Transcription
Hey, welcome to another episode of Talking with Docks. Today, we're talking about Uranus, and I don't mean the seventh planet from the sun, a.k.a. the third largest in the solar system, like your hat says. We are talking about things that can go wrong with your anus, such as hemorrhoids, and particularly the surgical side of hemorrhoids. We have some other videos to talk about the non-operative side, but we brought in a special guest, Dr. Ian Choy, a colorectal surgeon, to talk all about hemorrhoids and the surgical treatment of them. Welcome in! Thanks for joining us.
Thank you very much. Thanks for having me. I think we should start right at the beginning. We're going to cover this topic top to tail, so stick around till the tail ends. We'll put a good summary for you, but what is a hemorrhoid?
Well, what a lot of people don't realize is everybody has hemorrhoids. You have hemorrhoids. I have hemorrhoids. Hemorrhoids are completely normal. I got to go see my doctor. They're all there, and they actually serve a function. They are blood vessels that sit at the top of our anal canal, and they swell up to help prevent leakage of mucus and stool out the bottom.
Okay, now what happens, though, is that if you're not getting enough fiber and fluids in your diet, as the stool's going through the area, it pulls and stretches on those blood vessels, and they start to prolapse down out through the anal canal. That's where we start to get problems with hemorrhoids, like bleeding, pain, mucus leakage, irritation, itchiness, and scratching, which can lead to bleeding from that as well. I think that's where the name "piles" came from. It's actually a Latin word, "pila," which roughly translates to "balls," and that's because they look like small little balls hanging down. If you've ever seen a hemorrhoid, apparently they look like small little veiny balls.
Okay, news to me that everybody has hemorrhoids. We're going to be talking about the ones that are symptomatic and causing problems. So what is the history? Someone will have a history. You kind of mentioned it already. If I think I have hemorrhoids, I'm going to present to my doctor saying these following symptoms: pain, itchiness, maybe some bleeding.
Pain, itchiness, bleeding, swelling. People sometimes, when they get really bad, they prolapse down. Sometimes they'll go back in on their own after a bowel movement; sometimes people have to actually push them back in. They can be extremely irritating, and when they get really severe, such as with a thrombosed hemorrhoid, where you get a blood clot in them, they become very hard and extremely painful. It's life-altering for these patients.
Okay, now are there different types of hemorrhoids? Is there a way to classify them?
Yeah, so there's a few ways to classify them. There's internal versus external hemorrhoids. The internal ones are the ones I'm talking about where they start to prolapse out. The external ones are blood vessels more on the mid to external anal canal that get swollen. The internal ones we grade from 1 to 4, with 4 being the worst, where they are prolapsed out and you can't get them back in. Three is when they prolapse out but they do go back in, and one and two are the internal ones that swell, bleed, and cause problems.
Okay, so you've got a history that we just described, and you figure you need to go see your doctor. What kind of things is the doctor going to do for someone who presents with the history of hemorrhoids?
Well, for diagnosis, basically a few things. A physical exam is the first key thing. When people present with hemorrhoids, they can have all sorts of different things. We need to rule out cancers; that's a big thing. Whenever you have bleeding from the bottom end, you want to make sure that you're not missing something like cancer. We see so many patients that come to us for hemorrhoids, quote unquote, and then we examine them and find out there's something else going on. Things like rectal polyps, which are precursors to cancers, are another common finding that we see and have to rule out.
So, a physical exam will give us a quick diagnosis. We'll be able to get a sense of what grade the hemorrhoids are and also help us rule out those malignancies. This would be like a rectal exam inspection, obviously. Do you use any other devices to improve visualization?
Yes, and then usually after that, we also want to do some sort of scope. Putting a camera up the bottom, whether that's a sigmoidoscopy, where we just go up the bottom for about 30 centimeters, or a full colonoscopy, where we look around the whole colon, depends on your symptoms, how much bleeding you're having, what type of bleeding you're having, and any change in your bowel movements.
Is a sigmoidoscopy done like in the office? Do you have to be sedated for something like that?
