Thomas A. Kruzel, ND
A considerable number of Americans suffer from some type of anorectal condition at some time in their lives, but often do not discuss it with their physician until it becomes very uncomfortable. Additionally, many physicians do not ask their patients about anorectal disorders and are often uncomfortable conducting examinations of afflicted patients. Naturopathic medicine has much to offer those patients suffering from disorders of the anus and rectum, often more effectively than allopathic medicine, which relies on surgery and drug therapy.
There are a number of conditions of the anorectal region that patients may present with, and there may be more than one present at a time. An example is someone who has a rectal fissure as well as an internal hemorrhoid. As more than one disorder may be present, recognition of them is important for diagnosis and treatment. Patients also may attribute symptoms of the perianal region to a condition that is not present. For instance, anal itching, or pruritis ani, is commonly associated with hemorrhoids. However, hemorrhoids almost never have this accompanying symptom, and if present, indicates another disorder such as proctitis, parasitic infestation, irritable bowel disorder or food allergy, to name a few.
Recognition of the pathology present is perhaps the most difficult part of the patient work-up. A thorough history, coupled with an anoscopic examination should provide the clinician with enough information to diagnose and treat. For the inexperienced practitioner there are a number of textbooks and Web sites with excellent graphics that help in the identification of the presenting lesion. Additionally, referral for a second opinion to a qualified proctologist is helpful if the pathology is not clear. Some of the conditions encountered are internal and external hemorrhoids, rectal fissure, proctitis, cryptitis, anal fistula or abscess, pilonidal sinus, proctalgia fugax, and various skin lesions.
Internal Hemorrhoids
In the United States and other industrialized countries, hemorrhoidal disease is extremely common. In non-industrialized countries, whose diets are high in fruits, vegetables, and fiber, the incidence is much lower. A low-fiber diet, high in refined foods, contributes greatly to the development of hemorrhoids. Individuals consuming a low-fiber diet tend to strain more during bowel movements, as their smaller and harder stools are more difficult to pass. Straining increases the intra-abdominal pressure that in turn obstructs venous return. The increased abdominal pressure increases pelvic congestion and may significantly weaken the veins, causing hemorrhoids to form.
Some patients may begin to develop hemorrhoids in their 20s, but hemorrhoidal symptoms usually do not become evident until the 30s or 40s. Estimates have indicated that 50% of persons over 50 years of age have symptomatic hemorrhoidal disease at one time or another and up to one-third of the U.S. population has hemorrhoids to some degree.
Hemorrhoids occur because the venous system that serves the rectum contains no valves. Thus, when factors that increase venous congestion in the perianal region occur, backflow ensues and distends the rectal mucosa. These include increasing intra-abdominal pressure (e.g. defecation, pregnancy, coughing, sneezing, vomiting, physical exertion, and portal hypertension due to cirrhosis), increase in straining during defecation, and standing or sitting for prolonged periods.
Presenting symptoms are burning, irritation with passage of stool, swelling of the anus and perianal region, blood on the toilet paper or in the bowl, and seepage of mucus. Most often the hallmark of a hemorrhoid eruption is bleeding or protrusion which is noted following passage of stool. Pain from internal hemorrhoids occurs when they become strangulated from prolapse and with thrombosis, while pain from external hemorrhoids occurs when they become congested and thrombosed.
Internal hemorrhoids originate above the anorectal line and are primarily found in the right anterior, right posterior and left lateral quadrants. Occasionally an internal hemorrhoid will enlarge to such a degree that it will prolapse and descend below the anal sphincter. Internal hemorrhoids are usually not painful, as there are no pain fibers above the anorectal line. External hemorrhoids occur below the anorectal line and because of this involve tissue with pain fibers. Therefore, external hemorrhoids can become extremely painful while internal hemorrhoids do not unless they are prolapsed or thrombosed. It is possible that a patient can present with both types.
Internal hemorrhoids are classified according to symptomology and finding on examination. Stage I hemorrhoids bleed but do not protrude. Stage II hemorrhoids protrude following bowel movement, and then spontaneously reduce. Stage III hemorrhoids protrude with stool and must be manually reduced. Stage IV hemorrhoids protrude and are not reducible. Stages II, III, and IV may bleed and a Stage IV hemorrhoid presents the possibility of strangulation resulting in decreased blood flow and eventual thrombosis.
