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Scott Webb (Host): Hemorrhoids are common, treatable, but a little difficult for some of us to talk about. And joining me today is Dr. Adam Rothermel. He's Board Certified in General Surgery and the Director of the Genesis Center for Surgical Excellence. And he's here to tell us about hemorrhoids, the causes, treatment options, and why we shouldn't be afraid to talk about hemorrhoids if we need to. This is Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. I'm Scott Webb. Doctor, thanks so much for your time. Before we get rolling here, let's talk about hemorrhoids and exactly what are they?

Adam Rothermel, M.D. (Guest): Anatomically, you know, hemorrhoids are just veins down in the anus. As I think most people know we have these muscles called sphincters and at the higher up in the anus portion of those sphincters, there's a round circle of veins and those are what we're gonna be calling the internal hemorrhoids.

Now everybody has these veins. So, I guess technically everybody has hemorrhoids to some extent, but these are the kind of the high up ones and when they become dilated or enlarged, that's when you can start getting symptoms from these veins that are up in the anus called internal hemorrhoids.

Now external hemorrhoids are different. They're, they are veins, but they're on the external part of the anus. And when these become enlarged and bothersome, we call these external hemorrhoids. All right. So, that's what they are. Now what they are and where they are actually leads into how they become a problem.

Host: Yeah. So that's what I wanted to ask you. Exactly what causes hemorrhoids and how do you know if you have them?

Dr. Rothermel: Yeah, there's a litany of causes of hemorrhoids. And honestly you may not pin down exactly what happened to cause the hemorrhoids, but kind of the most typical things we tell people are that hey constipation or diarrhea kind of anything that causes you to be in the bathroom for a long time or straining leads to pressure down in these veins of the anus and they can become dilated and bothersome.

Another extremely common cause of hemorrhoids would be pregnancy and giving birth. I think that almost all women develop hemorrhoids during the late stages of pregnancy and during childbirth. Now you just hope that they go away or get better afterwards, but a lot of women are stuck with hemorrhoids after childbirth.

I guess another thing I would say about how do people get hemorrhoids is just, there's a lot of professions as well that these people find themselves in positions for long periods of time, that kind of lead to pressure in the anus and pooling of blood down in these hemorrhoid veins, like truck drivers, super common profession that I see with hemorrhoids because of the long trips on the road in the sitting position.

And also like mechanics that are down in a crouching position or working underneath cars and anything that really causes increased pressure down in the anus over a period of time will cause these veins to get big and dilated.

Host: Yeah. And you mentioned as we got rolling here, that this is a somewhat tricky subject for people. People may have hemorrhoids, as you say, they're very common, but people may not want to speak with their doctors about them because of some embarrassment, let's say. So, because it is so common and they do need to be treated right? Let's talk about the treatment options and mainly what happens if we don't treat them?

Dr. Rothermel: Yeah, absolutely. You know, hemorrhoids being so common, you really should have an idea for when is the right time to seek treatment for these things. And do you even necessarily have to bring it up to your doctor if you have hemorrhoids and, I would say that most folks with hemorrhoids don't really need to seek care or have some kind of procedure for their hemorrhoids. We should just talk about, okay recognizing that you have hemorrhoids and then how do you deal with it? And if you deal with it and it's still causing you significant problem, where do you go for help?

And the symptoms of hemorrhoids can be split up between the internals and externals. So, we typically say the rule of hemorrhoids is that internal hemorrhoids bleed and external hemorrhoids hurt or itch or burn, and all good rules in surgery, rules are made to be broken. And so there are exceptions to that. But basically internal hemorrhoids are above the nerve endings. And so generally internal hemorrhoids are not the ones that hurt or itch or burn. They are the ones that, bleed after you have a bowel movement or you strain, things like that. You may notice bright red blood on the tissue paper.

You might even notice some dripping of blood into the toilet water, and it can really turn that toilet water red, just even with a few drops. Those are most likely, if it is hemorrhoids, the internal hemorrhoids that are doing that. External hemorrhoids, you're going to feel when you're wiping this kind of grape or marble bulging from the anus and they can be itchy. They can be painful or just irritating. And a lot of folks will have difficulty getting clean after having a bowel movement, if they have significant external hemorrhoids. The exception I want to tell you is, cause a lot of those come to me and they say, hey, I have external hemorrhoids.

