How to Prevent Hemorrhoids with Arielle Kanters, MD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Hemorrhoids aren't exactly a topic that comes up in many conversations, but they're something a whole lot of us deal with. It's estimated that about 1 in 20 people experience hemorrhoids every year, and around half of all adults over the age of 50 have had them at some point. The good news? There are ways to limit your chances of getting hemorrhoids, and we're going to talk through them today with colorectal surgeon Arielle Kanters. She's one of the many experts at Cleveland Clinic who visit our weekly podcast to share wisdom and best practices. So with that in mind, let's find out what you can do to keep hemorrhoids from becoming a real pain in the ... well, you know.

Welcome back to the podcast, Dr. Kanters. We always appreciate you setting some time to come in and chat.

Dr. Arielle Kanters:

Well, thank you for having me. I'm excited to talk about one of my most and least favorite topics today.

John Horton:

Well, and this is ... I love that you enjoy talking about what are just not comfortable topics for the most of us because I don't think anybody, aside from you, really wants to talk hemorrhoids. So I guess, let's just jump in here and just give people a little background, because I know we were joking around at the beginning here, people say “hemorrhoids,” and they don't really know what it means, so give us that education.

Dr. Arielle Kanters:

Absolutely. OK. So there's two big things I have to say right off the bat about hemorrhoids. First of all, of the patients who come into my clinic with hemorrhoids, a lot of the time, there's actually another process going on. So just be clear, though we often classify all kinds of perianal issues as being hemorrhoid problems, they're oftentimes not. There's many different things that can happen around our bottom that may present-

John Horton:

…hemorrhoids just get the bad rap, it sounds like.

Dr. Arielle Kanters:

Yeah. Exactly. It's like we've over-labeled them. A lot of things cause bleeding, a lot of things cause discomfort, a lot of things cause pain. They're not always hemorrhoids. Don't get me wrong … that come and see me, I am happy to help reclassify things. But just to be aware, it's not always hemorrhoids.

Second of all, everyone has hemorrhoids. They're actually a totally normal part of our body anatomy. So we all have these veins in our bottom. They're called hemorrhoids, and they have tissue around them. They're called hemorrhoidal cushions. And what's interesting is that we actually need our hemorrhoidal cushions. Our hemorrhoidal cushions provide about a third of that pressure in our bottom that help keep poop in our body. So if you don't want to poop walking down the street, it's a good thing to have hemorrhoidal cushions.

John Horton:

Yeah. We do not. The-

Dr. Arielle Kanters:

…the thing ... no — exactly — polite company. Not a big fan of pooping your pants. If you're having that problem, come and talk to me, and we've got other plans, other ways of working with that.

That said, so patients will come in, they're like, "My hemorrhoids. My hemorrhoids." I'm like, "Well, yeah. I have hemorrhoids, too." Hemorrhoidal prolapse, hemorrh oidal bleeding, hemorrhoidal engorgement is oftentimes actually not the problem. It's a consequence of another problem. So the way that we treat the hemorrhoidal problems is by boiling things down to what is causing it. Are we straining too much? Are we constipated? Is there a muscle dysfunction going on? What led to these hemorrhoids becoming more aggravated? That's the key to having success in managing hemorrhoid problems. So coming in and just right off the bat saying, "Boss, you got to cut these off," you can say that, but there's a pretty good chance you're not going to like my answer. So coming and talking to us about your hemorrhoid problems is oftentimes an exploration in trying to figure out what's really wrong with how you're pooping.

John Horton:

Well, let's get into that a little bit because I think we all want to avoid hemorrhoid issues and I think we all want to avoid having to come into your office saying, "Cut these off."

Dr. Arielle Kanters:

Fair.

John Horton:

So let's figure out how we can keep our natural hemorrhoid cushion areas all happy. So [inaudible]-

Dr. Arielle Kanters:

…OK, cool.

John Horton:

I guess from what I understand, we can start with a real simple one, and that's time spent sitting on the toilet. How is that kind of irritating or making our hemorrhoids angry?

