Dear Dr. Roach • I am in need of a hemorrhoidectomy. The specialist I saw is highly recommended and respected, and I trust him. However, the only procedure he recommended was the rubber-band procedure. I have heard pros and cons about this. We did not discuss any other method.
Would it be possible for you to suggest other options? I would like to know the advantages and disadvantages of each, even the worst outcome. I don’t want any surprises. — M.P.
Answer • Hemorrhoids are normal blood-vessel structures in the anal canal. The most common problems with them are bleeding, pain (usually from clotting) and prolapse (protrusion through the anus). Most people need only conservative treatment, such as fiber added to the diet, sitz baths (exposing the area to hot water) and over-the-counter creams.
If these don’t relieve symptoms, the rubber-band procedure is the most common procedure performed. It is successful 70 percent to 80 percent of the time. It involves placing a rubber ring around the base of a hemorrhoid, and over a few days, the hemorrhoid shrinks and degenerates. Uncommon complications include clotting and infection.
Alternative office procedures include infrared coagulation (sometimes called laser) and injection of medication to treat hemorrhoidal bleeding. Both of these procedures can be complicated by bleeding. More-severe hemorrhoids are more likely to recur after these treatments.
The definitive treatment is surgical. Several types of surgery are done, the most common being a closed procedure, which has a 95 percent success rate and low risk of infection, but it can be complicated by both bleeding and difficulty urinating. Pain can be managed via oral medications. A second surgical procedure I am seeing more of is the stapled hemorrhoidopexy, which has less pain but may not be effective in as many people as the standard procedure.
Hemorrhoid surgery is not done nearly so often because the rubber-band procedure is effective in most people.
Dear Dr. Roach • My brother has a history of blood clots and has had two life-threatening pulmonary embolisms. He is on warfarin for life. There is a family history of blood clot issues, in particular my dad.
My brother does not go for blood tests on a regular basis. He is a very fit guy and plays squash and tennis regularly. He is 52. He believes that since he feels good because there is no need to have his blood levels checked regularly. I do not believe this and think that he is putting himself at risk. Also, please comment on the impact of sports when on warfarin therapy. — Anon.
Answer • You are completely right, and he needs to do one of two things immediately. The first is to get his INR — a test of the blood’s ability to clot — checked and dose adjusted if necessary. It is impossible to tell with any degree of safety whether the warfarin is too little, putting him at risk for another blood clot, just right, or too high, putting him at high risk for bleeding.
The second option would be to switch to a medication that doesn’t require monitoring, such as dabigatran (Pradaxa). Studies have shown this medication to be as effective as warfarin, at least for acute treatment.
In general, most sports are safe for people on anticoagulation. However, I have seen some squash players routinely throwing themselves on the ground or into the wall. That’s not a smart idea on any kind of anticoagulation.
Dr. Keith Roach is a physician at Weill Cornell Medical College and New York Presbyterian Hospital.Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at P.O. Box 536475, Orlando, Fla. 32853-6475