Many patients tell me, after we concluded the consultation and agreed on conservative treatment, that they were hesitant to come “to a surgeon”, because they were really hoping to avoid surgery. I also see patients frequently for second or even third opinions, because they were told to go ahead with some kind of proctological surgery, but their gut feeling told them not to!
Yes, I am a surgeon, but that does not mean I can only treat with surgery. Proctology, dealing with the anal canal and rectum, is a delicate discipline. As one of my great professors in the UK said: “the more you know as a proctologist, the less you do”, meaning that often waiting and allowing the body to do the healing will achieve the same or even superior result. The blood supply in the anal and rectal area is very good, although there are nasty bacteria living around there, the healing capacity is still excellent.
It is very important for a proctologist, and for a surgeon in general, to know in detail how to do great operations, however it is equally important to know when not to operate, who does not need an operation! Let me share a few “hemorrhoid stories” as examples.
(Names of people are changed to avoid recognition.)
Real Hemorrhoid Stories from My Practice
What is common in these patients is that all of them had hemorrhoids, or thought they had hemorrhoids and all of them believed they need surgery for hemorrhoids. For different reasons they found out that either they did not need surgery for hemorrhoids or they did not even have a hemorrhoid but rather a different kind of proctological problem.
Hemorrhoid story of Shareef
Shareef came to see me asking for hemorrhoid surgery. Upon detailed questioning on his everyday life and habits it turned out that he has been struggling with the toilet for more than a year. He has seen a few specialists and was prescribed anti-hemorrhoidal medications, which helped to stop the bleeding, but he was still taking a long time to empty his bowels.
I examined him thoroughly including anoscopy and rectoscopy. I could confirm he had prolapsing internal hemorrhoids, about grade 2, along with rectal lining prolapse. These are frequent findings in patients pushing hard or staying long on the toilet for months or even years. When I explained to him the findings of the anoscopy and rectoscopy, he was convinced these are the reasons for his problems. He found it surprising when I suggested that these are the results of his wrong toilet “behavior”. I also explained to him that with my examination I found he is keeping his muscles around the anal canal very tight, and he does not know how to relax them.
As we explored further, we found that his symptoms started when he started a highly stressful job. I went through the healthy toilet posture with him and taught a few relaxation exercises as well as advised pelvic floor physiotherapy. He was delighted to see the improvement when he came for follow-up. His hemorrhoids remained grade 2, maybe regressed a little, but they were not giving him any symptoms after he learnt to relax, so we never actually proceeded for hemorrhoid surgery.
Hemorrhoid story of Fatima
Fatima came to see me with painful lumps in her bottom for 2 weeks. She noticed them after a period of constipation, so she believed they were connected. She has already seen two surgeons before me. The first one told her that she has bad hemorrhoids, she needs surgery and suggested she do laser hemorrhoid surgery. Fatima did not feel comfortable with this decision. She was hoping to heal or at least get better without surgery. She decided to see another doctor before she would make such a big decision as to go for an operation.
The second doctor also advised surgery but told her that laser surgery would not be a good choice for her, she has grade 4 hemorrhoids, she needs a traditional hemorrhoidectomy with cutting. This confused Fatima even more.
When I saw her she was scared, still in pain although she felt her situation improved already by itself. I examined her with an anoscopy examination – she said she never had this test done – and found that she did not have internal hemorrhoids, not even grade 1. She had thrombosed external hemorrhoids. We had a detailed discussion about the treatment options. Surgery was one option to treat thrombosed external hemorrhoids, but conservative treatment was equally possible and the choice was down to the patient’s preference. She chose to go with ointments, rest and tablets. One week later, when she came for follow-up the lumps and symptoms almost completely disappeared.
Hemorrhoid story of Jasmin
Jasmin noticed blood on the toilet paper and experienced pain during toilet on and off for many months. She googled her symptoms and decided she must be having hemorrhoids. She went to her family doctor who prescribed her anti-hemorrhoidal suppositories. Since her symptoms were not getting better, she went back and was told to visit a surgeon. She was rather reluctant, because she wanted to avoid hemorrhoid surgery, but the bleeding was scary so eventually she booked.
When I saw her, she was in one of the bad phases of her disease, she was bleeding every time she went to the toilet and the pain felt like passing knives. After talking through her symptoms, I examined her. The pain and muscle spasm prevented me from doing anoscopy and proving the diagnosis at first visit, but from the story anal fissure was the most likely diagnosis. Initial treatment for anal fissure is always conservative unless the patient is refusing to apply the treatment and wants to go straight for surgery.