You don't need sedation for a sigmoidoscopy. It's a quick procedure that takes about five minutes but gives a ton of information. It's a great test—quick and easy. You walk out, and it's fine. Colonoscopies, obviously, are a little bit more invasive, require more prep, and you need sedation for all that, but both are very good tests.
Okay, to the viewer, please, we're trying to normalize this. Please don't be embarrassed about a hemorrhoid and not go see the doctor because you just heard there are other things that it could be that are important to find out. We joke about it; we're normalizing it. We're using words like anus, bum, bottom, sigmoid. He's wearing a hat that says "Uranus" on it. We're just trying to normalize it so you feel comfortable enough to say, "Hey, I think I got hemorrhoids," or maybe something else. Something's going on with my anus; I should go see the doctor about it. Don't be embarrassed and stay home and suffer with this because it could be something else that's treatable if caught early enough.
Exactly. Okay, so now you have your diagnosis. You have a diagnosis of a hemorrhoid, and you've tried the non-operative stuff. We've talked about this before: water, fiber, changing your diet, trying to avoid straining, which is the big issue. Now you get to a point where you think, "Would you do that for a couple of months? Would you give a non-operative try for a couple of months?"
It really depends on the scenario and the severity. There are some big grade four hemorrhoids where you look at that and think, "Well, fiber's not putting that thing back in." Exactly. So when you get to these higher severity cases, then you're starting to look at more invasive options. It's important to note that no matter what more invasive treatment we do, if you're not doing the fiber and fluids thing, the hemorrhoids are going to keep coming back no matter what you do. So I always start patients on the fiber and fluids, no matter what surgical option we're going down, just to make sure they don't come back.
Can you give our viewers a ballpark as far as the number of grams of fiber we're trying to target in a day? Because certainly, North American diets are grossly inadequate as far as fiber intake.
Yeah, what are we targeting? For women, I usually recommend between about 20 to 30 grams of fiber a day. For men, about 35 to 40 is the ballpark figure. Everyone's different; some guys are bigger than others, and so our dietary requirements change. We have a nutritionist, a dietitian, who works with us specifically to talk about these types of issues. There are lots of resources out there, and you can get it from your food or from a supplement, whether it's an over-the-counter one or something like Metamucil or Benefiber. Whatever there is, there are fiber brands like psyllium fiber. All of these are good options, and always, always, always, if you can get it from your food first, do that. You may have to change your diet to try and get a diet that's high in fiber. These supplements are available if you can't get there with your diet.
Okay, so for treatment options, usually the first thing we do is something called banding. Hemorrhoid banding is a quick procedure as well; it takes about five minutes in an outpatient setting. What we're doing with those is we put a little rubber band at the base of the hemorrhoid. The tiny little rubber bands you can barely see usually fall off within the first day to three days. What it's doing is it helps to cut off the blood flow to the hemorrhoid, but more importantly, it also causes scarring, which contracts and pulls a hemorrhoid back up to the top of the anal canal where the hemorrhoid is supposed to sit—almost like a skin tag.
Yeah, can we jump to an image just so that we can get a visual of this? An image of what you mean by internal, external, and making the thing go back up.
Exactly, so let's look at an image that you're kind enough to bring. So here's a picture. On the left side, you have the normal position of a hemorrhoid. On the right side, you see where the hemorrhoids have enlarged and started to prolapse down. Again, the idea with banding is you want to get those hemorrhoids pulled back up to their normal position.
All right, okay, so that's the first option: banding. Banding, you know, oftentimes we'll have to do a few rounds of these to get them to fully stick. Whenever you're treating hemorrhoids, we all have three main columns of hemorrhoids in our anal canal. You never want to treat all three at the same time because you can get complications with narrowing or stricturing of the anal canal, which is a devastating complication and can be quite problematic to treat.
So if banding doesn't work and we've done that a few times and you're still having issues with either bleeding or prolapse, then we have to look at a few other options. In Canada, usually what we go to after that is surgical hemorrhoidectomy.
