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ASK THE DOCTOR: Hemorrhoids are no laughing matter
By DR. JIM MITTERANDO
The Patriot Ledger

Q. With all this talk about colon cancer, do I need to worry about occasional blood when wiping?

Q. I have had painful hemorrhoids in the past. What can I do? Should I have them removed?

A. Hemorrhoids, often called piles, are swollen veins in your anus. A sometimes embarrassing topic of discussion, hemorrhoids affect most adults at some time.

Hemorrhoids occur when veins enlarge from straining or pressure. Pregnancy, straining when toileting, constipation, obesity and prolonged standing all can cause hemorrhoids.

There are two kinds of hemorrhoids: the painless, bleeding kind called internal hemorrhoids and the itchy or painful type called external hemorrhoids.

Internal hemorrhoids are inside the anus and lack pain fibers so they do not usually cause discomfort. Internal hemorrhoids can cause bright red blood on your toilet tissue (resembling a nosebleed) or in the toilet bowl or streaking the outside of the stool.

Anal fissures - small tears in the anus - also can cause bleeding or pain. If the bleeding is persistent, or blood is mixed in with the stool (rather than just streaking), follow up with your health care provider for further evaluation that may require using a short scope of several inches called anoscopy or a longer scope called sigmoidoscopy or colonoscopy. If you notice maroon-colored blood or black stools, this indicates older blood coming from further up the colon that requires further investigation.

If the bright red blood is just occasional and only occurs when wiping (as in your case), then no evaluation is necessary.

External hemorrhoids are the most well known being the subject of jokes about inflatable donut cushions to take the pressure off a tender spot and advertisements to take the itch or burning away. External hemorrhoids are truly a pain in the rear but, fortunately, occur less commonly than internal hemorrhoids.

External hemorrhoids can develop a clot (thrombosis) that causes a painful lump at the anus. Thrombosed external hemorrhoids are treated with warm baths to promote drainage and may require drainage in the doctor's office if they are severe or if they do not improve in several days. An abscess near the anus also can cause a very painful lump which also requires drainage and more extensive treatment than a hemorrhoid.

Tips for relieving symptomatic hemorrhoids:

  • Take soaks in warm water three or four times a day sitting in a bathtub, or better, a sitz bath. A sitz bath is a plastic container that fits over the toilet and is easier to use since you do not need to undress and requires less water. You can purchase one at a medical supply store or some pharmacies.
  • You also can use ice packs to relieve swelling.
  • Use ibuprofen (Advil, Motrin) or Tylenol for pain relief.
  • Wipe after toileting with moist toilet paper or baby wipes.
  • Use a stool softener such as Colace until the hemorrhoid symptoms disappear.
  • Avoid laxatives.
  • For painful hemorrhoids, apply a cream/ointment with a numbing medicine such as Anusol ointment or one with witch hazel such as Preparation H Cooling gel.
  • For itching or irritated hemorrhoids, try a cream/ointment with hydrocortisone such as Anusol HC-1 or Preparation H Hydrocortisone 1 percent or simply use any generic over-the-counter hydrocortisone 1 percent cream, which will be much cheaper than the brand name products and just as effective.
  • Don't bother using the standard Preparation H cream or ointment since they are not as effective.
  • Avoid suppositories that can be irritating.
  • Donut-shaped comfort cushions can help relieve pressure, particularly if you sit for long periods of time.
  • See your healthcare provider if symptoms do not resolve in several days.

To prevent hemorrhoids:

  • Avoid constipation by eating high-fiber foods such as fruits and vegetables, drink lots of fluids (eight glasses of water daily) and exercise.
  • Avoid straining when toileting and avoid sitting on the toilet for prolonged periods of time.
  • Avoid laxatives.

If you develop recurrent symptoms, surgery is sometimes required. Frequent rectal bleeding from internal hemorrhoids is easily treated with an office rubber band procedure that pinches off the hemorrhoid and stops the blood flow so that it withers away. Banding of internal hemorrhoids is painless.

Skin tags can accumulate over time from old hemorrhoids that can collect stool and make wiping and hygiene difficult. If this is a persistent problem, the tags can be removed but this can be painful.

If you get recurrent, painful, external hemorrhoids, you might require a hemorrhoidectomy, which is a surgical procedure that is painful and may require taking off work for a week or more to recover.

Dr. Jim Mitterando is a family doctor at Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.

Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.

Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible.

Copyright 2002 The Patriot Ledger
Transmitted Tuesday, September 24, 2002