By Tedler D. Depaynos, MD
The patient is in her early 30’s when she delivered her 3rd son. She noticed that every time she got pregnant she developed soft bulging masses in her rectal opening diagnosed by her Obstetrician as “hemorrhoids”. She was advised “hot sitz bath” or sitting in a container filled with hot water that she could tolerate for 10 to 15 mins. or until the water gets cold 2x/day. She did this initially but she found it inconvenient so that every time she takes a hot shower, she took time directing the shower to her rectal opening. She also avoided the spicy foods she was fond of and made sure that her stools were soft by doubling her usual water intake and even buying prune juice and ripe papaya at SM as advised by her Obstetrician. It was after her 3rd delivery that the “hemorrhoids” did not subside despite the advices of her Obstetrician and appears to be getting bigger especially upon moving her bowels. At one time she even felt pain and she has to push inside the bulging “hemorrhoids” into her rectum or do a manual reduction. Her Obstetrician advised her then to consult a surgeon.
The surgeon upon a rectal examination found out that the patient has a 3rd degree Internal and External Hemorrhoids. Surgeons in general grade the hemorrhoids based on their rectal appearance. If they are inside the rectum and does not come out, it is 1st degree. They are usually considered when there is rectal fresh bleeding. If they come out during bowel movement but spontaneously return inside, it is 2nd degree. 3rd degree is when they come out during bowel movements but could be returned only with manual reduction just like the patient. 4th degree is when they stay outside and cannot be reduced. Surgeons usually operate on 3rd and 4th degree hemorrhoids only. Conservative management is advised for the 1st and 2nd degrees as done by the patient’s Obstetrician. Spices and even alcohol irritates the rectal opening worsening the hemorrhoids. The heat applied thru the hot water makes them subside. Some patients insist that hot water with boiled guava leaves works better. Specific drugs and suppositories are prescribed to reduce the swelling, control pain and infection and to make the stools soft.
The hemorrhoids are actually veins found in the rectal opening. Those found in the lower extremities are called varicose. With the patient lying on her back, the major hemorrhoids at the rectal opening are found at the 7, 11 and 3 o’clock positions. These are the ones usually removed during surgery. In between them are the minor hemorrhoids that seldom enlarge. In some cases they enlarge and interpreted by some patients as recurrence. In other cases the major hemorrhoids which were not removed because they were only 1st or even 2nd degrees enlarge after some time and again interpreted as recurrence. A removed hemorrhoid does not recur.
Hemorrhoids are usually classified as Internal or External but most of the time they are Mixed. External hemorrhoids are covered with skin and are painful. The Internal Hemorrhoids are covered with mucosa and supposed to be painless. In this patient she had Mixed hemorrhoids.
Pregnancy may have contributed to the formation of the patient’s hemorrhoids because of compression of the draining veins. Heredity factors however may also be considered. As a rule surgeons advise colonoscopy prior to surgery especially in elderly patients to rule out any colonic etiology like malignancy. Finger rectal exam reaches only the rectum.
In the older Textbooks of Surgery hemorrhoids were removed by ligation by the use of rubber bands and injection of sclerosing substances to stimulate scar tissue formation. Classical excision with knife or cautery and suturing was the standard treatment and still being done by some surgeons. The surgery is done under spinal anesthesia but post-operative pain and swelling are usually the problem and it takes days or even weeks to recover. At present the use of Harmonic Knife which may be called a “super modern cautery” makes hemorrhoidectomy a simple surgery. The patient after overnight stay in the hospital could be discharged and the post operative pain and swelling are negligible.
The patient underwent hemorrhoidectomy with the Harmonic Knife and she was able to return to her bank where she works as assistant manager in no time at all. Although she promised herself not to have a 4th pregnancy, her husband still desires for a daughter.**