Okay, that's a surgical procedure under general anesthetic. You're fully asleep for that. Basically, what we're doing is putting you to sleep and cutting out the whole hemorrhoid itself.
Okay, again, it's a fairly quick procedure; it takes about 15 to 20 minutes. The issue with the procedure is it's extremely painful. Patients describe it as the worst pain they've ever experienced in the post-op period.
You mean in the post-op period? You know what's funny is that all doctors kind of say that because we had Peter Inson, and he's like, "Oh, kidney stones are the most painful, even more painful than labor." And then we're like, "Total knee replacement is the most painful thing you ever had." You're like, "Oh yeah, I know, ham."
So this is the thing about how medicine works. Unfortunately, there are a lot of things that are painful but are necessary to get through the treatment, unfortunately.
Yeah, okay, so very, very painful. For how long are we talking?
About two weeks for it to fully heal. Because of that pain, it's not something that I typically recommend.
All right, and that's why we really push the less invasive as a last resort. It is a last resort. As I said, hemorrhoids serve a function, right? If you cut them out, they're no longer there, and some people can have issues with leakage and stuff like that afterwards.
So there are some complications of this procedure in addition to the pain. Are there complications such as leakage or incontinence?
Almost, yeah. Because of that, there are a few other options that are available. If you're online and reading about these things, you'll come across this stuff. Not all of it is very popular, at least in Canada in our setting, but certainly internationally.
What kind of steps are we talking about?
One is a stapled hemorrhoidectomy. That's a procedure where you use a special stapling device that basically traps hemorrhoid tissue and excises it.
Like we commonly use for appendectomies or colon resections?
Yeah, it's a circular staple device. We use them similarly when you want to join pieces of bowel together.
But is the stapling thing kind of like banding, where you're just trying to constrict?
No, this completely cuts it all out, so it's like a hemorrhoidectomy, but it uses a stapling device.
Okay, but it's not as common here. There are complications with them, stricturing being the main one. I've had to try to fix a few of those for patients who have gone overseas to have this procedure done.
And that's the nature of your practice, right? You're a sub-specialist, so sometimes when things go wrong, they come to you to say, "Hey, can you try to fix a revision of a hemorrhoid surgery?"
Exactly. Is there any role for injections?
Yeah, so there are a few coagulation-type techniques. Injections, there's laser coagulation, and there's RFA ablation—radiofrequency ablation. These all are trying to do the same thing: you're putting a little probe or injecting into the hemorrhoidal tissue to cause the blood in it to coagulate and basically shrink down that hemorrhoidal vessel.
It's the exact same laser, almost the same probe and whatnot. So they work well; they're not as widely available, at least in our setting here.
They are expensive, right?
Yeah, they're a few thousand bucks to get that done. It's a good option for some people. If you're on blood thinners, for example, banding is not a great option. We can't do banding if you're on blood thinners, so something like injection or laser or RFA can be used in those situations.
Okay, so there are situations where it's useful, but at least where we are right now, it's not as widely available. So your standard protocol would be non-operative treatment, try to avoid and prevent, then you consider banding, and then as a last resort, hemorrhoidectomy. I mean, you may or may not try some of those other things.
Exactly. And on the blood thinner thing, is it possible—it's important for our viewers—if you're on a blood thinner and you have hemorrhoids, is it possible to experience a serious bleed that can require an emergency room visit?
Yeah, I've seen patients who've come in who've required multiple transfusions and urgent emergent surgery to get the bleeding under control. It's rare, but it does happen.
Take-home message for our viewers: if you do have hemorrhoids and you are on a blood thinner, you have to be careful. Be aware of this and be ready to go to the hospital if you start to get some bleeding that you can't control.
Okay, so let's talk about post-op. What does it look like for these people? I'm assuming they're not booking a night out with their friends the day after a hemorrhoidectomy or a seven-hour flight overseas.
For hemorrhoidectomy, as I said, for two weeks, life is miserable. You're typically off work. Would you say you're off work?
You're at home. It's hard to sit. Sitting is awful. You're kind of lying down, doing lots of sitz baths—like Epsom salt baths. Those are the main ways to help control the pain. Pain medication and creams just don't work that well in controlling that kind of pain.
