Dr. Miller: I'm here today with Dr. Bartley Pickron and he is a surgeon in the department of surgery. He is also a specialist in colorectal surgery. It's good to see you. I have patients that come to me and they ask, "I've got this pain in my bottom/rectum," and they say, "I think I have a hemorrhoid." How often is it a hemorrhoid or is it something else?
Is It a Hemorrhoid or Something Else?
Dr. Pickron: Most of the patients we see for anorectal pain don't have hemorrhoids, but everybody has hemorrhoids to some degree.
Dr. Miller: Most don't.
Dr. Pickron: Most don't, but the real causes of pain are more things like fissures, an abscess, and other things that aren't hemorrhoids.
Dr. Miller: Fissures can be incredibly painful.
Dr. Pickron: They're horrible.
Dr. Miller: What causes a fissure?
Dr. Pickron: Usually it's a tear and it happens directly in the front or directly in the back. Most of the time these things heal up just fine, but if they don't and they get deep enough to where the anal sphincter gets irritated . . .
Dr. Miller: Ouch.
Dr. Pickron: . . . then you get a spasm of that muscle and that prevents the tear from healing and then you just enter this vicious cycle that just won't quit.
Dr. Miller: So you use different therapies to try to repair that.
Dr. Pickron: Yeah, generally we focus not so much on the tear but on the muscle itself because if we could make the muscle relax and stop the spasm then the tear generally heals just fine on its own.
Types of Hemorrhoids and Associated Symptoms
Dr. Miller: While hemorrhoids aren't the usual cause, as you pointed out, they're both internal and external hemorrhoids, my understanding is that the external hemorrhoids can be painful.
Dr. Pickron: They certainly can. The most common thing we see when they are painful is a thrombosis, where you get a big blood clot with the pain and swelling.
Dr. Miller: Ouch. How do you treat that?
Dr. Pickron: Most of the time, we let them these reabsorb on their own. If patients come in within the first two or three days after the event happens, then there is some benefit to removing it surgically because they'll get better faster, but usually once they're kind of over the pain curve and their symptoms are getting better, then the pain and swelling will generally just take care of itself.
Dr. Miller: After you do the treatment, is there any kind of change in diet that they might need to make? My understanding is that constipation, straining, those things can contribute to external hemorrhoids. What's your thought on that?
Dr. Pickron: Absolutely. Constipation and particularly straining or sitting on the toilet for a long time during bowel movements reading the magazine, for example, all tend to predispose people to hemorrhoids. We recommend a change in bowel habits, usually by the addition of fiber or stool softeners and staying hydrated.
Treatments for Fissures and Hemorrhoids
Dr. Miller: When do you treat a fissure or hemorrhoids with a procedure?
Dr. Pickron: I'll talk about the fissures first and probably maybe 10 or 20% of those are actually treated surgically. We have creams that we can use that generally take care of things. If that doesn't work, Botox injection is an option. If those don't work, then the last resort is certainly surgery.
Dr. Miller: So that's treatment for fissures, how do you treat hemorrhoids?
Dr. Pickron: Again, most of these are treated non-operatively. There are procedures in the office we do. The most common thing we do is a procedure called rubber band ligation, where we put rubber bands around the hemorrhoids on the inside. That sounds pretty painful, but truthfully the internal hemorrhoids really have no sensation, so it's a very easy procedure to do and very well tolerated. It's usually just some mild pressure for about 24 hours and that's it. The ones that do need to be treated surgically, like I said, are typically the external ones and those are, fortunately for patients, fairly rare.
Dr. Miller: It would seem to me to be rare, but are there times that the pain could be induced by something like a cancer?
Dr. Pickron: It is. That's certainly one reason that these symptoms need to be evaluated very thoroughly.
Dr. Miller: So if they're going on for weeks, that's something that probably ought to be looked at?
Dr. Pickron: Right. So any combination of pain and bleeding and particularly if there is a little mass or something that just doesn't feel right, then that absolutely needs to be checked out.
Other Causes for Rectal Pain
Dr. Miller: Any other causes of rectal pain? I know that there's one that is a spasm that occurs from time to time in some people.
Dr. Pickron: Some people get this kind of vague rectal pain, which as you mentioned is just kind of a spasm, it's fairly poorly understood. There are some options for it such as physical therapy, biofeedback, but these can be challenging things to treat.
Dr. Miller: It comes on suddenly and then goes away over seconds to minutes, I think, sometimes.
Dr. Pickron: Yeah, usually happens in the middle of the night. People kind of wake up and they feel this intense pressure almost like a Charley horse in their rectum, which not a pleasant sensation.
Dr. Miller: Any other causes of pain?
Dr. Pickron: Those are primarily the big ones, infections, abscesses are fairly common and those are typically treated with surgical drainage.
updated: November 25, 2020
originally published: September 22, 2015
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