Choosing the Right Hemorrhoid Surgery: A Comprehensive Guide

How to choose the appropriate hemorrhoid surgery?

Hello, Doctor.
I have a few questions to ask.
I currently have mixed internal and external hemorrhoids and anal fissures, and I experience bleeding every time I wipe after using the restroom.
The most troubling issue in my daily life is the sudden, unbearable itching around the anus, accompanied by some pain, especially at night or on the second or third day after not having a bowel movement (I usually have daily bowel movements, but if I experience constipation and do not go, the itching is more severe the next day).
What is this situation?
Question 1: Is the itching and bleeding I experience caused by the mixed hemorrhoids or is it a reaction from the anal fissures when they scab over? How can I heal the anal fissures if I have daily bowel movements?
Question 2: Is there a way to determine in advance whether surgery can truly resolve my itching and bleeding issues? I am currently considering ligation and outpatient excision of the external hemorrhoids, but I noticed you mentioned that if the internal hemorrhoids are not prolapsed, ligation may not be necessary.
I currently do not have prolapse; I only experience bleeding after bowel movements, but I am unsure how to confirm whether the bleeding is from the external hemorrhoids, anal fissures, or the internal hemorrhoids.
How can I stop the bleeding?
Question 3: I saw in your other articles that outpatient excision of external hemorrhoids may leave "excess tissue." Can this be discussed with the doctor beforehand to ensure complete removal, or is it usually the doctor's decision to preserve some tissue? I currently have a small piece of excess tissue at the front of the anal opening, resembling thickened connective tissue hyperplasia, which becomes more pronounced after bowel movements, and there is a small mass that can be pushed out from inside the anus.
Is this considered an external hemorrhoid? If I ask the doctor to remove it, can they also cleanly excise the surrounding thickened connective tissue to restore the original appearance of the anus?
Question 4: I have read your other answers and found that there are currently three main surgical methods for hemorrhoids: traditional surgery, pain-free surgery promoted by cosmetic surgery clinics, and ligation and outpatient excision of external hemorrhoids.
If my treatment goal is to relieve my daily itching, prevent bleeding after wiping, remove the excess connective tissue and external hemorrhoids, and maintain the integrity of the anal opening, which method would be suitable for me? I am currently leaning towards ligation and outpatient excision since it does not require hospitalization and is relatively low-cost.
However, could you explain why some people still choose the expensive surgeries at cosmetic clinics? I also care about the integrity of the anus post-surgery; if I undergo surgery, I would like to achieve both symptom relief and aesthetic results.
Thank you for your guidance.

Minxin, 20~29 year old female. Ask Date: 2021/07/13

Dr. Ke Fangxu reply Surgery

1.
Anal itching may be caused by excessive wiping.
If accompanied by bleeding, it could indicate bleeding from internal hemorrhoids.
There are three important points to note: 1.
Do not scratch to avoid causing an infection in the wound.
2.
Temporarily avoid spicy foods to prevent capsaicin from irritating the skin.
3.
Avoid using soap or body wash to clean the anal area to prevent excessive removal of the skin's natural oils.
If these points are followed, improvement can generally be seen in about a week.
If there is no improvement, a physician should be consulted for examination and medication.
2.
Based on your current condition, I personally recommend trying conservative treatment first.
If improving lifestyle habits and bowel habits do not help, and both oral and topical medications are ineffective, then considering surgical treatment would not be too late.
It is essential to determine the cause of the bleeding, which requires a physician's examination for proper diagnosis.
3.
Surgery can remove the hemorrhoidal tissue, so the protruding part can be completely addressed.
However, the healing process itself may lead to the formation of excess skin, which is related to individual wound care and is not entirely controllable by the physician.
4.
Personally, I have only undergone traditional surgery because I believe this method is more effective for severe hemorrhoids and is not very costly (the out-of-pocket expense is approximately 2000 TWD).
For less severe symptoms, surgery may not be necessary.
As for why some people opt for cosmetic surgery costing tens of thousands, I cannot comment on that.
I recommend finding a reliable colorectal surgeon for a thorough examination before discussing and evaluating the necessity of surgical treatment.

Reply Date: 2021/07/13

More Info

When considering hemorrhoid surgery, it's essential to understand the various options available, the underlying causes of your symptoms, and the potential outcomes of each procedure. Based on your description, you are experiencing a combination of symptoms related to internal and external hemorrhoids, as well as anal fissures. Let's address your questions systematically.

Question 1: Causes of Itching and Bleeding
The itching and bleeding you are experiencing can indeed be attributed to both internal and external hemorrhoids as well as anal fissures. Hemorrhoids can cause discomfort, itching, and bleeding, especially during bowel movements. Anal fissures, which are small tears in the lining of the anus, can also lead to bleeding and significant pain, particularly when passing hard stools. The fact that you experience increased itching after a day without a bowel movement suggests that the pressure and potential irritation from stool buildup may exacerbate your symptoms.
To manage anal fissures, it's crucial to maintain soft stools through a high-fiber diet, adequate hydration, and possibly the use of stool softeners. Over-the-counter topical treatments may help alleviate discomfort and promote healing.

Question 2: Understanding Surgical Necessity
To determine whether surgery is necessary, a thorough examination by a healthcare professional is essential. They can assess whether your bleeding is primarily due to hemorrhoids, anal fissures, or a combination of both. A proctoscopy may be performed to visualize the internal structures and confirm the diagnosis. If your symptoms are significantly affecting your quality of life and conservative treatments have failed, surgical options may be considered.

Question 3: Concerns About Residual Tissue
Regarding the concern about "excess tissue" or residual skin after external hemorrhoid removal, this is a common issue. Surgeons typically aim to remove the hemorrhoids while preserving as much surrounding tissue as possible to maintain the functional and aesthetic integrity of the anal area. However, you can certainly discuss your concerns with your surgeon beforehand. It is essential to communicate your desire for a complete removal of any excess tissue to achieve the best possible outcome.

Question 4: Surgical Options
There are several surgical options available for treating hemorrhoids, including traditional hemorrhoidectomy, rubber band ligation, and minimally invasive techniques. Each method has its pros and cons:
1. Traditional Hemorrhoidectomy: This is the most effective method for severe hemorrhoids but involves a longer recovery time and more postoperative pain.

2. Rubber Band Ligation: This is a less invasive procedure that can be performed in an outpatient setting. It is effective for internal hemorrhoids but may not address external hemorrhoids or significant tissue growth.

3. Minimally Invasive Techniques: These include procedures that aim to reduce discomfort and recovery time. However, they may not be suitable for all cases, especially if significant tissue removal is required.

Given your goals of alleviating itching and bleeding while maintaining the aesthetic appearance of the anal area, a thorough discussion with your surgeon about the best approach is vital. They can help you weigh the benefits of each method against your specific symptoms and preferences.

Conclusion
In summary, your symptoms of itching and bleeding are likely related to a combination of internal and external hemorrhoids and anal fissures. A comprehensive evaluation by a healthcare professional is necessary to determine the best course of action. Surgical options vary in terms of invasiveness, recovery time, and effectiveness, so it's crucial to have an open dialogue with your surgeon about your concerns and goals. By doing so, you can make an informed decision that aligns with your health needs and lifestyle.

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