Dr. Arielle Kanters:

Absolutely. I'm a mom. I like to escape to the toilet. There's no doubt about it. It's my couple minutes of reprieve. And sometimes, I start swiping and I swipe to the point that I'm like, "My legs are numb. I have officially been sitting on the toilet too long." You zone out. It is what it is. The problem is that when we're sitting on the toilet, we're sitting in this funnel space, right? There's a hole in the middle. And all the blood is pooling. Also, when we're sitting on the toilet, we may be pushing. We may not really be paying attention to what we're doing. And so you can end up with a lot of blood pooling in the bottom, which will cause those cushions to start to swell up more and more. My general rule is less than five minutes on the toilet. You should not be sitting on the toilet for more than five minutes, both either scrolling ... Do not scroll.

Frankly, don't bring your phone in the toilet or in the bathroom.

Second of all, pushing. If you're sitting on the toilet and nothing's coming out within those first couple minutes, get up, move on, do something else. Come back when your body is telling you it's time to have a bowel movement.

John Horton:

So basically, when you just sit there for that long, like you said, the blood just pools up in those veins and they just kind of swell, and that's where you get that irritation, that burning feeling that I guess they can even pop out?

Dr. Arielle Kanters:

So it's actually not the burning. What you'll start to feel is more of a swelling feeling. A fullness in the bottom, which if your hemorrhoids are too engorged, they may even trigger your bottom to think things are full. The burning pain is actually more often a consequence of either over-wiping because you feel like something's wrong down there, or there could even be mucus drainage because those cushions can start to secrete extra mucus. Burning is actually usually a consequence of something else, though oftentimes, people will associate it with hemorrhoids because they can go hand in hand.

John Horton:

OK. Well, let's talk about that burning then. So it sounds like ... is that something where you irritate the hemorrhoids by over-wiping, just if there's no other issues? I get the sense those veins are kind of in there a little bit. Or once you're sitting there, they swell up a little bit, and you wipe, and they're just kind of a little more out there.

Dr. Arielle Kanters:

So interestingly … so you have internal hemorrhoids, you have external hemorrhoids. And the way we distinguish between the two is you have this line in your bottom. It's a line of sensation called the dentate line. Stuff that's up above that, you actually don't have any feeling in it. But when they become so swollen and that blood continues to pool, they can start to pop down and you can get hemorrhoidal prolapse, which can cause some irritation around there because this tissue isn't meant to be outside our body. And when it's outside our body, it's extra irritated. And then it starts to secrete this mucus, which your brain then starts to feel as wetness, which, it tells you, "Hey, something's dirty down here." So then you start to wipe, you wipe, you wipe, you wipe. And continuing to wipe in that area could cause little tears, which can feel like burning and further itching.

The other thing that could happen is that those cushions can get so swollen that it's almost like there isn't enough room for them to spread anymore. So then the skin around the anus starts to stretch. Now, that part does have sensation. And if you have persistent swelling down there, you can have some irritation where you just feel like you're rubbing, get some friction down there. And yet, rubbing can cause the burning sensation. Yeah. That's not supposed to have friction.

John Horton:

When you say external — and I'm trying to visualize because I'm not that flexible, I can't see back there. I don't spend a lot of time, nearly as much time, I think, looking at derrieres as-

Dr. Arielle Kanters:

…bottoms.

John Horton:

...as you do. Yeah.

Dr. Arielle Kanters:

Most people don't, to be clear.

John Horton:

So when you say ... what is happening? Something that's internal is going external down there?

Dr. Arielle Kanters:

No. So sometimes, your internal hemorrhoids can pop down. That's called hemorrhoid prolapse. But also — I don't know if you know — a lot of people may notice that they have a little extra skin around their bottom. What I like to tell them is you can get wrinkles on your forehead. You can get wrinkles on your bottom. They're actually called skin tags. Typically, we will call these little extra skin around the anus. If you've ever had kids, you probably know what I'm talking about. Those little tags around the outside are skin tags, but they're also external hemorrhoids. So when that skin on the outside of the anus starts to swell up, they can look like grapes, almost like-

John Horton:

…oh, good God-

Dr. Arielle Kanters:

...purple grapes.

