Everything You Need to Know About Hemorrhoids with Dr. Michael Valente

Podcast Transcript

Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Welcome back to another episode of Butts and Guts. I'm your host Scott Steele, Chairman of colorectal surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. I'm very pleased to have one of my staff members here and a good friend, Dr. Michael Valente. Michael is an associate professor of surgery at Cleveland Clinic Lerner College of Medicine. Mike's also our program director for our illustrious fellowship in colorectal surgery. Mike welcome to Butts and Guts.

Michael Valente: Thank you, Dr. Steele it's a pleasure to be here.

Scott Steele: So tell listeners a little bit about your background; how did it come to the point where you're from, where you trained, that you wind up at Cleveland Clinic.

Michael Valente: So I actually grew up in Cleveland, Ohio. I’m a born and raised here.

Scott Steele: West Side? East Side?

Michael Valente: Born at Marymount Hospital; lived on the west side for most of my life and I live in Brecksville, Ohio. 

Scott Steele: Where’d you train? 

Michael Valente: I trained for general surgery at Akron City Hospital down in Akron, Ohio, and then did my colorectal fellowship down in Columbus, Ohio.

Scott Steele: So Mike, we're going to talk today about something that is all too common. Over 1 million visits to the doctor in the United States alone every year and that's hemorrhoids. So let’s start out at a 10,000-foot level, what’s a hemorrhoid?

Michael Valente: That’s a good question, Dr. Steele. Hemorrhoids are actually part of our normal anatomy. Every single person listening to this podcast has hemorrhoids whether you know it or not. Most of the time you don't even know that you have them; they’re part of our normal anatomy. And really what they are is a conglomeration of blood vessels that sit in the anus, so they’re there for a normal function.

Scott Steele: And what type of function do people have that hemorrhoids would be able to do?

Michael Valente: Hemorrhoids, in their normal resting state, fill with blood and they help actually keep some continence or control of our gas, our bowel movements, under normal circumstances.

Scott Steele: So I get a lot of people that will go online and they'll have some anal rectum complaints, and one of the very first things that come up is hemorrhoids. And one of the first things that you'll see is external hemorrhoids versus internal hemorrhoids. What's the difference between the two?

Michael Valente: Internal hemorrhoids are as the name states – inside. They’re internal, so those are usually cushions of blood vessels that are not able to be seen by the naked eye; they’re inside. And internal hemorrhoids usually are a cause of rectal bleeding. They can cause pain sometimes if they swell and bulge, or prolapse. External hemorrhoids are usually what we could see from the outside. Those are also referred to as sometimes skin tags, and sometimes external hemorrhoids can be quite painful if they become what we call thrombosed external hemorrhoids.

Scott Steele: So Mike, you said a little bit ago that every single person, and I know it’s going to be a lot of listeners out there that would disagree that they have hemorrhoids, but you know you brought up a good point that they serve to act as little ball valves together so that you don't have seepage. They’re your last little line of defense in the war to preserve continence. But one of the things is that patients get them removed. So if they're normal and everybody has them, I don't understand this. Why would somebody need to have their hemorrhoids removed?

Michael Valente: That’s a great question and I discuss this with patients every week. When hemorrhoids become problematic or troublesome they, they become what we call hemorrhoidal disease and, and that's when these normal hemorrhoids that do serve a function become abnormal. And what I mean by that is they overfill with blood, or they become lax or loose, and they prolapse or herniate. And really the hemorrhoids at this stage are causing more problems then they're doing good. And what I mean by that is they may bleed, which is one of the most common problems with hemorrhoids that we see. They can cause pain with the prolapse, quite debilitating pain sometimes. They secrete mucus and they may cause trouble with keeping hygienic down there as well. So when it reaches that point where they become so troublesome, that's when we recommend some sort of intervention.

