~ By Dr. Peter J. Senatore
Board Certified in Surgery and Colon and Rectal Surgery Anorectal surgery, or proctology, is a specialty that elicits more laughs and jokes than almost any other profession, yet when patients have problems in this area of the body they are rarely smiling, let alone laughing! Many people are embarrassed to seek medical attention for problems in the anal area and when they do, the diagnosis and treatment they receive may be inaccurate, since many health care providers are not familiar with the latest care options. The most common anorectal problems are hemorrhoids, anal fissures, and anorectal abscesses/fistulae. Here is a brief overview of these problems and the current options for treatment.
Hemorrhoids are the most widely known anorectal problem. Most over-the-counter medications are labeled as “hemorrhoid treatments,” so it is natural to attribute any symptoms in that area to hemorrhoids. In fact, EVERYONE has hemorrhoids; the hemorrhoidal arteries and veins are the normal blood supply to the rectum and anus and the vessels that communicate between the arteries and veins (sinusoids) are a normal part of the anatomy. Swelling and shrinking of these vessels plays a role in fecal continence and normal rectal tone. Abnormal “hemorrhoids” develop when the connective tissue that holds them in place weakens, usually due to straining, alterations in bowel function, or increased blood flow such as during pregnancy, with the result that they descend or “prolapse.” Hemorrhoids are described as internal when they are inside the anal canal and external when they are at the anal verge, or edge. A basic rule of thumb is that internal hemorrhoids bleed, while external hemorrhoids cause pain. This is because the mucosa, or lining of the anal canal, is soft and easily irritated, but has no sharp pain nerves, while the skin at the anal verge is tough but has innervation. In fact, except for thrombosis (clotting) of the external hemorrhoid, most symptoms can be attributed to the internal hemorrhoids with swelling, prolapsing, and increased mucous production that will cause itching, burning, and breakdown of the skin externally. Successful treatment corrects the internal hemorrhoid issue rather than focusing on the external disease. There may be enlarged external vessels with associated redundant skin or tags, but unless they interfere with normal hygiene, they do not require specific treatment. They also belong outside. Attempts to reduce or push them back in will be unsuccessful and potentially painful. The current emphasis is on returning the hemorrhoids to their proper size and location rather than trying to remove all of the enlarged tissue. Not only does this reduce patient discomfort (surgical hemorrhoidectomy has been long recognized as an extremely uncomfortable procedure) by reducing trauma to the skin, but this also avoids potential narrowing or stricture of the anus, and alterations in sensation, tone and continence.
The vast majority of hemorrhoids can often be controlled without any significant intervention using dietary and hygiene adjustments, a short course of topical steroids, and avoiding straining or prolonged attempts to defecate. When these measures are not sufficient, there are many varieties of office treatments that have been employed, including rubber band ligation, infrared coagulation, DC electric current, injection of sclerosing agents, and cryotherapy (freezing). All are designed to create fixation of the internal hemorrhoid to the lax connective tissue and prevent engorgement and prolapse. The disadvantage to these therapies is that they treat only a segment of the tissue and often require multiple sessions to correct the entire problem. In the past, the only option when these office treatments failed was an excisional hemorrhoidectomy in the operating room. This is still an appropriate treatment in selected patients who have significant external problems, such as non-reducible prolapse. Over the past decade an alternative operative approach has been utilized, called the Procedure for Prolapse and Hemorrhoids, or PPH. This is similar to the office treatments in that it reduces and fixates the hemorrhoids rather than removing them. It utilizes a special circular stapling device that treats the entire circumference of the anal canal at once. This provides a complete treatment of the hemorrhoids while avoiding significant trauma to the anal skin, reducing pain and avoiding stricture or loss of sensation.
Robert P. Driscoll, M.D., F.A.C.S
Giovanni A. Ferrante, M.D., F.A.C.S.
Joseph F. Iovino, M.D., F.A.C.S.
Gregory J. Lareau, M.D., F.A.C.S.
Peter J. Senatore, M.D., F.A.C.S., F.A.S.C.R.S.
OUR NURSESDebra Cardarelli, L.P.N.
Eileen Hall, R.N.
Andrea Norton, L.P.N.
South Shore Surgical Specialists
The Vein Center
780 Main Street, #2A
South Weymouth, MA 02190
Monday – Thursday: 9 a.m. to 5 p.m.
Friday: 8:30 a.m. to 4 p.m.