Dr. Stephanie Pannell - Hemorrhoids and Other Common Perianal Problems

Transcript

Voiceover:
Welcome to Prescribed to Listening from the University of Toledo Medical Center. Each week, UTMC providers sharing insight into their medical specialty. This week, Dr. Stephanie Pinell.

Dr. Stephanie Pinell:
Hello everybody. My name is Stephanie Pinell and I am a colorectal surgeon here at the University of Toledo Medical Center. I'd like to talk a little bit about what made me choose the field of colorectal surgery. I get asked that a lot by my patients and the students that rotate with me. The way that I like to think about it is, is a lot of times in surgery, you'll find somebody that's a really great mentor and you like the actual operations and what they're doing, but you also kind of see yourself doing that. And that kind of leads you to be more interested in the field and then kind of lead you into your career path. And so I had a great mentor that I met my fourth year of residency when I was kind of trying to decide, what am I going to do?

Dr. Stephanie Pinell:
I don't know if I just want to be a general surgeon because in general surgery and many surgical fields, you do five years, sometimes six years of general surgery residency, and then you can finish and practice general surgery, or you can go on and do a fellowship. And I was at that point where I hadn't made a decision of what I wanted to do. And I met an incredible mentor and also had the opportunity to work with some patients who kind of told me that they think that this is something that I should do. So I feel like I found my niche and they told me they were very comfortable talking with these very sensitive things with me and that they encouraged me to go into colorectal. So for me, it was kind of a gamble because it was a little late in my career path to choose to do a fellowship, but it was something that I thought I can do it.

Dr. Stephanie Pinell:
And if I ever don't like it, I really still enjoy doing general surgery and still do some general surgery. I can always go back and just practice general surgery. So it seemed like a great opportunity for me. So today I'd like to talk a little bit about what I mostly see in my clinic. As a colorectal surgeon, I see a lot of diverticulitis and colon disease, including Crohn's disease, ulcerative colitis, and cancer, but those are pretty clear cut when it comes to diagnosis. When they see me most of the time they've already been worked up and already know why they're in my office. The things that aren't as clear cut are the perianal disease, and what's going on around the anal canal. So if you ever come to my office and have the opportunity to rotate with me as a medical student, or just shadowing me in general, you'll see that the majority of the patients who come to my office for periodontal disease all have a pre diagnosis from either a physician or themselves as having hemorrhoids.

Dr. Stephanie Pinell:
So out of all of those people that are diagnosed with having hemorrhoids, I would say probably less than 10% actually have hemorrhoids. Why do we all think we have hemorrhoids is the big question. I think probably to answer that it would be it's the most publicly acceptable and famous peri-anal problem. I would guess there's hemorrhoid creams out there that are advertised and everybody knows what they are, the preparation H and all of those creams that they use for those. But there aren't really creams and other things that are advertised for the other conditions of the peri-anal diseases. So I'd like to talk a little bit about what hemorrhoids actually are and how you can pretty much diagnose yourself. I came up with a nice little way of diagnosing peri-anal disease during our COVID outbreak, when we had the AR pandemic, basically. When we had to do telemedicine visits. As you can imagine, being a colorectal surgeon and people with peri-anal disease, you have to get a little creative doing a telemedicine visit when you can't see somebody face-to-face, but to face or however you want to say it in my clinic.

Dr. Stephanie Pinell:
So I learned a little way to kind of help me diagnose patients over the phone. So you can kind of break it down by what their symptoms are when you talk to patients. And there's a group of only a few things that usually go on in the peri-anal region. Those first of all, and most commonly and what everybody knows are hemorrhoids. And there's two types of hemorrhoids, there're internal hemorrhoids and there're external hemorrhoids. And these are basically just blood vessels that get clots in them. And when they get a clot in them, if it's external and on the outside of the anal canal, it's large and very painful. And it's something you can feel. And these people are in extreme discomfort. Usually the pain only lasts a couple of days, and that goes away on its own. If it's a little further up in the anal canal, the nerve endings are different and you won't really feel the pain, but you'll have bleeding.

Dr. Stephanie Pinell:
So if I walk into a room and see a patient and they're standing up and they can't sit down, usually that makes me immediately think they may have external hemorrhoids. But if they're sitting very comfortable and they say they have really bad hemorrhoids, then automatically, if they do have hemorrhoids, it's probably going to be internal and not external in nature. So with the process being the same, it's just the location which makes the two different. That being said, they both can have bleeding, but the big factor is the pain when it comes to hemorrhoids. Now you'll have people who come in and say they have pain, or when I talked to him via telemedicine or whatever method, and they say, I have severe pain and I'll ask them so people will get very uncomfortable, but I say, is there anything that you feel around your bottom?