Internal hemorrhoids can become large enough that when you have a bowel movement, when you're exerting pressure, those internal hemorrhoids bulge out of the anus. And even though they are on the outside, they're still considered internal hemorrhoids. So, those are the ways to recognize that you may be dealing with hemorrhoids.

So, let's talk about, okay, what do you do? I guess the first line of treatment for hemorrhoids would be to regulate your bowel movements better. Most of us in America don't get enough fiber in our diet. I think the daily recommendation is 25 grams and you could really go up to 35 grams safely. We should eat more fiber.

Fiber is the great equalizer. You know, if you're having diarrhea, eat more fiber, if you're having constipation take more fiber, it should make our bowel movements easier to come out so that you don't have to strain so much. And along with eating more fiber, we should be drinking more water. And so we want to have enough fiber, enough water in our colons so that we don't have to strain to have bowel movements that will help relieve the pressure on the anus and hopefully cause those hemorrhoids to regress or get smaller. Now, if beyond that, there's a lot of over the counter topical hemorrhoid treatments. We're talking about the Preparation H, the Anusol, I mean, if you go to your local pharmacy, there's probably going to be an entire wall of treatments for hemorrhoids, because it's just that common of a problem. Most of these medications have either hydrocortisone, phenylephrine or some kind of lidocaine, or even witches hazel. All of these treatments are basically just to reduce the swelling of hemorrhoids or to help with the discomfort, itching, burning, caused by hemorrhoids.

And so they're all good. That's fine. Definitely, if you're having issues with your hemorrhoids, I'm going to tell you do the fiber, do the water. And here's an over-the-counter medication that you should apply, you know, multiple times a day to try and have those hemorrhoids regress. So that's, those are really the things that, we initially tell people, hey, your hemorrhoids, aren't killing ya. They are causing you some significant discomfort, try these things for a while, weeks or even a month or two, and see if you can get them to regress.

Host: When would surgery be indicated?

Dr. Rothermel: And so let's talk about hemorrhoid surgery. It's not a walk in the park, all right. And there are some options for hemorrhoid surgery, and we're going to talk about that a little bit, differences in procedures and stuff. But ultimately I find myself trying to talk people out of getting hemorrhoid surgery when I see them in the office sometimes instead of trying to talk people into it. Yeah.

Host: It's a funny thing about surgeons. We assume that surgeons just live to perform surgery, but I talk to a lot of docs and they all say the same thing. That surgery is usually a last resort for most people.

Dr. Rothermel: Yeah. And that's right when it comes to hemorrhoids, I just know the patient that needs a hemorrhoid surgery when they come in. And it's typically not the person that is dealing with mild symptoms from their hemorrhoids. It's just not worth it. But when folks do have bleeding with every bowel movement or heaven forbid, bleeding in between bowel movements from their internal hemorrhoids well, you've reached a point where that's going to be necessary. People that have developed severe pain, constant itching, burning issues with their external hemorrhoids, that they haven't been able to get relief from these over the counter methods and changing their diet and things. That's somebody that's going to benefit from hemorrhoid surgery. And so what I tell you about hemorrhoid surgery is it's not pleasant. If we're just dealing with internal hemorrhoids and like I alluded to earlier, those are above the area of the nerve endings. It doesn't have to be so bad. There are procedures we can do that are called like hemorrhoid banding, where we put tiny little rubber bands on these internal hemorrhoids in surgery and it will squeeze them off and then basically fall off. And that can be a good procedure for internal hemorrhoids without so much pain and discomfort after the procedure. But when you're dealing with big internal hemorrhoids or internal and external hemorrhoids, really surgical excision or cutting out of these hemorrhoids is the tried and true way to deal with them. And it's a surgery I do all the time. It's a pretty straightforward, simple surgery for me, it only takes, 20, 30 maybe Yeah, I do great with it. But, but the healing process is pretty uncomfortable. My, my speech in the office with my patients is that man, you're really going to hate me for the first week. I'm not going to be your best friend, even in the second week, but by week three, after you have your hemorrhoid surgery, you're probably going to be glad you did it and you'll come back and shake my hand, but not until then.

Scott Webb (Host): Not until then, right?

