Online Health Chat with Ursula Szmulowicz, MD

October 23, 2012


Cleveland_Clinic_Host: ‘Hemorrhoids’ are a common complaint, producing symptoms such as rectal bleeding, perianal itching and anal pain. After the age of 50 years old, approximately 50 percent of people will experience symptoms due to hemorrhoidal disease. About one million Americans develop hemorrhoidal symptoms each year. Common causes of hemorrhoidal disease include straining during bowel movements or activity, a low-fiber diet, constipation or diarrhea, older age and pregnancy. Prolonged time sitting on the toilet is a notorious source of hemorrhoid problems.

Hemorrhoids are a normal part of the anal anatomy. Internal hemorrhoids are the anal cushions—the blood vessels and soft tissue—located in the anal canal. These anal cushions help us maintain continence—the ability to hold stool until we reach the toilet—and also let us discriminate between liquid and solid stool and gas.

Treatments for hemorrhoidal disease have been sought for centuries. Even ancient Egyptian papyri from 1100 to 1200 BC listed topical remedies for hemorrhoidal complaints. The management of hemorrhoidal complaints begins with diet modification and a change in toilet habits. Among the office-based procedures are rubber band ligation and sclerotherapy. Certain individuals may instead require a surgical procedure such as an excisional hemorrhoidectomy, stapled hemorrhoidopexy (PPH) or Doppler-guided hemorrhoidal artery ligation (DG-HAL).

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About the Speakers

Ursula Szmulowicz, MD is a staff surgeon at the Cleveland Clinic in the Digestive Disease Institute. She is board certified in general surgery and in colon and rectal surgery. Her specialty interests include anal dysplasia and cancer, HPV-related disease, anorectal disease, pelvic floor disorders and colonoscopy.

Dr. Szmulowicz completed her fellowship in colon and rectal surgery at the Greater Baltimore Medical Center and her general surgery residency at Indiana University in Indianapolis. She earned her medical degree from the New York University School of Medicine in New York.

Let’s Chat About Hemorrhoids

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Ursula Szmulowicz. We are thrilled to have her here today for this chat on Hemorrhoids.

Hemorrhoid Diagnosis—Signs and Symptoms

K2M:  If you think you have hemorrhoids, is it better to have them diagnosed by a doctor or is it OK to just treat them over-the-counter?
Dr__Szmulowicz: ‘Hemorrhoids’ are a very common complaint that encompasses a wide range of symptoms. In most cases, the self-diagnosis is correct. However, there are many other conditions that have the same symptoms as internal hemorrhoidal disease. Most of these conditions are benign, but some are malignant (cancerous). To ensure that you have reached the correct diagnosis, I suggest that you see your doctor for discussion and an examination. Your doctor may also be able to recommend more effective measures to treat your symptoms, should he or she confirm your self-diagnosis. 

Thankful: I am having intense itching and some bleeding, but no protrusion. Could it be pinworm, psoriasis or some other serious condition?
Itching is a symptom that could be caused by internal hemorrhoidal disease. More commonly, itching results from excessive cleansing and/or the use of an irritating agent, such as wipes. Pinworm and psoriasis are conditions that I have very infrequently encountered, but are potential sources of itching. I suggest that you see a colorectal surgeon to determine the cause of your itching and bleeding, and to start the appropriate treatment.

Smart_move: What causes hemorrhoids? Can I prevent them?
We all have hemorrhoids as part of our normal anatomy. The internal hemorrhoids, which are located within the anal canal, are composed of arteries and soft tissue, while the external hemorrhoids are veins, which are found around the anal opening. So, we cannot prevent hemorrhoids.

However, we can possibly prevent hemorrhoidal disease, that is, the symptoms that can arise from the internal and/or external hemorrhoids. It is important to maintain a high fiber diet (30 grams per day), consisting of fruits, vegetables and whole grains. Good hydration, about eight 8 oz glasses of water per day, should be established. These measures produce soft, easily passed bowel movements, in addition to the other health benefits of these lifestyle changes.  Straining should be avoided.  When an urge to have a bowel movement occurs, it should be acted on as soon as possible, instead of deferring it for a long period of time. Also, most importantly, prolonged sitting on the toilet must be stopped. No reading or playing video games while sitting on the toilet!

Marnie_p: How do you know if you have ‘internal’ hemorrhoids?
Dr__Szmulowicz: The internal hemorrhoids are a normal part of our anatomy.  So, we all have internal hemorrhoids. Also known as anal cushions, the internal hemorrhoids are thought to play a small role in maintaining our bowel continence, that is, our ability to hold stool until we can reach a toilet. In addition, the internal hemorrhoids may help us distinguish between gas and stool before we pass gas.

Jaqui: How are hemorrhoids diagnosed? Should I just see my primary care doctor or someone special?
Dr__Szmulowicz: Hemorrhoidal disease is usually diagnosed during an office visit.  Your doctor discusses your symptoms with you, after which an examination is completed. The exam starts with an external assessment of the anal area, followed by a digital rectal examination, in which a lubricated finger is placed into the anus. Next, a short, lighted probe—an anoscope—is inserted into the anal canal to directly look at the internal hemorrhoids.