Scott Steele: Let's take a step back and we'll go back up to the symptoms that patients go. You mentioned that patients can have bleeding; is the bleeding associated with hemorrhoid any different from other sources of bleeding along the G.I. tract?

Michael Valente: Yes and no. Most hemorrhoidal bleeding occurs with bowel movement or during the active defecation, and a lot of times that bleeding is a bright red in nature, and it usually may drip into the toilet, but usually associated with the act of having a bowel movement. Other causes of gastrointestinal bleeding can be more severe, more volume, if you will, and maybe associate with other conditions that are more serious.

Scott Steele: Are there some hints that you might say, hey, this is hemorrhoid bleeding versus some more benign disorders that are in the anal rectal region, that you would say this is associated with another diagnosis?

Michael Valente: When we usually talk about hemorrhoid bleeding, it's what we would call a painless bleeding most often, as opposed to bleeding that occurs with a bowel movement that may cause severe sharp pain that would point us toward something called an anal fissure.

Scott Steele: If we're going to talk about the symptoms that patients get, when should they go and see the doctor?

Michael Valente: That’s a great question. When the patient is having rectal bleeding, we do recommend that they do come to see us because it very well may be just hemorrhoids. But you need to have a trained professional colorectal surgeon, if you will, or even your family doctor, really investigate that, because even though the hemorrhoids do bleed, and it's a major cause of anal or rectal bleeding, there could be other causes that we must rule out first.

Scott Steele: So if I go to the doctor, with or without hemorrhoids or suspicion of hemorrhoids, what can I expect at that doctor visit?

Michael Valente: At the colorectal surgeon’s office, for example, a very detailed history asking a lot of questions about type of bleeding, when it's occurring. And then after a good conversation about maybe leading us towards a diagnosis, a good examination in the office is compulsory. And what I mean is usually that consists of a rectal examination and sometimes the use of what we call an anoscope, a small device that usually has a light on it to evaluate the most distal part of the rectum and anal canal.

Scott Steele: Mike, are hemorrhoids cancer or can they turn into cancer?

Michael Valente: No, hemorrhoids are not cancer. Hemorrhoids do not turn into cancer. But what I want to emphasize is many patients have been told they have hemorrhoids, or potentially just chalk up their symptoms to “hemorrhoids,” and they may be missing a more serious diagnosis like rectal cancer or anal cancer.

Scott Steele: Is that common that it be cancer or is it more common that it's going to be hemorrhoids?

Michael Valente: It's most common that it's going to be hemorrhoids. But we don't ever want to take any chances.

Scott Steele: Yeah, absolutely. So what causes hemorrhoids?

Michael Valente: Many things – multifactorial, we like to say. I tell a lot of my patients sometimes hemorrhoids are just the act of one's ageing process, where the hemorrhoids, themselves, are getting loose, and they tend to have the effects of gravity like other body parts may as well. We do see hemorrhoids in very young people as well. And I think one of the most common causes of hemorrhoids is a lack of a good diet and exercise. What I mean by that is people who don't have a good dietary intake of fiber tend to be constipated tend to spend a lot of time on the toilet, a lot of times straining on the toilet to get a bowel movement to come out, and those definitely precipitate hemorrhoidal disease.

Scott Steele: Let's focus in a little bit about treatment or even first prevention of hemorrhoids. You mentioned fiber, how much fiber is the average Western diet type person taking?

Michael Valente: Yeah, the average Western diet is extremely low in fiber. I have patients tell me all the time “I eat very well, I have salads, and I have oatmeal for breakfast, and I have lots of fruits and vegetables. And that may be true, but the average American or Western civilized countries maybe get 10 to 15 grams of fiber in the best of circumstances. What we recommend, as the Society of Colorectal Surgeons, is between 25 and 35 grams per day. And the normal western diet really can't achieve that goal, and that's where we get into having supplemental fiber as part of one's daily routine.