Adam Rothermel, M.D. (Guest): Yeah. Afterwards, it's just, it's a raw surface on your anus. It's a very sensitive area. You do a lot of things like sitz baths or soaking your butt in water for 10 or 15 minutes to take away the sting. You're applying topical pain medication to the area. You're taking stool softeners so that you don't have to pass a boulder through the area, and you're also probably for the most patients, taking a narcotic pain medication for the first few days until you're kind of over the hump. And I'll say that in terms of recovery, most people are not able to work for about the first week after surgery, maybe even for some, two weeks, because it's just so sensitive and you don't want to be at work. You're not going to injure anything by going back to work or doing activities, but it's just going to be that uncomfortable.

Host: Yeah. It sounds like it would be uncomfortable and definitely difficult to sit for long periods of time. Maybe even just in the car. Doctor, other things that we confuse with hemorrhoids, you know, when we all try to self-diagnosis. Are there things that seem like hemorrhoids, but actually are something else?

Dr. Rothermel: I am so glad that you asked that question because as a general surgeon, I sit in my office and I have folks come in and they're a lot of them are under the impression or have even been told, heh you have hemorrhoids, go see the surgeon. And I usually start my speech by saying, hey, I need to do a good physical examination on you because there are other things that simulate the symptoms of hemorrhoids, but they're just not hemorrhoids.

And so a couple of those things, the most common condition of the anus that simulates hemorrhoids is what we call an anal fissure. And an anal fissure is actually like a tear or crack in the lining of the anus. And it bleeds like crazy when people have bowel movements and it hurts like crazy. And so I can almost tell by the story that I get from a patient, if we're dealing with hemorrhoids or anal fissure, because like I said earlier, internal hemorrhoids bleed, but don't hurt. But if I have that patient that comes to me and they say, when I sit down and have a bowel movement, I have bright red blood on the tissue paper. And it feels like something put out a match right on my anus. It just burns like crazy for anywhere from like 15 seconds up to an hour or two. And they have this terrible spasm pressure in their anus with bowel movements. They of course assume they have hemorrhoids, but ultimately that almost always turns out to be this anal fissure.

Or crack in the anus. And it's a real common thing for it, the same things that bring about hemorrhoids, bring about fissures. And so you need to, if you're having that bright red blood with a lot of pain, you really should see a surgeon and we should do a good physical exam and help you diagnose that. The treatment for that, it's going to be similar, you know, over the counter medications, dietary changes, topical pain medications, and there's even some topical prescription medications for fissures that can help resolve that problem. Ultimately, there are surgical interventions for that. The most common thing I will do is put people under anesthesia and actually inject Botox to the anal sphincter muscle and Botox is, what people commonly think of with plastic surgery. But it, what it does is help paralyze part of that sphincter muscle and allows the anus to heal by preventing the spasm that occurs after having bowel movements. And it's been very successful, and it's really not a painful procedure for people to go through.

And yeah, anal fissure is one of the most common things that people confuse with hemorrhoids. Other things that people may confuse with hemorrhoids are like perirectal abscesses, or an infection that occurs beside the anus. That can be very painful. And cause similar symptoms to what they think are hemorrhoids or anal fistulas.

And I don't want to get into the technical details about fistulas, but this is somebody that's having itching, burning pain, and puss like drainage from around the anus. These are all things that you should see a general surgeon for.

Host: As you say, all of these things are very common, easy because of the symptoms, easy to confuse one for the other. The best thing to do would be to reach out to your primary and then possibly see a surgeon. Doctor I'm so glad you suggested this topic. This is a, this has been really interesting. As we wrap up, anything else you want folks to know? What are your takeaways about hemorrhoids?

Dr. Rothermel: I just want people to be reassured that, hey, hemorrhoids are super common. You're not the only one dealing with this problem. And rest assured that hundreds of patients have gone to their doctor before and said, hey, I think I might have hemorrhoids. Can you check? And if they do check and the symptoms are bad enough, come see a surgeon. We're not going to try to talk you into a hemorrhoid surgery, but we're certainly going to help you try to get over the symptoms of hemorrhoids and ultimately if it's necessary, we have the ability to get rid of them for you.

Host: Yeah, that's good to know that you're doing that work at Genesis. And as you say, they're so common, we just need to get over the hump a little bit and go in and speak with our doctor, have a physical examination. There's lots of treatments, therapies available before we would ever about surgery. So it really fascinating. Yeah, really fascinating topic. Thanks so much, Doctor. And you stay well.

Dr. Rothermel: Yeah, my pleasure. Thank you so much.

Host: Call 740-454-5777. Or visit Genesishcs.org for more details. And thanks for listening to Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. If you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. I'm Scott Webb. Stay well and we'll talk again next time.