John Horton:

OK.

Dr. Arielle Kanters:

[inaudible]. If anyone's ever heard of a thrombosed hemorrhoid, that's what we're talking about. Those can hurt like stink because when they fill with blood, the blood can actually form a clot. And you think about it, your bottom's one of the most sensitive parts of your whole body. So if you get a blood clot down there, it will hurt so bad. That's when you come in and see us because we can actually lance them. We can cut it, which I know sounds absolutely atrocious, but there'll be instant relief when we pop the clot out.

John Horton:

OK. Well, I got to tell you, 1) grapes are off my shopping list this week.

Dr. Arielle Kanters:

I'm so sorry.

John Horton:

What? It's going to be a no-go for a little bit, but I'll get over it eventually. It's going to take a little bit of time.

Dr. Arielle Kanters:

I can help you. Don't worry about it.

John Horton:

All right. So we're talking about then the blood's going down there, whatever. What about when you over-strain? We've all had that moment where you're really ... I don't know, there's a big poo or something. You got to get something out. When you do that, are you putting extra pressure on those veins and making them swell more?

Dr. Arielle Kanters:

Yes. Absolutely. So first of all, if you're straining, consider why you're straining. You should not have repeat ... a once-in-a-while straining episode, because you have a hard poop or because whatever's going on down there, once in a while, that's OK. If you're consistently straining, that's worth investigating because there's different reasons that you may have a hard time getting a bowel movement out.

Chronic constipation is not an infrequent problem. We can treat that. We can make that a heck of a lot better sometimes with something as simple as just drinking more water. But there also can be scarring around the bottom. There's a lot of things that may make it hard to poop.

But regardless, when you're sitting there, when you're pushing hard, you're forcing all the pressure down into your bottom. Just like how you know you can get those big veins in your forehead, you got veins in your bottom. The same thing is happening down there. If you're pushing, you should be breathing. There is productive pushing, and there is counterproductive pushing. Holding your breath and clamping your abs down, not productive pushing. Breathing through and actually breathing and relaxing your pelvic floor, though it feels a little bit like you're straining, it's actually relaxing things so that stuff can pass more easily.

John Horton:

I got to say, the whole … the angry vein in the forehead thing, knowing that that's downstairs, too, that's blowing my mind right now, so it-

Dr. Arielle Kanters:

…yeah, don't blow those.

John Horton:

…and I know you were on a previous podcast, and we had talked about just even positioning yourself and doing whatever — there's ways to poop that it can make that a little bit easier to come out so maybe you don't have to strain.

Dr. Arielle Kanters:

I like to say Americans are the worst poopers. We don't drink enough water. We like tall toilets. We love wipes. We like to over-wipe our bottom.

That tall toilet thing is a real problem. So the pelvic floor, there's a sling muscle around your bottom that's actually kinked when we're standing up. And as we start to sit and then squat, it starts to relax so that there's a much straighter channel for things to empty. So having our legs at a standard 90-degree angle or even a bigger angle is actually not helpful. You really want to get your bottom and your feet as close to the same level as possible. I realize for a lot of us, that's not feasible, but there are little, simple things you can try, like putting a little step stool in front of your toilet, whereby, putting your feet on top of it, it'll relax your muscles, A, which is important for getting a good pelvic floor relaxation. But even more, B, it'll actually help relax that sling muscle, making it easier to have a bowel movement. Some people just put their feet up. If they have a bathtub in front of the toilet, just plop your feet right on top of it. It's a really easy way to get that relaxation.

John Horton:

And just so everyone knows, we had an entire podcast where we discussed how to poop better. So you can definitely look that one up and you can get a lot more information on it.