Dr. Stephanie Pinell:
Like when you wash your bottom or wipe your bottom, do you feel anything on the outside of your anus? And if the answer's no, and they have pain, then more than likely they don't have any type of hemorrhoid. This most likely is a fissure, which is a small tear. This is probably the most common thing that I see in my clinic. And even though they're all diagnosed with hemorrhoids, fissure is what most people are experiencing, but they just attribute it to hemorrhoids because it's painful. And a lot of people will have tried hemorrhoid cream around the area just to try to help with the pain. And actually it can make it worse. So that's not a good idea. And what a fissure actually is, is it's a small tear. So somewhere along the line, you had a large bowel movement or diarrhea and the skin right around the anus tore, just very slightly and very small.

Dr. Stephanie Pinell:
Now there's a muscle that overlays the internal, it's called the internal anal sphincter. And it's right inside the anus. And when you tear the skin there, it's an involuntary muscle. So you have no control over it. And we're very thankful for that muscle because it keeps poop from falling out of our butt. We don't even have to think about it. So when it gets a tear of the skin right over the anus, it contracts and stays very tight. Now, like I said, we don't have any control over it. So when you go to have a bowel movement and you bear down that internal sphincter there says, "No, no, no, I have a tear and it hurts." And it doesn't want to release. And so you're basically pushing through a muscle that doesn't want to relax. And therefore you tear even more so it'll bleed. Most of the time the patient say they experience a little bit of blood on the toilet paper after a bowel movement and they have extreme pain.

Dr. Stephanie Pinell:
And this is almost in my opinion, diagnostic for an anal fissure. So that being said, we've gone through the most common few things that I do see. The next thing I'd like to talk about that causes peri-anal pain is an abscess. And these are very apparent when people come to see me, they will complain of a fullness and a pain in a specific area. Usually you can think of it like a zip, basically it's an area right outside of the anal canal. It gets very hard. It hurts very bad. And then it will get softer and almost like pop. Sometimes people can come to see me before they pop, which is fine. I will help surgically pop this and help it drain. But that is a problem that I see of the peri-anal area also.

Dr. Stephanie Pinell:
And one of the things that can happen, an abscess forms around the anal canal, when you have these little glands that are right inside of your anus. And the reason why you have them there is we have mucus cells that produce throughout our colon so that when our stool is moving through our colon, that it moves smoothly through our colon. But then when it gets to the end, the skin changes and it turns into regular skin, the skin that hurts, like when you get an external hemorrhoid on the outside. So we still need an extra little bit of lubrication there, from those glands to kind of push it out so that it comes out smoothly. And those glands that secrete mucus and things that help us have bowel movements can get clogged and form an abscess.

Dr. Stephanie Pinell:
And so that's where we think most of these abscesses come from. And the reason why that's important is if you drain the abscess or the abscess drains right outside of the anal region, and you get what we call a perianal abscess, you have a 30 or 40% risk of developing a fistula. And that is another thing that is common around the peri-anal area. But these fistulas, they follow the rules and you can diagnose them pretty well. The patients most likely have a remote history of having an abscess. It may have drained on its own, or they had it drained and then it got better and then it came back, same area, and then it pops and opens. And it's a continuous cycle and they come to see me and I can help break that cycle, which is a little outside of the scope of this conversation.

Dr. Stephanie Pinell:
But these people, this is another common problem of the peri anal area. Another one that is very common, but often way underdiagnosed is basically called pruritus ani, which is Latin for itchy butt. A lot of people have this problem and they contribute it to hemorrhoidal disease when it's not. And they commonly come in and tell me that their bottom itches and it's worse at night. They've tried all these creams. They're now using multiple different types of wipes to clean themselves and they're bathing multiple times a day. Because for some reason, we, as human beings, associate itchiness with uncleanliness. And so we feel that the area's not clean. So then we excessively clean it and it actually exacerbates the problem.