Scott Steele: There's a lot of supplemental fibers out there, and it's difficult if I'm a patient, I'm looking at this grocery store aisle full of fiber and I'm thinking where do I start? What do I choose? Where do I go?

Michael Valente: Over the last several years, I’ve made a note to try several ones out to see so I could tell my patients what works best or what works best for them and, and it's really what works best for your individualize routine. I recommend, and most of us do, the powdered fiber supplements that tend to work the best. And the key ingredient is what we call psyllium in most of the fiber products. And the question goes back to, will it work right away? It does not. It's a slow gradual process where you need to start with a very low dose and work your way up, and every patient is going to have their kind of sweet spot amount that they need each day or every other day to get the right effect. Because if one takes too much fiber too quickly, the patient will have some side effects of bloating, gas and potentially too much bowel movement. And we want to avoid that, so we start slow and kind of work our way up.

Scott Steele: I think it's also important that patients understand that with any fiber product out there you need to make sure you take enough water in there because, for sure, dehydration can cause symptoms. Mike, you said something a little bit earlier about having good bowel habits and good bowel regimens, and that potentially having poor bowel regimens and bowel habits can lead over time to exacerbation of hemorrhoids. What does that mean having good bowel habits?

Michael Valente: The first thing I want every listener to do is leave your phone outside of the bathroom. Don't take the newspaper, your book, or your iPhone, or any other device in there with you. The bathroom is meant for one reason and one reason only, and that’s to have a proper bowel movement. And what that means is if you have a proper diet with good fiber and enough water intake, your bowel movements should be a very short occurrence. You should be able to sit down on the toilet with minimal straining, if any, and within a few minutes you should be done going to the bathroom. Anything more than five to 10 minutes – I mean, five minutes really should be the maximum time you spend in the bathroom.

Scott Steele: So we talked a little bit about prevention with good bowel regimen, and fiber being the mainstay of that. Let's focus a little bit more on a couple of myths. I take a lot of enriched bread or I take a bunch of oil flaxseed oil. Is that fiber? 

Michael Valente: No.

Scott Steele: And if I'm somebody who doesn't want to take the pills or the gummy bears or the powders. What foods are pretty good in fiber that you can be able to take? 

Michael Valente: Certain breads definitely have a lot of fiber in them, but these are more the whole grains. White the bread has the least amount of fiber you're going to have in there. Those are things you should avoid. Obviously, oatmeal and other refined grains are quite beneficial as well.

Scott Steele: Let's say that they don't have somebody that is responding to prevention, and they got hemorrhoids. They’ve gone to the doctor. Are there some therapies that can be done that are short of having an excision that patients could undergo?

Michael Valente: Absolutely. Honestly, in my practice, over 90 percent of my patients who receive some treatment do not have surgery, and we generally perform various office-based procedures that work quite well.

Scott Steele: One of the ones that I read about was banding. Tell me a little about who gets banded and how does that happen and where does it occur?

Michael Valente: Hemorrhoid rubber band ligation is a technique that’s very well tolerated and used widely throughout the world, actually. Patients who have bleeding hemorrhoids – these are for internal hemorrhoids, only the bleeding internal hemorrhoids or internal hemorrhoids that may have some prolapse where they aren't stuck on the outside. So bleeding hemorrhoids and prolapsing hemorrhoids are very well treated with hemorrhoid banding. Hemorrhoid banding takes place after a proper office-based examination, and people always ask me, “Do I need to take off work? Is this going to be very painful?” And it's really not painful; it's more of a pressure sensation. And what that hemorrhoid band does is causes the hemorrhoid to lose its blood flow and allows that hemorrhoid to actually fall off several days later, in the toilet usually, you don't even notice it. And what that does is it cuts down the size of the hemorrhoid, causes some scarring, and prevents it from bleeding or prolapsing again.

Scott Steele: So the band itself is what we use in order to take up that extra tissue. The band is placed around kind of the neck of that extra tissue and then over the next few days it’ll fall off, you won't even know it’s there. So do you get all the hemorrhoids with just one band?