Dr. Kanters, you had mentioned something just a few seconds ago, chronic constipation. What is the line for that? Because I think we've all had maybe a couple days where you don't go. What would you consider chronic constipation to the point where maybe you should go talk to somebody?

Dr. Arielle Kanters:

So typically, we say less than two bowel movements a week. So if you're going more than three days consistently between bowel movements, that is starting to raise a concern. Now, if you don't feel constipated, if you feel like you're emptying well and you're not straining and you're passing your bowels regularly, I don't care if it's once every four days. If you don't feel like there's a problem and you feel that you're emptying effectively, not having abdominal pain, great. But if you're noticing that you're always pooping rabbit poops, those little hard rocks, that's not supposed to be like that. Our bottom is not designed to do that.

Sometimes, constipation can actually present with diarrhea. You can develop something called overflow diarrhea or overflow incontinence even, where if you have a really hard poop ball sitting at the bottom, the stuff up top starts to liquefy and sneak around.

So I know, again, that sounds crazy, but it's like these irregular changes in your bowels, if they're just happening in a way that you're feeling symptomatic, they're all worth investigating. And again, oftentimes, it's just a matter of thinking about what you're eating. I know that if I eat cheese, I'm going to have a problem the next morning. How much water we're drinking, how much fiber we're taking in our diet. That's a really important one. Both what we actually eat in our fruits and vegetables, but also maybe supplemental fiber, like a psyllium husk. But all of these little adjuncts can oftentimes be something to easily fix a symptomatic constipation.

Then, there’s a whole other extreme, just as a side note. I have patients who will poop once a month. That is obviously an extreme setting. That's a situation where, myself and my GI partners, we really need to be involved because there are ways that ... A, you should poop more than once a month. But, B, there are ways we can make your quality of life so much better by working on these things.

John Horton:

And it sounds like you said diet is the main way to do this. So 1), it sounds like you need to get fiber in. And obviously, I think we all know there's some high-fiber foods we can look at, but it sounds like we need a little more than that. You recommend a little supplementation, too.

Dr. Arielle Kanters:

Yeah. I think part of the reason I recommend this is just so that we can be really consistent. One day, I may have a salad. The next day, I have all meat and potatoes. And sitting there and trying to calculate how many grams of fiber I took every day is kind of tedious. My simple solution to that is just to take a daily fiber supplement. Psyllium husk is kind of the most common one people are aware of, but there are other forms: wheat dextrin, methylcellulose. There's a bunch of different active ingredients all going by different names. The point is that it doesn't have to cost a lot. The generic over-the-counter is just as effective as the fancy one you see on social media. But fiber supplementation guarantees a certain amount of fiber in your diet every single day. Listen, I tell patients every day in clinic to try fiber. And they're like, "I just can't tolerate the powder." So I've tried the gummies. I've tried the capsules.

I feel like I'm a perfect test subject to see what seems to be available on the market. Gummies, I have found, though they can be stimulating, they don't quite do the same thing about giving you that really nice well-formed bowel movement. Capsules, good option if you really can't tolerate the powder, but the reality is, pay attention to how much you're taking because you'll oftentimes have to take a handful of these capsules. Gets kind of expensive. So my go-to, the easiest thing to do, is just do the powder. And you can play around with different ones in different concentrations, using an agitator bottle, something that you can shake it up and then drink it quickly. It helps get it down a little bit faster. But the other really big thing I tell people is, because we're typically not used to taking this much fiber, if you just kind of go hog wild into it and read what the back of the bottle says and start going full dose, you'll oftentimes find you feel burpy. You feel kind of like you've got bubble gut. You just don't feel well.

John Horton:

Little gassy.

Dr. Arielle Kanters:

So that's a major … yeah, gassy, thank you — that's an appropriate term. So that's a main reason a lot of people are non-compliant or don't really feel like taking the fiber supplement. So instead, I just tell them, "Let your body adjust to it. Start low. Go slow." Start with a really little dose, like half a teaspoon or one teaspoon a day. Do that for a whole week. Then, go up by half a teaspoon or one teaspoon each week until you reach the amount that you achieve something called the ghost poop. Now, I know you and I have talked about this before. This is a great term. A ghost poop is when you sit down, it comes right out of you, you wipe, there's nothing on toilet paper. It's like it was never there. So that is the ideal bowel movement. This is what we're all trying to achieve.

