it does it really sucks. I wouldn't even care, except now its poking it's head out of my butt and it's really embarrassing in the bedroom with my boyfriend if you know what I mean. Is there a way to remove this thing without surgery?

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

I hat the surgery n its he'll. You are a psuedo priest holyier than thou. Drs like u should only treat humans like u. Why do u act tough mr knowledge? U look down on ur patients, did u take the oath ? Do u hate return customers? Enjoy the years if helping pple u have ahead,

hemorrhoids relief said...

In my opinion, do not undergo surgery as much as possible, you should try herbal treatment first if you can. By the way, good information here.

Anonymous said...

Finally an article that lays it out concisely without all the attempts to sell "herbal remedies" and magic cures that I've found elsewhere. Thank you.

Anonymous said...

After giving birth to my daughter, I suffered for 18-years with severe external hemorrhoids. Numerous stories I heard and read caused me to be too embarrassed to see a doctor as well as too terrified to undergo surgery. I decided to do something about it when the pain became so severe that I couldn't do activities I loved like cycling and sitting at my work desk made me feel like I was ripping in half. To my pleasant surprise the pain after hemorrhoidectomy surgery was nothing compared to pain I had dealt with for 18-years. I went back to my yoga after only 3 days following surgery and returning to work after 4 days. Used Vicodin on day one only & Ibuprofen for only a few days. My message to those people that love to tell their war and horror stories I beg you to stop - if you have nothing good to say then keep it to yourself. I blame you for my years of agony, embarrassment, and fear of dealing with something that was so easily and painlessly handled.

Anonymous said...

i too just had thr surgery and went through 20 yrs of being too embarrased to see a doctor. even when they exploded and had blood everywhere.
This time there was wayyyy too much pain involved and it was more embarassing trying to walk around work hiding it then it was to let three doctors look at it and do the surgery immediately as they were the size of 2-3 golfballs.
so far its Day 1 and very minimal pain as long as i take my meds.. i will try and return each day to go through it so noone else lives in fear..
ask questions like how many times the surgeon has done this procedure first and dont accept half ass answers cuz it your whole ass that is having to deal after..
i have no regrets so far, pain is expected but i feel 1000 times better even with the pain.

Dr. Adam Dachman said...

Dr. Adam Dachman
April 17, 2011 at 1:33 pm
I had a THD done three days ago. That morning I performed three of them on patients, then my partner did mine. I had suffered from my hemorrhoids for years and the past few months were unbearable. I had to do something. I was genuinely frightened of hemorrhoid surgery having done so many prior to THD. I had been doing stapled hemorrhoid procedures for years but was never that happy with the results. Removing hemorrhoids was too painful to offer to the average sufferer and many of them either lived with the problem or waited as I did for something better.

Well, I am pleased to say that aside from some very manageable pressure and mild pain I am doing great! I had my first BM last night just 48 hours post op. I admit the first BM was a bit scary, but it really wasn’t that bad. And this morning I had an easy BM. No bleeding at all, no fevers or chills. My anus looks and feels absolutely perfect. I am amazed! For all of you hemorrhoid sufferers who have been searching the Internet for answers STOP. THD is the answer today. I have reviewed and/or personally performed every other treatment out there and this was my personal choice. I am a real chicken too.

I will be back to doing surgery in one week. I could go back sooner, but my kids are on spring break so what the heck I will enjoy life a little. Give us a call for a THD consult at 608-935-2018. You will be glad you did. I know I am.

Anonymous said...

To Dr Adam Dachman et al: have had them for 4 yrs and Im considering getting the THD... but more for the anal secretions and mild discomfort. Are the secretions normal. Can someone comment on whether they still have occastional secretions down the road post op??

Anonymous said...

I am a Dr. and i've managed a handful of post hemorrhoidectomy pains. Truthfully, down here in Africa, it's never funny.
I've had a 3rd degree hemorrhoids for about 5yrs and just summoned up courage to go for a hemorrhoidectomy 5days ago! The post-op pain for the first 24hrs, was hell! Subsequently, with the removal of the anal pack( which was left in situ, to secure hemostesis and avoid anal stenosis ) and with strong analgesics, the pain became bearable.

Anonymous said...

Having only been able to watch approximately 2 mins of the Beck video, maybe I'm not qualified to comment on whatever dribbling message this guy was trying to get across, but I seriously couldn't bring myself to do anything other than hit "escape" and end that You Tube blah blah!

I had hemorrhoidectomy 4 weeks ago. Granted, I'm still a bit sore and it is a bit scary that I'm still bleeding and have some unusual ooze. However, I don't feel compelled to post a whinging and rambling You Tube video about my experience - all I wanted to do was use the University of Google to find out whether there was some other postoperative care that I could or should be doing to speed up my postop recovery.

Having seen the Beck video, I now have a pain in my head, as well as a pain in my lower regions. :-)