Dr. Stephanie Pinell:
It's kind of one of those things where somewhere along the line, the natural flora and bacteria around that area got disturbed and started itching. And then we make it worse. And the treatment for that is to actually cut back on the cleaning and to let things go back to normal. So those are the biggest problems that I see with peri-anal disease. And it's not actually hemorrhoids. So basically if you're having problems your perineum in any way around your anus and you kind of want to figure out before you come to see me, or want to try to treat it on your own, which is very understandable. It's a pretty sensitive area, not everybody's running to the doctor to have their bottom looked at. So if you are wondering what's going on with yourself, there's a few questions you can ask to try to help you get to the bottom of it. Ha ha ha. All right

Dr. Stephanie Pinell:
Are you having pain? If you're having pain, then you have a few options. It could be an external hemorrhoid. It could be a fissure, or it can be an abscess. So to rule this out and figure out which one you have, when you wash your bottom, or when you're wiping feel around the outside of your anal canal. Do you feel a large bulge? Do you feel anything on the outside of your anus? If you don't, then you don't have an external hemorrhoid or you don't have an abscess. Most likely you have a fissure and if you're having bleeding, but no pain, then you probably don't have a fissure. You probably have internal hemorrhoids. So the disclaimer I'd like to make about all of these things, if there's anything wrong with your bottom and things are different, especially if you're having bleeding, you should come see your surgeon, your colorectal surgeon, or your primary care doctor, because you need to make sure you've had a recent colonoscopy.

Dr. Stephanie Pinell:
Anybody who comes to see me that has blood in their stool or any type of rectal bleeding, they automatically get a colonoscopy in any age because as we all know, colon and rectal cancer can be deadly if it's not detected early. So if you've had a recent colonoscopy and you want to self diagnose yourself, this is a good little workup to do, to figure out what you have. But if you haven't had a scop or recently or ever had one, then I recommend that you go get a colonoscopy. So let's say that you are one of the lucky people who come to my office that do have hemorrhoids. If you have an external hemorrhoid that's really large and very painful and very recently within the last 48 hours appeared, I usually do an excision of this and I will numb up the area and excise the hemorrhoid. It does help immediately with the pain relief and will help it heal faster.

Dr. Stephanie Pinell:
But if it's been over 48 hours, since you've had the development, it actually could make it worse and make it more painful. Because after about 48 hours, it starts to get better on its own. And if you do anything to it, it makes the area worse. So people have the misunderstanding with any hemorrhoid, internal or external hemorrhoid. These are blood vessels that get clots, remember. So if you can't deplete the blood vessels in that area. So just because you have a surgical treatment of a hemorrhoid, doesn't mean it will completely go away. You can get, if you don't fix the problem, whether that's constipation or diarrhea, whatever bowel issues you're having, then they can come back. So the bleeding internal hemorrhoids, they can be fixed by multiple means. If they're minimal, usually we start off with high fiber diet.

Dr. Stephanie Pinell:
I don't have any stock in either one of these, but I prefer Metamucil or Citrucel, this the powder form I'd like for people to take it as directed and drink plenty of water. That's the first-line treatment. After that, if they're minimal and they're not really large and excessively bleeding, then we could try banding these internal hemorrhoids. And remember, this is only for internal, not external. And if they're really large, then we do an excision and that's an extremely painful operation, but it will kind of give you a chance to start over. It will get rid of these temporarily and they will stay gone if you can fix the problem that's causing. And usually a successive straining.

Dr. Stephanie Pinell:
People sometimes with large internal hemorrhoids will admit to spending greater than 10, 15, 20 minutes on the toilet, which is not necessary. Your local colorectal surgeon here says you should never take a book, a magazine, or your phone to the bathroom. You should go in there and take care of business and get right off. One shouldn't take longer than a few minutes. And if you can't do that, then you shouldn't go in there to start with. So the other common problem I talked about, which are the fissures, are the tear. So we talked a little bit about how it's a vicious cycle where you tear it worse because the muscle won't relax. So the way you have to fix these is to make the muscle relax.

Dr. Stephanie Pinell:
And there's a few methods. So usually there's a cream, there's a compound ointment that I like to use that relaxes the muscle. And if you use it twice a day on that area, about 75% of people will have successful healing after a couple of weeks because it relaxes the muscle. And also you have to use a stool softener so that you don't exacerbate the problem also. If that doesn't work, I'll take people to the operating room and use Botox into the internal anal sphincter. And it paralyzes the sphincter in that area and allows the fissure to heal. And lastly, if it doesn't heal completely, I will cut a little bit of the muscle as the last resort. Abscesses, like I talked about earlier, the treatment is just to drain the infection and let them heal. Most of the time, they don't even require any antibiotics once they've been drained, unless people are diabetic or have other problems.