John Horton:

Goals.

Dr. Arielle Kanters:

And I think it would be easy ... the goal — yeah, life goals. I'm pretty sure my kids would tell me that's an old saying at this point. But aiming for that is really a gold standard that we try to achieve. And the easiest way I've found to achieve that is fiber supplementation and good water intake, so at least two liters of water a day.

John Horton:

Yeah. And you had mentioned, I know, before, the importance … you got to keep hydrating, especially if you're upping your fiber content, or if not, you're going to make bricks down there. You got to get a little moisture in the equation.

Dr. Arielle Kanters:

Exactly. Yeah. Please don't aim for the bricks. That is not the goal.

John Horton:

What else do we need to know to protect against hemorrhoid issues? I know we've covered a lot of stuff, the big things, but what are just a couple other items that maybe we should pay attention to?

Dr. Arielle Kanters:

So I guess bleeding. Like I said, hemorrhoidal problems are oftentimes not the underlying issue. So when an average patient comes into my clinic and we're talking about hemorrhoids, I can pretty much take care of whatever their symptoms are by just getting them on fiber, by having them have a more regular bowel movement, poop a little bit more naturally, get off the toilet. Social media, phones, and toilets, that's a hemorrhoid's best day. But the reality is that sometimes even then, these have been going on too long, there may be some other problems. So if you're having persistent bleeding that isn't getting better with simple improving your bowel regularity, that is something you should definitely come and see us about. It could just be the hemorrhoidal cushions, but we also need to make sure nothing else is going on. It could also be that you've been getting treated for hemorrhoids when, in fact, you had an anal fissure all along.

So hemorrhoids are not always hemorrhoids. And so it's important to recognize if you're having persistent problems, if you're really having irritation around your bottom, you're really having itching, you're really having bleeding, pain, those are all reasons to come and seek additional input because it's possible that there's actually a totally different thing we need to address.

Other little things about hemorrhoids is that it is normal to have skin around your bottom. I know I mentioned that once before, but I'm really going to drive this home. As we age, wrinkles, totally normal. And in reality, they just feel bigger. So sometimes, they feel bigger than they probably are. Sometimes, the advice you might end up getting from me by coming to my clinic is “do less.” You have a great bottom. Nothing to do about it. It's fine.

But if you do find that they're causing a lot of irritation with running, with walking, with whatever the case may be, this is probably not going to be the most popular recommendation, but actually using diaper cream can help a lot.

So just like you can get ... diaper cream. Yes. Zinc oxide. So just like you can get chafing between your thighs, different folds around your body, you can have chafing on your bottom as well, which can cause a lot of pain and irritation, especially if you have that extra skin. So actually using a little bit of a zinc oxide that can help lubricate the space can counteract a lot of that chafing feeling. I don't love talc powder. I don't love baby powder. It's almost more drying.

John Horton:

I was going to ask about that with the ... I run, and a lot of times, I'll put some talc powder down there to avoid chafing because that is horrible.

Dr. Arielle Kanters:

Yeah.

John Horton:

That's bad?

Dr. Arielle Kanters:

It's not that it's bad. It's bad if you're having problems. If it works for you, great. But if you're like, "Oh, I just keep putting it on there because it just keeps hurting," that's probably a sign we need to try something different. So my personal go-to is using a zinc oxide. It kind of functions like a liquid Band-Aid™ because sometimes, even sweating, I know this sounds ... you're a runner — having a sweaty bottom can also be what some people come in with when they're convinced that they have hemorrhoids, and it's actually just that they sweat a little bit more on their anus. And so putting a zinc oxide on that area, it'll actually function as a repellent so that water isn't sitting on the skin and isn't causing skin to get worse.