Your primary care doctor may be able to diagnose hemorrhoidal disease.  He or she may a good place to start. Alternatively, you can see a colorectal surgeon, who is a specialist in hemorrhoidal disease. Your primary care doctor may ultimately refer you to a colorectal surgeon for further assessment and treatment.

Excuse_me: If I have hemorrhoids and I'm treated, what are the odds they will come back? Will I have problems for the rest of my life?
Dr__Szmulowicz: With most surgeries, not just those for internal hemorrhoidal disease, recurrence is included as a risk factor. In medical journals, the surgical literature on hemorrhoidal disease reports that the success and recurrence rates for the various office-based and surgical procedures vary according to the procedure, the experience of the surgeons, and the duration of follow up. After a surgical treatment, it is very important to maintain a high-fiber diet, good hydration and good toilet habits to attempt to minimize the risk of a recurrence over time. So, no, you will not necessarily have hemorrhoidal issues for the rest of your life after you are treated.  If recurrent symptoms develop at some point, then treatment can be reattempted.  


Hemorrhoids and Pregnancy

Trust_me: I am pregnant. What are some safe treatments for hemorrhoids?
Dr__Szmulowicz: Internal hemorrhoidal disease is common during pregnancy, especially during the second and third trimesters. Treatment usually focuses on conservative measures: a high fiber diet, fiber supplements and good hydration.  Since many pregnant women become constipated, a stool softener or laxative might be necessary. Medications that can cause constipation as a side effect (such as iron supplements) should be adjusted if possible. Straining and prolonged toilet time should be avoided. Warm baths can help minimize symptoms. Sometimes a steroid cream or suppository is prescribed.

Usually an office-based or surgical procedure is avoided during pregnancy. However, if such a procedure becomes necessary, after discussion with your obstetrician, rubber band ligation or Doppler-guided hemorrhoidal artery ligation might be considered.


Constipation and Hemorrhoids

cschulzie: With the various drugs that I need to take that also cause constipation, I am wondering what the value of treating hemorrhoids is. I do add fiber and eat well. It seems as if another hemorrhoid comes along after you get the previous one to go away.
Dr__Szmulowicz: I am glad that you are proactive in treating your constipation by maintaining a high-fiber diet. As you know, medications can be constipating. In addition to the fiber supplementation and good hydration, you might need a regular stool softener or laxative to help with your bowel movements. You can discuss this with your doctor. Often, a hemorrhoid problem is precipitated by straining or hard bowel movements. Beyond improving the underlying constipation issue, various procedures are available for internal hemorrhoidal disease. If you have frequent recurrences of the anal symptoms, then you might do well with one of these procedures.
Russ:  I take Plavix®, and have had bleeding since April. In August I had banding in the office and I am still bleeding. My doctor who is located in Erie, Pa. has suggested that I take something to stop the constipation. Should I do something else?
Medications such as Plavix®, aspirin and Coumadin® make it more likely that the internal hemorrhoids may bleed with bowel movements.  Hard bowel movements and/or straining can further increase the risk of hemorrhoidal bleeding.  A high-fiber diet, fiber supplement and good hydration are good to add to your normal routine, even for those who do not have a hemorrhoid issue.  If these measures do not produce soft, easily passed stools, then a stool softener or laxative may be necessary, after discussion with your doctor.  Also, you should try to avoid straining and prolonged toilet time. Should the bleeding continue despite these changes, then you might require a different procedure for the internal hemorrhoidal disease.


Hemorrhoid Manipulation

acho7: I have had hemorrhoids for many years. They bother me particularly after moving my bowels. I then sit on the edge of a chair to push everything back up. Is there anything wrong with that?
Dr__Szmulowicz: Among the various symptoms associated with internal hemorrhoidal disease, one can have prolapse (protrusion) of the hemorrhoids. Usually, our internal hemorrhoids are located inside the anus. But, sometimes, these internal hemorrhoids can slide out of the anus, especially with bowel movements. Occasionally this can also happen with activities such as squatting. Often, these protruding internal hemorrhoids will spontaneously return into the anus. However, in some cases, we have to push them back inside, either manually (with our hand) or by applying pressure, such as sitting on them.  It is best to return the internal hemorrhoids into their normal location of the anus to prevent symptoms such as pain, itching, bleeding on the underwear and drainage.  There are procedures that can be performed to take care of your hemorrhoid problem, so that you do not have to deal with the prolapse. The best procedure—whether it is surgical or office-based—will be determined by an office examination.


Hemorrhoid Surgery

how_r_u: I have heard that surgery is very painful. Is this true? What other options do I have?
Dr__Szmulowicz: For the treatment of hemorrhoidal disease, we often start with non-surgical measures. I usually recommend a high-fiber diet and, if appropriate, a fiber supplement. Stools should be kept soft. Straining should be avoided. And, most importantly, do not linger on the toilet. That is, no reading on the toilet!

