Frequently Asked Questions
WHAT COULD BE CAUSING MY RECTAL BLEEDING?
Rectal bleeding can be caused by a multitude of possible diagnoses. Fortunately, benign etiologies account for 90% of all bleeding episodes in adults. Hemorrhoids are one of the most common causes (30-90%). Anal fissures (tears), polyps, proctitis (rectal inflammation) and colo-rectal cancer account for the remaining causes. As it is important to identify the true cause, we always must look inside. For those people under 35, a short office exam called a sigmoidoscopy is performed in my office as most of the causes of bleeding in this age group are within reach of this shorter instrument. If over 35, a colonoscopy at a surgery center is usually indicated as many sites of bleeding can be beyond the reach of this short instrument that sees only a quarter of the colon or less. If you have had a colonoscopy done within the past 3 years, we may not need to repeat this providing we can review the outside procedure report including photos of the internal hemorrhoidal area.
WILL MY TREATMENT HURT?
There should be very little pain during either the IRC or the RBL treatments. For IRC, we do a half second test cauterization to confirm we are above the dentate line, the line that separates the inner rectal tissue and the outer anal tissue. Generally, there are no pain fibers beyond this line. If you do not feel the test cauterization, we will perform a treatment in this area. If you do, we will treat a little higher up where you should not feel anything.
For Rubber Band Ligation (RBL), we begin by gently suctioning the tissue right above your hemorrhoid into the CRH modified syringe. If you feel pain, we move the instrument a little higher up, again in an area that you should not feel pain. Despite these measures, a few percent of people may still feel the band placement. This is why we keep you in the office for 15 minutes after an RBL treatment. If pain occurs in this time frame, we can easily loosen the band and take the pain away in 100% of cases without compromising the treatment. Rarely, if needed, we can remove the band completely.
WHY DOES PREGNANCY WORSEN MY HEMORRHOIDS?
Approximately 30 to 40 percent of pregnant women are affected by hemorrhoidal development. Symptoms usually occur in the third trimester or during the peripartum period. The presence of the enlarging baby in the pelvis pushes on the major veins that return blood to the heart from the legs and the pelvis. The resulting downstream pressure increase causes the inability to easily return blood from the lower body resulting in both hemorrhoids and leg swelling or varicose veins. During pregnancy, we provide symptomatic care such as anti-itching and swelling creams and suppositories. We wait several weeks after delivery to evaluate the hemorrhoidal size and prescribe a treatment plan based on the size. If patients are to have more children, we encourage treatment of the hemorrhoids between pregnancies rather than waiting until your family is complete. Otherwise, we sometimes see hemorrhoids become so large after multiple deliveries that a painful surgical excision may be the only option. So again, please come in after your first pregnancy if hemorrhoids were a problem. This way, we can stay ahead of their growth from subsequent pregnancies and again avoid painful surgical options.
WILL RBL TREAT MY EXTERNAL HEMORRHOIDS?
We see many patients complaining of protrusions from their rectum. These may be external hemorrhoids, old thrombosed hemorrhoids or simply tags of loose anal skin. These can be responsible for significant local irritation resulting in itching and burning. When addressing these, we also look inside to see if there are internal hemorrhoids as well. If there are, we generally treat the internals first as more than 50% of patients note a decrease in external symptoms when the internal hemorrhoids are treated initially. We also can see external hemorrhoids completely disappear after treating the internal hemorrhoids as they share a common blood supply in over half the patients. If despite internal treatments, the external symptoms do not improve, we can excise these via a simple office procedure with very little post-procedure discomfort.
WILL MY INSURANCE COVER MY HEMORRHOID TREATMENTS?
Yes, most PPO insurances and Medicare cover these treatments with your usual copay and co-insurances once your deductibles have been met. We have an affordable CASH pricing plan for those with HMO plans or no health insurance whatsoever.
HOW MANY TREATMENTS WILL I NEED?
Hemorrhoids develop from a triangular-shaped area just above the anus. Therefore, we treat each of these 3 areas separately to cut off the blood supply to the hemorrhoids. So at least 3 treatments on separate appointments (mean is 3.4) are required to control bleeding and other local systems. For prolapsing (hanging outside) hemorrhoids, 5 or 6 treatments may be required; and, this is the only option short of surgery that may help these types of hemorrhoids.
WHY DO YOU TREAT ONLY ONE AT A TIME?
The only significant, though treatable, complication is post-procedure bleeding. This risk is 1-in-200 if we treat one at a time. If we treat more than one, the risk increases to an unacceptable 1-in-10 patients. The premise is that we want to decrease the blood supply to this area slowly over 6 to 8 weeks. If more than one hemorrhoid is treated, blood flow can be shunted to the other hemorrhoids and cause them to rupture.
IS THERE ANY PREPARATION FOR THE PROCEDURE?
No, because we do not need to go all the way into the rectum, there is no pre-procedure preparation. For those patients on a blood thinner, we usually stop those for a period of time before the procedure. This is individualized based on the type of blood thinner and the reason you have been prescribed this. Menses, also, will not interfere with the treatment.
ARE THERE ANY RESTRICTIONS IN MY ACTIVITY AFTER RBL, IRC OR EXCISIONS?
No, there are usually no restrictions on your activities after either procedure. Activities such as driving, biking, swimming, flying and exercising are permitted. Also, there should be no interference with sexual activities. After excisions of external tags or hemorrhoids, we do restrict you from bathing for 24 hours and exercising for 48 hours.
IS THERE A TREATMENT PLAN THAT CONTINUES AFTER MY HEMORRHOIDS HAVE BEEN SUCCESSFULLY TREATED?
Yes, we educate our patients on ways to prevent the rapid development of new hemorrhoids. That is, we encourage fiber and stool softeners if constipation and straining have contributed to the development of your hemorrhoids. We advise exercise which promotes colon motility. We ask patients to refrain from reading for more than a few minutes while sitting on the toilet bowl. We teach improved peri-anal hygiene to help with local symptoms. Importantly, we like to see people once a year after they have completed a course of IRC or RBL to identify the early development of new hemorrhoids. An occasional “touch up” treatment or two may be needed after a few years.
The GI Issue Affecting 10.4M Americans
18800 Delaware Street, Suite 850
Huntington Beach, CA 92648