Any topicals or local anesthetics that they can use, or not really?
You can, but it just doesn't help very well. Really, what comes down to it is Epsom salt baths and time is the main thing to control that. For banding, you're good to go that day; you can go to work. It's not that big of an issue. If people are having pain with banding, sometimes you can get that, but that usually means the bands have been placed too low.
Banding really shouldn't be painful afterward. People may have looked online; that's where we're talking about the dentate line, essentially, right? Where the inner part of our rectum is sensitive to stretch, and then the lower part is sensitive to pain and touch and that kind of stuff.
What about over-the-counter things? Before someone goes to their doctor, "Hey, I'm going to try the over-the-counter things like Anusol."
There are lots of creams you can get out there. There are special kinds of pills that you can take, but they're kind of temporizing measures.
Control, yeah, right.
Which is fine; it gets you to control things until you see a colorectal surgeon or a general surgeon. But, you know, again, to really deal with this properly, you'll need one of these other kinds of interventions.
I'm assuming another big part of the post-op protocol is staying on the fiber, right? Because, like you said, these can come back or could cause failure of your interval treatment. I'm assuming if you had a very large, hard bowel movement shortly after you had a big operation, it could tear the repair or whatever.
Yeah, and again, it goes back to what I was saying right at the beginning. Every patient I see with hemorrhoids, I start them on the fiber and fluids right away because that's what they're going to need to be on forever afterward.
Okay, so do you personally take any fiber supplements, or do you get it in your diet?
I do. I use bran buds. I put some bran buds in yogurt with a little bit of fruit. I do that in the morning and when I get home. My wife makes granola at home; she throws a bunch of bran buds in that, and we feed that to the kids.
Yeah, the whole family's on it. We're practicing what we preach. When we talk about fiber, we're not just saying it; we actually all monitor how much fiber we take in and do things about it to keep our fiber up. So if we're doing it, you got to do it too.
Last thing, we always talk about complications or risks and complications of the procedure. So obviously, there are the inherent risks of any type of anesthetic or sedation. What about specifically the procedure? So the acute complications as well as the long-term complications that we're kind of hinting at before.
So acutely, what would be the risk?
I mean, yes, as you said, all procedures have risks. For banding, you can get bleeding afterward; you can get infections from the bands. It's very rare, but these infections can be quite serious. You'll know that if you have fevers, pain, or sometimes difficulty urinating. So if you have any of these symptoms after a banding procedure, I always tell my patients to come back to emerge and get it checked out. Sometimes we actually have to remove the band.
And there have been some cases as well of quite significant bleeding, again, where patients have had to come back to emerge and had that dealt with. For the surgery side of things, really pain is the biggest thing. But again, bleeding after the procedure and infections in the area are rare.
But as you're talking, the main thing that we're worried about is some level of incontinence or urgency after a big procedure like that.
Incontinence is rare. It's quite hard to damage the sphincter muscle when you're doing a procedure like that, but people can feel some issues with urgency or leakage after a procedure like that.
The infection one surprised me. I mean, I'm amazed that there's not more infection. You've got the anus, which is an incredible organ because if you have bleeding anywhere else in your body and you rub feces on it, you're going to get an infection. Now you've got bleeding, and feces are passing through it on a daily basis. An infection is bound to happen, but it's so rare.
There's so much blood flow to the area that it just heals itself up.
Incredible. I know, that's a great summary.
Yeah, Uranus. Is it called Uranus now or Uranus still the planet?
I mean, the seventh—I have no idea. I thought they changed it to Uranus. They didn't want to say "anus," and you put the word "urine" in.
Where is those astronomers? One of the other—how's it any better?
Oh man, okay, well, now you know. Please leave a comment if you had an experience with hemorrhoids or with a surgical procedure—good, bad, anything. Please share because it will help other people make decisions about their hemorrhoids. If you liked this video, please like it, subscribe to our channel, check out our other long-term content, and remember you are in charge of your own health. Thank you so much for that.
Thanks for having me!