With an episode of external hemorrhoids the patient will often notice a painful perianal lump that may have some bleeding associated with it. External hemorrhoids usually pose mild to little discomfort and will largely resolve on their own if homeostasis is restored. External anal skin tags found on examination are the remnants of previous external hemorrhoids.
If, however, the external hemorrhoid starts to become enlarged due to a developing thrombosis, the mass becomes increasingly distended resulting in varying degrees of pain and swelling. This is often exacerbated by passage of stool or from prolonged sitting. The patient may report bleeding after stool due to a disruption of the hemorrhoid. If thrombosis occurs the patient is often in excruciating pain, has difficulty sitting down, and will move around to get relief. Surgical intervention through incision and drainage is warranted.
Treatment
A high-fiber diet is perhaps the most important component in the prevention of hemorrhoids. A diet rich in vegetables, fruits, legumes, and grains promotes peristalsis because many fiber components attract water and form a gelatinous mass which keeps the stool soft, bulky, and easy to pass. The net effect of a high-fiber diet is significantly less straining during defecation.
Sitting on a toilet and trying to pass a stool while reading “War and Peace” contributes to the formation of hemorrhoids. Therefore I advise patients not to sit too long, not to strain to pass a stool, and to lean forward slightly to decrease the sigmoid-rectal angle for easier passage.
Flavonoid preparations have been shown to be beneficial in the prevention and treatment of hemorrhoids due to their strengthening effect on venous tissues. Pregnancy increases the risk of hemorrhoid development, but several studies using a micronized flavonoid combination (diosmin 90% and hesperidin 10%) for a median of eight weeks before delivery and four weeks after delivery helped to prevent either hemorrhoid formation or to decrease the size and number of hemorrhoids.
Topical treatments for acute or chronic hemorrhoids involving the use of suppositories, ointments, and anorectal pads, in most circumstances, only provide temporary relief. Many over-the-counter products for hemorrhoids primarily contain natural ingredients, such as witch hazel (Hamamelis), cocoa butter, Peruvian balsam, zinc oxide, allantoin or homeopathic preparations, to name a few. Many patients will use hydrocortisone cream to help with itching. Prolonged use can often aggravate the pruritis ani setting up a cycle of continued use. In addition, prolonged use of hydrocortisone creams in the presence of an anal fissure ultimately weakens the tissue resulting in further tearing. Usually the patient has been given a prescription for the cream without an examination because the clinician thinks it is a hemorrhoid. Fissures in their early manifestation may not have the sharp searing pains associated with their presence, but have the dull aching associated with hemorrhoids. Therefore, examination becomes all the more important.
Botanical Medicine
Botanical medicines such as Aesculus, Althea, Butcher’s broom, Cinnamomum, Collinsonia, Ginger, Hamamelis, Hypericum, and Yarrow have had a long track record of use for hemorrhoids throughout history. They can be used topically, as suppositories, or taken internally to support redundant tissue and facilitate healing. While botanical medicines are useful for hemorrhoids, once the pathology has become fixed, they are not as effective in reversing it. Rather, they support other treatments such as electro or infrared coagulation.
Botanical medicines are also useful for prevention during pregnancy and for those patients who seem to have a genetic predisposition to development of hemorrhoidal tissue.
Hydrotherapy
Hydrotherapy is an effective non-invasive treatment for uncomplicated hemorrhoids. Warm sitz baths are a useful treatment for an acute hemorrhoidal flare-up, while alternating hot and cold sitz baths are better suited to facilitate healing of chronic conditions. Constitutional hydrotherapy also has been shown to facilitate healing of hemorrhoids, but is more effective when anorectal disease is a part of irritable bowel disorder or Crohn’s disease.
Surgical Treatment
A variety of surgical and non-surgical methods of treating hemorrhoids exist such as injection of sclerosing agents, rubber band ligation, rectal suppositories, homeopathic medicines, cryosurgery, or hemorrhoidectomy.