Dr. Stephanie Pinell:
But they do oftentimes result in a fistula, which requires further treatment. And then the pruritus ani the itchy butt, the big treatment for that is don't use antibacterial soaps down there. Don't use excessive wipes, just use toilet paper and wash the soap and water. Don't over wash. Don't buy expensive things to carry around to wipe your bottom or clean your bottom with because you're just making the problem worse. And a lot of times you can treat the itching and the discomfort with some type of a barrier cream, whether that's a Desitin, like what you use on babies or something of that nature or camuseftin. Which is more for adults, that'll help put a barrier around that area so that it can get back to normal.

Dr. Stephanie Pinell:
So anytime you have rectal bleeding, even if I see a fissure or see something that I think it could be causing it, I think that you should have a colonoscopy. That's a personal opinion. There's nothing set in stone where everybody says that anybody who has a tiny amount of rectal bleeding should have a colonoscopy. But I usually recommend it to all my patients, just because in my training, I have seen people that have been treated for other problems, even though they did have them. And then we later found out that it was something a little more serious and I never want to have that happen to any of my patients. So I always recommend a colonoscopy, but there's nothing specific. The rectal bleeding is kind of a sign that it could be something else, but it's not always other problems.

Dr. Stephanie Pinell:
So these fissures and these abscesses that I was referring to earlier can allude to other problems like Crohn's disease and things like that if they become excessive and severe problems. But usually it would require people having multiple episodes of these types of things before we would start investigating those type of diseases. So constipation is a big one that can cause a lot of problems. A lot of it is people not drinking enough water, but then people who tell me that they have GI issues where they have fluctuating diarrhea, and constipation, or things like that, or have hemorrhoids that keep coming back and then going away, I think it's important that they get on a bowel regimen that's good for them. Once again, I like powdered fiber smart fiber. Hey, as an experiment once when I was in fellowship, I think the recommended dosage of fibers like 30 grams. And I think I got up to like 22 in one day and had severe abdominal cramping.

Dr. Stephanie Pinell:
So if you're not used to eating that much fiber in that brand and all of those things like that they recommend you eat in a regular diet, it can be pretty painful to your stomach. So I think the best way is to get on something like Metamucil or Citrucel, if you're having problems and take it every day that can alleviate you from having these recurring cycles of fissures and hemorrhoids and things of that nature. And also what I see sometimes that people do is people are obsessed with their bowel habits. And it can cause a lot of problems. So people can get rectal prolapse, where they push so much that their actual inside of their rectum actually comes out of their anus. And usually when you interview these people, when I talked to them in the office, they give me a story of, "Oh, every morning I sit on the toilet until I have a bowel movement."

Dr. Stephanie Pinell:
And they basically are sitting there and straining and straining, and it can cause severe problems with the function down there and cause prolapse and then all kinds of other problems that I have to tell them, "Don't. It's okay to not have a bowel movement every day. It's okay to not have a bowel movement every other day." And it should be something that you don't really think about. It should be something that you say, "Oh, wow, I've got to go to the bathroom." And you go, it shouldn't be like the center of your day. So I kind of have to re-orient these people to understand that they're actually by over focusing on their bowels, that they're making the problems worse.

Dr. Stephanie Pinell:
I think the big takeaway from all of this, is that I wanted to talk about peri-anal disease, but I also wanted to make sure that everybody understands that if you have anything wrong with your bowels or things are different, that you do see a surgeon and you do see, or a GI doctor so that you can make sure that you don't have something more serious going on. We're seeing more and more young people with colon and rectal cancer. And when you talk to them, they would say, "Oh, a couple of years ago, I started to notice this problem, or I knew something was wrong, but I just was like not wanting to go to the doctor because of COVID." Or, "I thought it was just a hammerhoid hanging out when it was a large tumor and things like that.

Dr. Stephanie Pinell:
So if something's wrong, go see your doctor and get treated. That's the big thing. All of these things are preventable. The death is preventable if you get screened and you get scoped and we get diagnosed early enough, colon and rectum. Even stage four colon and rectal cancer is treatable, but you've got to get in and you got to get scoped and you've got to start the treatment.

Voiceover:
Thank you for listening to Prescribed to Listening from the University of Toledo Medical Center. To learn more about the provider you heard on today's show, visit utmc.utoledo.edu. More Prescribed to Listening next week from UTMC.