Most of the time surgery will not even be needed. For Jasmin we started the ointments. After 2 weeks of applying the treatment she got so much better that I could examine her with anoscopy as well as rectoscopy without any pain and could prove she had an anal fissure. It is important to examine the whole anorectum in a patient who reported bleeding for several months. With the anoscopy and rectoscopy I could assess the whole length of the rectum and the anal canal. I could exclude proctitis, inflammation of the rectum, rectal polyp and rectal cancer.
I could thoroughly assess the anal canal to tell how high the fissure went and could examine the internal hemorrhoid cushions as well. Once the diagnosis was clear, we continued the started treatment until she fully healed.
Insights from Hemorrhoid Stories
These hemorrhoid stories, provide invaluable insight into the wide-range of experiences patients might go through before they find the proper help for the anal pain, anal bleeding and suspected hemorrhoids they are experiencing. It also shows how confusing the different advices may be, from the internet, from the family doctor, from different surgeons. Clear cut investigations with definite visualization of the anal canal and or the rectum, and explanation of the findings, whether internal hemorrhoids, anal fissures, complicated thrombosed external hemorrhoids or other pathologies of the anal canal or rectum are found will make sure the patients get on the right track towards healing.
The decision to visit a surgeon might mean an operation for many patients. But in proctology it is often not the case. Anal diseases traditionally belong to surgeons. But this does not mean anal diseases always need surgery.
Shareef’s hemorrhoid story was rather a story about bad toilet habits and stress resulting in hemorrhoids. In his case making Shareef realize that the primary problem is not the hemorrhoid, but the way he is emptying his bowels, did the most untoward healing. Once he changed his habits, relaxed his muscles and stopped straining, his defecation experience became instantly more normal. In the long run his hemorrhoids stopped becoming bigger, stopped becoming more prolapsed and even regressed a little bit. He did not need a hemorrhoid surgery.
Fatima’s hemorrhoid story is a story of the difference between grade 4 internal hemorrhoids and thrombosed external hemorrhoids. Thrombosed external hemorrhoids occur relatively sudden, in the matter of days. They are large, painful, purple lumps outside the anal opening or inside the anal canal at the lowermost part. They contain clotted blood i.e. a hematoma, from a burst hemorrhoidal vessel under the skin. Often this is not related to stooling and diet at all. Rather to lifting heavy or staying in an asymmetrical position for a sustained period of time. The hematoma attracts water to it: large edematous lumps may develop, looking really scary and giving the impression they can only be fixed with surgery.
A grade 4 internal hemorrhoid is a very different disease. It is the furthest advanced internal hemorrhoidal prolapse, which takes years to develop. Prolapsed internal hemorrhoids are not painful, they cause discomfort only. The internal hemorrhoids prolapse so far that they are outside the anal canal and they do not return any more. Since they are internal hemorrhoids they are covered with mucus membrane, which looks a bit purplish especially if the anal sphincter is closing on it. If one does not look close enough or not examine in detail with anoscopy as well, it is possible to make a mistake between these two very different types of hemorrhoidal diseases.
While grade 4 hemorrhoids can only be fixed with surgery, thrombosed external hemorrhoids can settle completely on conservative treatment, however over several weeks. Fatima had thrombosed external hemorrhoids and the reason why she was suggested surgery must have been the mistake between advanced grade 4 prolapsing internal hemorrhoids and her problem. Or because the surgeon believed she would benefit most from a surgery rather than waiting weeks for complete settling by herself.
Jasmin’s hemorrhoid story is the trap of “common things happen commonly”. Jasmin had anal bleeding. And the far most common reason behind anal bleeding is hemorrhoids. However anal fissure is not too much behind! Anal fissures are less frequent than hemorrhoids but in a proctological practice they are daily findings. For anal fissures the first line of treatment is always conservative. Sometimes we have to resort to surgery, but even the surgery is trying to be as “conservative” as possible: instead of fissurectomy and lateral sphincterotomy (cutting into the anal sphincter to allow it to relax in order to provide sufficient blood supply for the fissure to heal) nowadays we give Botox injection to relax the sphincter muscle in a reversible way. Chances are, that an anal fissure will heal without surgery in 60-80% of the cases.
In summary, even if you are absolutely sure you are not willing to do any surgery, do not be scared to visit a proctologist. After you have been examined and your diagnosis has been established, it is highly likely that you will be told you do not need a surgery, or at least you are offered the option of conservative treatment as one of the valid and successful management to many proctological diseases.
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