Scott Webb (Host): Hemorrhoids are very common and there's lots of ways that medical providers can help and provide relief. I'm joined today by Dr. Alison Tammany. She's a General and Colorectal Surgeon with Salinas Valley Health and she's going to tell us all about hemorrhoids and give us some suggestions for how we can help ourselves.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk hemorrhoids, as people do, apparently. You and I are definitely going to talk about hemorrhoids. And I think it's one of those topics where I think most people think they know what hemorrhoids are. I'm kind of like that about bunions. Like I think I know what bunions are, but I'm probably wrong.

And I'm probably, very similar when it comes to hemorrhoids. So what are hemorrhoids and are there different types?

Alison Tammany, MD: Yes, there definitely is a lot of confusion about hemorrhoids and the symptoms they can cause. Hemorrhoids are actually a combination of arteries and veins and they're described as little vascular cushions that are inside the anus and up in the rectum. There is a difference between internal hemorrhoids and external hemorrhoids.

Internal hemorrhoids are actually a part of everyone's normal anatomy. So I will get people come to the office with a colonoscopy report saying, oh no, I have internal hemorrhoids. Like what should I do? And a lot of the times I have to reassure people that these are actually normal. The internal hemorrhoids do play a role in your continence or your control of having bowel movements.

They actually comprise about 10 to 20 percent of that function, so I don't recommend removing them routinely unless people are really having issues. The internal hemorrhoids are actually up inside the rectum, right above the intersection of the anus and the rectum, which has a different skin cell type and also a different innervation, whereas the external hemorrhoids are more as described external and on the skin of the anal region.

So this is important because they're innervated differently. So typically the external hemorrhoids will be more painful and they can sense pain and temperature and pressure. Whereas internal hemorrhoids typically do not cause pain but they can sense pressure and they usually cause issues with bleeding.

Host: Okay. Yeah. So it sounds like internal anyway, I'm just deciphering this, trying to stay with you. So it sounds like internal is just pretty natural, pretty normal. As you say, removing them is not usually something that you recommend. And as you say, the external ones really can be painful. How do they form? How do people get hemorrhoids?

Alison Tammany, MD: Hemorrhoids form or people call them hemorrhoids when they start having issues with them and they can enlarge and start causing issues or you can actually have a blood clot in an external hemorrhoid and that's really when people have what's called a thrombosed hemorrhoid and they have a really tender lump that they can feel on the outside of their anus.

So people can develop issues with their hemorrhoids over time if they have certain risk factors and also if they have poor bathroom habits. Severe straining can lead to that thrombosis or the blood clot to form in an external hemorrhoid on the skin and that can be very painful. Typically this will be a mass that someone can feel that will ache for a couple of weeks at a time until the blood clot resorbs similar to how a bruise would resorb.

Host: Yeah. And you mentioned risk factors there. I'm assuming maybe age, pregnancy. So I wanted to have you address that, the risk factors and also, are they dangerous? Can they be dangerous?

Alison Tammany, MD: That's correct as well with those two risk factors. Definitely getting older puts people more at risk for having issues with their hemorrhoids as does pregnancy. Other risk factors include people with COPD or chronic cough, chronic constipation, and also prolonged sitting on the toilet. If they're spending more than one or two minutes on the toilet to have a bowel movement, you are straining and kind of allowing gravity to overtake the hemorrhoids and let them kind of descend out into the anal canal.

So, those are the typical risk factors I talk about in my clinic. They aren't necessarily dangerous, but they can be in certain rare instances, especially if people are prone to bleeding. You can have severe bleeding, but typically people have intermittent painless bleeding and it's not necessarily life threatening.

Fortunately, they also rarely get infected, so they're not really dangerous from an infection standpoint. The internal hemorrhoids can enlarge to the point where they can actually come out of the anus, and in a very severe kind of rare case, you can get something called a hemorrhoidal crisis, where the hemorrhoids are strangulated and external when they're supposed to be inside, and that would be a situation that would be dangerous, and you would require urgent surgery for that situation.

Host: Yeah, I understand why the word crisis is in there. That does feel a bit like a crisis and something to seek, you know, immediate medical attention. It sounds like some hemorrhoids can be prevented or sometimes we can prevent them and sometimes we can't, right? We can't get away from our age, right? We are as old we are, right? Pregnancy or gravity even, right? But are there some instances, things that we can do to prevent hemorrhoids?

Alison Tammany, MD: There definitely are ways to prevent having complications from them. I talk a lot about good bowel habits in my clinic and we'll touch on some of that later on, I'm sure, but I always recommend fixing some of the bowel habits, a diet rich in fiber, making sure that people are drinking enough water and also staying physically active to help with their gut motility.

Host: Yeah, and it sounds like, you know, in most instances, for most folks, the hemorrhoids will go away, or maybe some topical treatment, something like that, and you said earlier that you don't really recommend removing them, but let's just say, for example, in the case of a colonoscopy, is that when hemorrhoids, if they were going to be removed, is that when you do that?