Michael Valente: We don't. Every once in a while there may be one particular hemorrhoid area that's causing a major problem, where that one band may do the trick. But usually this is a procedure that requires repeat banding in the office setting, which is once again very well tolerated. And I tell my patients it's not going to potentially cure your hemorrhoids – the hemorrhoids are still there in other areas, and more of them may form in the future, especially if poor bowel movement habits are undertaken still. It's not uncommon that I’ll have the patient go back two, three weeks after the first hemorrhoid banding to do another one. And then potentially another one after that to do the trick.

Scott Steele: Are there any side effects to the banding?

Michael Valente: Hemorrhoid banding is very safe. There are some side effects that we do talk about during the procedure. And all my patients go home with an instruction sheet to look out for. The biggest thing that can happen in our practice is that if a patient says, “I’m on a blood thinner,” we usually have them stop that. But once you resume that blood thinner, like even aspirin, there could be some severe bleeding that occurs afterwards which you need to seek medical attention.

Scott Steele: So in general, they are very well tolerated; occasionally you're going to feel a dull ache. A lot of patients out there will get on the internet and read various things, and they may read about a severe infection that can occur with banding. But it's important to know that this is extremely rare, and most of the physicians that use banding have maybe never even seen it associated with banding. But it is something that you might read about, but it's important to put it in perspective. So banding is for internal hemorrhoids only.

Michael Valente: Yes.

Scott Steele: The kind that may prolapse out and the kind that typically bleed, or the kind that you may not even know is there and just causing you to have problems. You don't do banding on external hemorrhoids. What are some other office-based procedures that can be done for hemorrhoids?

Michael Valente: Another less popular treatment is sclerotherapy, and sclerotherapy works actually very well. Sclerotherapy is the injection of a caustic agent into the hemorrhoid pedicle itself to cause scarring of the hemorrhoid to stop it from bleeding. Sclerotherapy really works well in patients who are on some sort of anti-platelet or anticoagulation medicine where they really can't come off of that. And we like to use sclerotherapy in those situations to help with the hemorrhoids. Some practitioners routinely use sclerotherapy with banding in combination. But I would say the vast majority of my patients will get a banding, maybe a sclerotherapy if they can't come off their blood thinner.

Scott Steele: If you really think about hemorrhoid therapy, in broad terms, we're either talking about trying to get rid of them or trying to fix by the anus, and that's where the sclerotherapy works a little bit better on. So we'll kind of skip over some of the infrared coagulation that people may have, or sclerotherapy. There are all sorts of things that people might have that are more office-based procedures, but the mainstay of therapy for internal hemorrhoids is to have them banded. But then the next thing is for those who fail the medical therapy, or are not candidates for some of the office-based type procedures, and go onto surgery. Surgery typically involves two different types of lumps – the removal of them or this ligation that I hear about. Let's start with the ligation first.

Michael Valente: Sure.

Scott Steele: What is ligation of hemorrhoids?

Michael Valente: Ligation of hemorrhoids is a procedure where you're essentially tying off the hemorrhoid mass with suture material, usually, and that is usually meant for patients without much external hemorrhoid disease, where they really have prolapse or bleeding hemorrhoids that are quite large or really fail banding therapy.

Scott Steele: And is that for internal or external hemorrhoids?

Michael Valente: Those are for internal hemorrhoids.

Scott Steele: If somebody’s got a large degree of external hemorrhoids, probably, they're not going to need to have something in conjunction with the ligation of that.

Michael Valente: Correct.

Scott Steele: OK. Now in terms of the excision or cutting out of the hemorrhoids, there are also two different things in terms of that. We talk about the stapler that's used or we also talk about the good old-fashioned excision. Mike, when do you decide to use these and what is the difference between the two?