And you said you had kids. I got kids, too. I was not the best about diaper rash. But you know that moment when the kid has a bad diaper rash and they won't let you wipe their bottom? Maybe you were a better parent than me on that one. They run away from you. That can happen to adults, too. And the thing is we treat it the exact same way, diaper cream.

John Horton:

OK. Yeah. We've all had that where you see the kid walking and they're like ... you know something's not quite right downstairs. So just with that oxide, you said the zinc oxide, you just kind of reach down there and just, I don't know, just aim, put it on, hope for the best?

Dr. Arielle Kanters:

Yeah. And I tell people an icing-thick layer. Now, I know that ... so you know those ... I say-

John Horton:

…now cake's off my shopping list now too, so...

Dr. Arielle Kanters:

…use a lot of food analogies to describe bowel-related disease. Very popular. So icing-thick layer on the skin. I shouldn't see the skin. Zinc is not going to rub in, just like you put the zinc sunscreen on your face. I've literally used diaper cream as sunscreen, just as a side note. But it's not going to rub in. It's supposed to sit on the skin so that any moisture, any friction sits on top of it. It protects the skin. When you go to the bathroom, you're just going to wipe that coat off. You're not going to scrub it all the way. You're just going to wipe the top layer off and apply some more right back on top. And that'll take care of the problem.

John Horton:

I'd say you've made all of this sound very easy. And I know when I started researching for this, I was really surprised at how many people deal with hemorrhoid issues. It's so common and something that I don't think any of us really want. It's not comfortable, it's a little embarrassing, things like that. If you take these steps, if you get more fiber in, you hydrate, you don't linger on the potty, all the things that we've been talking about, are your hemorrhoids just going to live happily downstairs and not cause you any issues?

Dr. Arielle Kanters:

Most of the time, yeah. Most of the time, though — and a little bit of it is retraining and just getting the knowledge that, hey, this is OK to have skin. So those little things, those aren't going to go away. They're probably stretched out. It is what it is. But the point is the bleeding should get better. The mucus drainage, the itchiness, all of those things collectively should get better. If they're not, again, that's when you come and see us because there may be another reason and something else we need to investigate further.

So I would say the majority of patients will get better with just these conservative management. Even my father — that's embarrassing. My dad finally told me. He has a colorectal surgeon as a daughter. He finally told me he had hemorrhoid problems. And all I had to do was get him on fiber. That was all. Tells me all the time how much he loves his fiber. And so yeah, most of the time, that's all you need.

John Horton:

Simple as that. Well, hey, if it's advice you're giving your dad, I take it it's advice that all of us could benefit from. So I don't think anything comes with a bigger gold star than that.

Dr. Arielle Kanters:

Yeah. Exactly. Listen, I am a religious consumer of my fiber. My husband is, my whole family. We've got everyone. My kids, not yet. They do try the fiber gummies, but we're working on that.

John Horton:

Well, I think we can all kind of strive to add a little fiber to our diet and do some of these other things, and then hopefully we won't have to come to your office and have to ask you to cut anything out.

Dr. Arielle Kanters:

Yeah. Exactly. But don't forget about your colonoscopies. Stay on top of it. Age 45, make sure you're doing your preventive health.

John Horton:

Always got to get that in.

Dr. Kanters, I can't tell you much how much we appreciate you coming in and how you make conversations on these sorts of topics just absolutely so much fun. So thank you.

Dr. Arielle Kanters:

Well, thank you. I happen to like talking about this stuff.

John Horton:

Well, I'm glad somebody does because I would not want to be in the midst of this all day, so I'm glad somebody is.

Dr. Arielle Kanters:

Thank you for inviting. I'm excited to ... always happy to share more about the beauty of fiber.

John Horton:

Thanks a lot.

Dr. Arielle Kanters:

Bye.

John Horton:

Hemorrhoids may be common, but they are largely preventable, too. Do a few simple things, like adjusting your bathroom habits, eating more fiber and hydrating, and you'll probably put hemorrhoid problems behind you.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.