Alison Tammany, MD: I don't usually recommend removing them at the time of a colonoscopy. And the reason why is they are actually a little bit deeper than a polyp, which are routinely removed during colonoscopy. The polyps are more superficial and it's easy to get like a snare or some kind of a device around it and cut it off.

But unfortunately the internal hemorrhoids are deeper than that. Another reason I recommend against doing both a colonoscopy and a hemorrhoidectomy at the same time is that if there are any issues or complications, it's a little bit difficult to determine exactly what the cause of that complication is.

Host: Yeah, let's talk about fiber. I know I hear, you know, from experts like yourself and in the news, you know, fiber is a good thing and especially it seems to be, when it comes to hemorrhoids. How much fiber should we consume or how much fiber is too much? Like, how's that work?

Alison Tammany, MD: I don't know if I've ever had somebody eat too much fiber. It's, that's usually the opposite complaint that I have, especially in kind of the Western American diet that we have. The recommended fiber intake for women is 25 grams a day, and for men it's 35 grams a day. But because that's a pretty aggressive amount of fiber for men, I typically will recommend both men and women to aim for 25 grams a day.

And there are apps on the phone and ways to kind of check to see how much fiber you're getting. But it's pretty difficult even with a high fiber diet with eating like salads and vegetables and fruit every day and whole grains; it's hard still to get to that 25 grams without using a supplement. So I will recommend all of my patients to also use a fiber supplement or a powder that's all natural, you know, over the counter, doesn't have any side effects as a medicine, and for them to use that every day.

Host: Yeah. As you say, it's probably pretty rare if ever, where you tell someone, you know, you really need to cut back on the fiber, right?

Alison Tammany, MD: Definitely.

Host: Yeah. So

Alison Tammany, MD: It hasn't happened yet.

Host: Right. Yeah. So the nature of hemorrhoids and really what they are, and you said earlier that it's pretty rare that it becomes life threatening in any way, but can hemorrhoids turn into something else if they just sort of go untreated or don't go away? Can they turn into cancer, for example?

Alison Tammany, MD: Hemorrhoids don't typically turn into cancer. There are times when sometimes you will find an incidental cancer in your specimen in the operating room, but it isn't from the hemorrhoid itself. It's usually a skin cancer or an anal cell cancer that started as a different, etiology. So the hemorrhoids themselves not turn into cancer.

If people though have chronically inflamed or irritated external hemorrhoids and they are excessively wiping or they have like recurrent inflammation of that area and the skin starts changing and becoming thick; you know, maybe 20-30 years down the line they would be at higher risk for having some sort of a skin or an anal cancer down there. But the hemorrhoids themselves, those blood vessels, do not turn into cancer.

Host: All right. So I see what you mean. Yeah. Sort of indirectly hemorrhoids could turn into something else, but not directly. And I want to ask you about treatment for hemorrhoids. I know there's a lot of OTC type stuff, over the counter stuff. I see that when I'm walking the aisles, but generally speaking between that, things that we can just walk in and buy and working with you, how do you treat hemorrhoids?

Alison Tammany, MD: So hemorrhoids are treated in a variety of ways and it really depends on what the complaint is and what the problem is. In general, I recommend all of my patients to optimize their bowel habits with again, the high fiber diet, drinking 64 ounces of water a day, and only spending a few minutes on the toilet and avoiding straining.

And I didn't discuss this a whole lot yet, but the fiber, is meant to help bulk the stool and it kind of helps patients with both loose stool and with really hard solid stool to make something in the middle that is an easy bowel movement to pass without straining. And that's why that's the cornerstone of treatment and prevention for hemorrhoidal issues.

If patients are still having issues where they're bleeding from internal hemorrhoids, then I will offer the rubber band ligation in the office, which takes a few extra seconds during the normal endoscopy exam to look at the internal hemorrhoids. There are other options for bleeding internal hemorrhoids, and those include sclerotherapy, which is an injection of a medicine to necrose and shrink the hemorrhoid.

There's also something called transanal hemorrhoidal dearterialization, which is a special device that we can get in the operating room that finds the artery via a doppler and you actually suture ligate the arterial branches and that can help shrink down the hemorrhoids as well. There's also infrared photocoagulation which is similar to a laser that will help shrink down the hemorrhoid and we also have an electrocautery device in the operating room that can shrink the hemorrhoid and burn it as well.

We can use traditional suturing and try to ligate the blood supply based on what we can see with a suture and the traditional way of treating hemorrhoids is by excising them with a scalpel or an energy device. One of the other options is using a stapler. However, I typically don't recommend this in my practice as you can get severe complications, if it is not done correctly.

But typically where I am in my office, I'll start with the conservative management and then I'll offer rubber band ligation and then surgical excision if the patient is still really having a lot of issues. Another time I'll offer surgery up front is if the hemorrhoids are so large that they're prolapsing or coming out of the anus and I know that they're too big to be shrunk down successfully by the rubber bands.

Then I'll recommend up front surgery. The external hemorrhoids are what people traditionally will put the over the counter creams on and I recommend doing that if they do have some issues with inflammation or blood clot around the anus, and you can use that for one to two weeks at a time, but I don't recommend long term use of the steroid cream because it can actually thin the skin and then create more issues with bleeding and healing. Then you end up actually causing a problem with chronic use of those creams.