If those measures are ineffective, then we have some other options, either office-based procedures or surgeries performed in the operating room. The degree of pain or discomfort that one experiences after these interventions varies according to the procedure. Not all of these procedures are ‘very painful.’ The perception of pain is very individual. We offer different pain control options after procedures to try to minimize your pain and discomfort. Warm tub or sitz baths are helpful for pain control after surgery. Also, it is necessary to keep your stool soft, to reduce the pain associated with bowel movements. Your doctor will be happy to discuss what procedure and pain control would work best for you personally at an office visit.

Laura_NB:  I want to learn more about surgical options for hemorrhoids and when they are appropriate. Also, what are the dietary approaches to managing chronic constipation and hemorrhoids?
Dr__Szmulowicz: Internal hemorrhoidal disease often develops as a consequence of constipation. When hemorrhoidal symptoms are associated with hard bowel movements or straining, addressing the constipation is the first step in treatment.  I recommend a high-fiber diet, which includes about 30 grams of fruits, vegetables and whole grains per day.  Some people might find that an over-the-counter fiber supplement may assist them in reaching that daily amount of fiber intake. Stay well-hydrated, with about eight 8 oz glasses of water per day, which is also helpful in keeping the stool soft.  In some cases, a stool softener or laxative may be needed, if suggested by your doctor. 

The surgeries for internal hemorrhoidal disease include Doppler-guided hemorrhoidal artery ligation, stapled hemorrhoidopexy (PPH) and excisional hemorrhoidectomy. The decision as to which surgery is best for a particular person is based upon the size of the hemorrhoids and the associated symptoms, especially the degree of prolapse (protrusion).  Usually, with my patients, I review the various interventions that I believe would be appropriate for their particular problem. We then discuss what their needs and concerns are in terms of recovery time, pain, and risk of recurrence. We then reach a decision about the best procedure. 

Bailee: What procedure do you recommend if internal hemorrhoids have prolapsed? Is sclerotherapy an option and what exactly is that?
Dr__Szmulowicz: Sclerotherapy is an office-based procedure, which is done without any sedation. It is performed by some, not all, colorectal surgeons. The procedure involves the injection of a solution into the hemorrhoidal tissue, where it then hardens and creates scarring. The scarring fixes the internal hemorrhoidal tissue and interrupts its blood supply. It is used for internal hemorrhoids that bleed and, sometimes, for those that prolapse (protrude) but then return into the anus without any intervention (spontaneously). In many practices, rubber band ligation is more commonly used in place of sclerotherapy.

Vira: How do you determine when hemorrhoids should be treated with surgery?
Dr__Szmulowicz: For minor or intermittent symptoms, it is possible to start treatment with changes in diet and toilet habits. If symptoms are significant or chronic, or if more conservative measures are ineffective, then a procedure—whether it is office-based or surgical—may be discussed.  

Vira: What are the negative aspects to surgery?
Dr__Szmulowicz: Every intervention has possible risks, even the ‘minor’ surgeries or office procedures for hemorrhoidal disease. In most cases, these risks occur infrequently.   Some risks shared by the various hemorrhoid procedures include bleeding, infection and swelling. Every hemorrhoid procedure could be followed by a recurrence of hemorrhoids at some point, especially if good diet and toilet habits are not continued indefinitely. Also, as with any procedure, there is pain or discomfort with the degree dependent upon the intervention and on the individual.


Bleeding Hemorrhoids

Bailee: I am a 56-year-old female. When I was 40 years old, I had a colectomy due to diverticulitis (with a long family history). My surgeon connected my small bowel directly to my rectum, alleviating the need for a colostomy. Since I have a 'short track', I have four to six liquid bowel movements each day. I developed bleeding hemorrhoids about four years ago. This past weekend, I had a bleeder that saturated my underwear through to my jeans. That has never happened before. I've only had bleeding with a bowel movement. It's hard to change toilet habits in my situation. I'm worried that this will happen when I'm out in public. Any suggestions?
Dr__Szmulowicz: I understand your worry in this situation. I have met a lot of people with the same problem with bleeding from the anus when it is not at all expected. I do suggest that you see a colorectal surgeon for an examination of the anus. Most likely, this is a hemorrhoid problem that is caused by your frequent bowel movements. An examination will confirm this assessment. Also, we can offer recommendations to address your bowel habits. We can additionally discuss various interventions for internal hemorrhoidal disease, and which would be best for you.



patti2222: What is the risk of incontinence issues after the various non-diet/non-toilet habit interventions (including surgery) to treat hemorrhoids?
Dr__Szmulowicz: There are various interventions for internal hemorrhoidal disease. The two office-based procedures—rubber band ligation and sclerotherapy—really have no association with fecal incontinence. The Doppler-guided hemorrhoidal artery ligation and the stapled hemorrhoidectomy (PPH) have very minimal to no risk. The excisional hemorrhoidectomy, in which the internal hemorrhoids are cut out, could infrequently result in fecal incontinence.


Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic surgeon Ursula Szmulowicz, MD is now over. Thank you Dr. Szmulowicz for taking the time to answer questions today about hemorrhoids.
Dr__Szmulowicz: Thank you for participating in this web chat on hemorrhoidal disease.  I enjoyed answering your insightful questions on this topic.  I hope that I have been of some assistance in guiding you to the appropriate treatments. 

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