Michael Valente: Probably in the last 15 years a newer procedure called the stapled hemorrhoidopexy, or hemorrhoid surgery, was implemented. I'll be honest, I don't do that procedure myself. It's something that I think is decreasing in occurrence throughout America. I think that procedure can be performed well with certain types of hemorrhoids. But in my practice I prefer the excisional hemorrhoidectomy if we're going to go to surgery, to do hemorrhoid surgery. The excision is the way to go.

Scott Steele: What does that involve? I'm going to go in for hemorrhoidectomy, what can I expect and what are you actually doing in there after I go to sleep?

Michael Valente: So after you go to sleep we take the internal and external hemorrhoid and I prefer using a good old-fashioned scalpel. We cut out the hemorrhoid all the way down to its base, get all the blood vessel on the disease tissue out – that includes both the internal and the external part – and then we sew them up with suture material. And that usually is at least two, sometimes three, different columns of hemorrhoid tissue. That’s under general anesthesia or some sort of anesthetic in the operating.

Scott Steele: Do you remove all of the hemorrhoid tissue?

Michael Valente: Generally speaking we don’t. We remove the vast majority of the problematic hemorrhoid tissue, but we definitely have to leave some hemorrhoid tissue behind. It does have a function. We really can't take out the entire circumference of the anal hemorrhoids because that would lead to certain complications.

Scott Steele: If I was a patient that is going to plan on having a hemorrhoidectomy, or is having one that’s coming up or thinking about it, what's the postop like after the hemorrhoid surgery?

Michael Valente: It's very painful. It’s a painful operation. I think patients, overall, tolerate it extremely well. But I think that first week, and I tell my patients you're not going to like me very much, that first week potentially you’re going to wonder why you had this done. But really with proper pain control, multimodal pain treatment with ibuprofen, sometimes also narcotics. That first week is a very tolerable, and after a couple weeks you really start feeling really well and you're really happy that you had it done.

Scott Steele: I appreciate your full honesty, and in reality, I try to tell the patients that again this is something that it's a sensitive part of your body, there's no way getting around it. We'll do our best to control your pain through a lot of different mechanisms, and by and large most patients do very well. But it is a sensitive area. And the other important aspect is that that area of your body can swell, and it does take a couple of weeks to completely heal all the way in. So you have your hemorrhoidectomy, you get better with that in time, can hemorrhoids recur?

Michael Valente: They can.

Scott Steele: And how often does that occur?

Michael Valente: I would say in my experience not that often to the type of situation where you would need another surgery. Every once in a while if I do a good hemorrhoid surgery, a few years later I may have to put a rubber band ligation back on for another smaller area. But, generally speaking, if it's done properly by a well-trained surgeon you should do very well.

Scott Steele: So Mike, some last take home points about hemorrhoids.

Michael Valente: Number one, everyone has them; don't be alarmed by the fact that you have them. Number two, proper dietary factors – drinking at least two liters of water a day, about 64 ounces, is extremely important to help prevent this. Please get off the toilet as soon as possible. Any time you have symptoms of rectal bleeding, please don't just chalk it up to saying that you have hemorrhoids without seeing a trained professional to make sure you don't have some other condition that needs to be taken care of.

Scott Steele: So we're going to end with the four quick hitters. Your favorite sport?

Michael Valente: American football.

Scott Steele: Favorite meal?

Michael Valente: Anything my mother makes.

Scott Steele: What’s the last book that you read?

Michael Valente: The Sun Also Rises by Ernest Hemingway.

Scott Steele: And you're a native Clevelander. So tell me, what do you like about here in Cleveland?

Michael Valente: I love the weather, Scott.

Scott Steele: That sounds good. To learn more please download our free hemorrhoids treatment guide at clevelandclinic.org/hemorrhoids. To make an appointment with a Cleveland Clinic specialist please call 216.444.7000. Mike, thanks so much for joining us here on Butts and Guts.

Michael Valente: Thanks for having me, Scott.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.