Hemorrhoidectomy, or the surgical removal of redundant tissue, is by far the most invasive of the hemorrhoid procedures. This procedure often requires an outpatient surgical setting and results in lost time from activities of daily living so healing can take place. Complications such as pain and rectal sphincter instability are frequent; hence, many patients seek alternative treatments in order to avoid surgery.
The monopolar direct current technique, or Keesey technique, has been around since the late 1800s. Further developed and refined by Wilbur E. Keesey, MD, the technique utilizes negative galvanism to obliterate the existing hemorrhoidal mass. The negative current essentially coagulates the hemorrhoidal mass allowing it to reattach to the rectal wall. Over the next seven to 10 days the scar is replaced by healthy tissue.
What makes the Keesey treatment so attractive is that it can be performed as an outpatient procedure, takes less than half an hour, and allows the patient to return to normal activities quickly. In addition, it is virtually painless. Any grade internal hemorrhoid can be treated with from one to several treatments being required for complete healing.
So why isn’t it the treatment of choice for hemorrhoids? The monopolar ablution of hemorrhoidal tissue lost favor in conventional medicine, not because it was ineffective, but because newer techniques and advances in surgery, as well as greater reimbursement for surgery made it less attractive.
Coupled with the Keesey technique is the use of Infrared coagulation (IRC). IRC is effective with Stage I and II hemorrhoids but can be combined with the Keesey treatment for Stage III and IV. While the Keesey technique utilizes current, the infrared coagulator employs a burst of intense heat generated internally and shot through a blue anodized sapphire tip to the surface of the hemorrhoid. The IRC “coagulates” the redundant tissue to a depth that is a function of the amount of time of the light burst, usually 1 to 1.5 seconds. When compared to rubber band ligation, laser or cryotherapy, IRC has been shown to produce better results and less morbidity.
Nutrition
A high-complex carbohydrate diet rich in dietary fiber is indicated in the treatment of hemorrhoids. The diet should contain liberal amounts of proanthocyanidin- and anthocyanidin-rich foods, such as blackberries, cherries, and blueberries to strengthen venous integrity. Supplements such as Vitamins A, B complex, antioxidants such as Vitamins C and E and Zinc will help maintain vascular integrity and facilitate healing. I also place the patient on a diet based upon their blood type. I do this because if there are hemorrhoids or other anorectal diseases present, there is a greater likelihood of there being problems in the gastrointestinal tract. Therefore the diet is added for prevention purposes.
Treatment of External Hemorrhoids
For external hemorrhoids that have not reached the stage of thrombosis, I initially prescribe Protease enzymes 315 mg two capsules between meals TID and two capsules at bedtime. This reduces the thrombosis and decreases pain. Alternating hot and cold sitz baths act to relieve pain and increase blood flow, while a number of homeopathic medicines such as Aesculus, Aloe, Hamamelis, Muriatic acid, Ratanhia and Sepia are effective in relieving pain and speeding the course of healing. Most external hemorrhoids can be treated medically with surgical intervention used only as a last resort.
Placing the patient on herbal anodynes such as Piscidia, Belladonna, if pain is due to rectal spasm, and Hyoscyamus niger can facilitate postoperative management. As the surgically drained hemorrhoid is left open to heal so there isn’t a recurrence, alternating sitz baths with 1/2 ounce of betadyne added enhances healing and helps decrease the chance of infection. Topically, healing and pain relief can be afforded with the use of Arnica, Hypericum, and in particular Calendula succus.
Thomas A. Kruzel, ND, is a naturopathic physician who is in private practice at the Scottsdale Natural Medicine & Healing Clinic in Scottsdale, Ariz. He is the former Vice President of Clinical Affairs and the Chief Medical Officer at the Southwest College of Naturopathic Medicine in Phoenix, Ariz. He received a BA in Biology from the California State University at Northridge, and his Doctorate of Naturopathic Medicine degree from the National College of Naturopathic Medicine. He has been an Associate Professor of Medicine at National College of Naturopathic Medicine. He is the author of the Homeopathic Emergency Guide A Quick Reference Handbook to Effective Homeopathic Care. He is Past President of the American Association of Naturopathic Physicians and was selected as Physician of the Year by the AANP in 2000 and Physician of the Year by the Arizona Naturopathic Medical Association in 2003.