Another common complaint I get are skin tags. Skin tags are synonymous with external hemorrhoids and I typically won't remove those unless they're really causing issues with patient's hygiene.

Because usually when you cut off skin tags, just the way that the anus is shaped and the incision has to be made, you actually can still form skin tags while you're healing for your surgery to remove the skin tag. So I find that, you know, that causes pain and discomfort and that people aren't really satisfied with the outcome. So I typically don't recommend cutting off the external hemorrhoids.

Host: All right, so Doctor, I think I know the answer to this one, but I'm just wondering, it sounds to me like no matter what we do, and we work with an expert like yourself, and we all do our best, it sounds like hemorrhoids can recur, if you will. I'm assuming that's true.

Alison Tammany, MD: Yes, that's definitely true. If people don't improve their bowel habits or have those risk factors, they can recur. Typically, I want people to work on their fiber intake and limiting their time on the toilet before I do the surgery as well, as part of the education for that because I don't want them to form the hemorrhoids again.

And there can be complications from hemorrhoid surgery. So really the best way to undergo that surgery is to only undergo it one time. You know, anytime you operate on the anus, you can cause scarring and you can cause issues with narrowing of the anal canal or chronic pain. And people really need to focus on improving their bowel habits so that they don't come back.

But you are correct. They definitely can come back. And I never remove all of the hemorrhoidal tissue when I do an excisional hemorrhoidectomy. Because of the risks of those complications. If you remove absolutely everything, you can really cause somebody problems and make their anus so narrow that then they can't have normal bowel movements again.

Host: Yeah. And you touched on there, and we've hit on this a couple of times about good bowel habits. So what does that mean in practical terms?

Alison Tammany, MD: So a big part of that again, is the fiber. I'll tell my patients to try to incorporate more fruits and vegetables and salad in their diet, which fortunately is pretty easy since we live in the Salinas Valley. Whole grains also are a good source of fiber. A great way that I recommend people to start their day with a fiber rich breakfast is to actually get some oatmeal and put two teaspoons of whichever fiber supplement they're using, which is a powder, and then mix it in. And usually you can't tell at all that you have added fiber to your oatmeal.

And then you can also add some fruit to start the day with at least 10 grams of fiber. I also recommend drinking eight glasses of water a day, anything caffeinated doesn't count towards that number, and staying physically active. A big thing is really the time spent in the bathroom as well, especially with all of our technology that we have.

People bring their phones into the bathroom, which used to be, you know, reading a book in the bathroom, which also I don't recommend. But people will sit on the toilet and they'll read and they'll strain and then they won't notice that, you know, 20 minutes have passed. And while that's happening, your anal sphincter, your muscle is open and your hemorrhoids are coming out and descending out because of gravity.

So I recommend, you know, that people don't bring their phones in the bathroom for hygiene reasons and for their hemorrhoids. Um, I actually had a patient one time tell me that they watched movies while they were in the bathroom and brought their laptop because they were spending so long on the toilet.

And that definitely is an extreme case, but I kind of use that as a warning that if you're doing that, you're going to probably end up in a colorectal surgeon's office one day.

Host: Yeah, if you're watching Braveheart while you're on the toilet, you're definitely in there too long, right? And it's, yeah, that's, that's a battle that I fight with both of my kids. They're 17 and 21 and they spend so much time in the bathroom. And then I'm told later, well, yeah, cause I was playing on my phone.

I'm like, just listen to the experts, you know, that they don't want you sitting on the toilet. for that long. You don't need to. Gravity can be a bad thing. Good stuff today, Doctor. Really helpful. A lot of great information. Just want to give you a chance here at the end, sort of, you know, take home points for folks. Just kind of sum it all up for us.

Alison Tammany, MD: Another adjunct that people can use is a squatty potty. The anorectal angle, which allows you to pass the bowel movement is in a more natural state when you actually using either a squatting potty or hug your knees kind of up more towards your chest.

So you can even put a little step stool underneath. It's another way to help pass bowel movements easier and not strain so much on the toilet. Some of the other take home points about hemorrhoids is just to know that they're a very common issue. There are over 3 million outpatient visits a year to doctor's offices to discuss hemorrhoids.

So they're a little bit taboo, but they're very common. Hemorrhoids are also a part of the normal anatomy. So I definitely spend a lot of time educating people that they do serve a purpose and they're overall trying to help you and that hemorrhoid surgery isn't always the answer because it can be very painful.

We didn't get too much into the hemorrhoid surgery, what it entails and the recovery, but it can take months to recover from that surgery. So I always try to avoid that and still try to make an individualized plan for people who come to see me.

Host: Yeah. My takeaway doctor is, you know, try to avoid getting hemorrhoids if you can. Right. So listen to the experts, right? Good bowel habits and the eating and the exercise and all of that. And then of course, you've gone through lots of treatment options today, things we can do to help ourselves to sort of live with and manage and surgery, perhaps being a last resort in most cases. So, I really appreciate your time. Thanks so much.

Alison Tammany, MD: Very good. Thank you so much for your time as well.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.