ASK A PROCTOLOGIST
Thousand Oaks proctologist Dr. David Rosenfeld answers the questions patients ask most about hemorrhoids, colonoscopy and colon health.
Yes, they can. Bleeding, prolapse and swelling often settle with fiber, better bowel movements, warm baths and topical hydrocortisone.
“Hemorrhoid symptoms like bleeding, hemorrhoids coming out then going back in – we call that prolapse – and swelling, they can resolve on their own. Patients can use topical therapies like hydrocortisone, taking fiber like psyllium fiber, having better bowel movements, sitting in hot water, all can help relieve the symptoms of hemorrhoids.”
Dr. David Rosenfeld
Any time. Bright red blood painting the stool comes from a hemorrhoid, blood mixed into the stool is more alarming, and any bleeding is a reason for a colonoscopy if you haven’t had one recently.
“Any time there’s blood in the stool, it’s time to be concerned. The blood can be bright red, painting the stool. That’s from a hemorrhoid that ruptures. It basically looks like a paintbrush painted the stool. If it’s mixed in the stool, it’s a little bit more alarming. However, any bleeding is a concern, because most Americans will have polyps that are what we call pre-cancerous, and any bleeding is an indication for a colonoscopy if one hasn’t been done recently.”
Dr. David Rosenfeld
It depends on the pain. Sharp, glass-like pain points to an anal fissure, a tear in the anal skin. Throbbing, aching pain with swelling points to hemorrhoids.
“Pain during bowel movements can vary. If it’s sharp pain, like glass pain, that’s an anal fissure, or tear of the anal skin. If I have throbbing, aching pain and swelling, those are hemorrhoid symptoms.”
Dr. David Rosenfeld
A fissure is a tear in the anal skin, caused by hard stools from constipation or by bad diarrhea. It heals with psyllium fiber for bigger, softer bowel movements, topical ointments such as nitroglycerin, diltiazem or nifedipine, and hot baths.
“An anal fissure, which is a tear of the anal skin, can be caused by constipation from a stool that’s hard and stretches the anus and causes it to split. Or a case of bad diarrhea, where we hold the stool in for a long time and then it explodes out of the anus, and the anus opens wide really quick and it cuts the skin.
“An anal fissure is treated typically by getting a better bowel movement, adding psyllium fiber. You want the bowel movement long and big, so that it stretches the anus; that helps it heal. That’s physical therapy and then topical therapies like nitroglycerin ointment, diltiazem ointment, and nifedipine. Hot baths can also help, as it relaxes the muscles.”
Dr. David Rosenfeld
If your colonoscopy is normal and you have no personal or family history of polyps or cancer, repeat it every 10 years. If precancerous polyps are removed, it’s every three or five years.
“A colonoscopy should be performed if everything is normal, if there is no family history of polyps, no personal history of polyps, or cancer. Once a colonoscopy is done, if it’s normal, it’s every 10 years. If polyps are found and removed, if they’re pre-cancerous polyps, it could be every three or five years, depending on how many polyps, the size of the polyp, and the type of pre-cancerous polyp.”
Dr. David Rosenfeld
Unexplained weight loss, abdominal pain, thinner stools, blood in the stool and anemia.
“Warning signs of colorectal cancer include unexplained weight loss, abdominal pain, change in stool caliber (it gets very thin and narrow), blood in the stool, and anemia. Anemia is when we are low on our blood levels.”
Dr. David Rosenfeld
It mostly comes down to too little fiber and water. Take 5 grams of psyllium fiber a day, aim for about 30 grams of fiber in total, and drink 32 to 64 ounces of water.
“Chronic constipation primarily is not getting enough fiber and not getting enough water. Fiber is the strength of a plant, so it’s a plant-based substance, and it needs water to bind, because it acts like a sponge. A dry sponge is hard, and a wet sponge is expanded and soft. Psyllium fiber is the best fiber to take to help with constipation. So: adding 5 grams of psyllium fiber every day, trying to keep about 30 grams of fiber in the diet, and drinking at least 32 to 64 ounces of water.”
Dr. David Rosenfeld
Leakage is different from incontinence. It’s usually soft, pasty stool that’s hard to wipe clean and seeps out later. Adding fiber, especially psyllium, is the main fix. Mucus from internal hemorrhoids can also contribute.
“Fecal leakage, which is not fecal incontinence, is when stool seeps out of the anus and that happens because our stool is like toothpaste. If we wipe and we wipe and we wipe to get clean and we can’t get clean, there’s more stool inside the anus and that’s going to seep out later and it’s going to stain the underwear and that’s leaking of fecal material.
“The reason that happens is not enough fiber. If we eat more fiber, especially psyllium fiber, our stool becomes solid, long, soft, and clean. So when it comes out, we wipe and there’s nothing there and nothing is going to come out later. So the reason people experience fecal leakage is because of stool consistency. The way to combat that is to add more fiber, especially psyllium fiber. The second part of that, internal hemorrhoids also secrete a mucus that does allow for stool to seep out.”
Dr. David Rosenfeld
It’s stool coming out before you’re ready. The main causes are muscle damage from a vaginal delivery with an episiotomy or large tear, or from earlier anorectal surgery.
“Fecal incontinence is when stool comes out of the anus when we are not ready for it, and it’s a normal volume of stool. That can happen after delivery, for women who deliver babies vaginally, if they had an episiotomy or a large tear, or for patients who had anorectal surgery where the muscles have been damaged. Those are the main causes of fecal incontinence.”
Dr. David Rosenfeld
Most often it’s stool that’s hard to wipe clean, which irritates the sensitive anal skin. Scratching, soap and laundry detergent can all make it worse.
“Anal itching has many factors to it. It is multifactorial; it’s not one problem. The biggest thing with anal itching is that it is a skin problem. Skin can itch anywhere, and the anal skin is very sensitive. When it itches and we scratch, we get a feeling of euphoria. It releases endorphins in the brain, so the brain wants to bring it back, and there is a little bit of an addictive effect to that. When we scratch, it damages the skin, and that causes pain and burning. When that finally goes away after a few days, those little wounds have to heal. Histamines and leukotrienes are released in the healing process, and those are itch proteins, the allergy itch proteins, and they make it itch even more. So you get rebound itching, an itch-scratch cycle.
“The main reason people have itching is stool consistency. When they wipe a lot to get clean, more stool seeps out later. It coats the skin, it irritates the skin, and we feel the need to scratch. Another thing people do when they don’t feel clean is use soap on the anus. Any soap, even a hypoallergenic, good-for-the-skin soap, dries it out. The anal skin is thinner than regular skin and it needs the oils. Once those oils get removed and the skin gets damaged, that leads to more itching. And sometimes it is the detergent we’re using for our laundry, and that causes a contact dermatitis.”
Dr. David Rosenfeld
Stop scratching, add psyllium fiber so stool wipes clean, and treat any hemorrhoids. For bad itching, a proctologist can prescribe a 2.5% hydrocortisone ointment.
“The number one thing is definitely do your best not to scratch, and see a professional proctologist like me. Hemorrhoids also play a role in anal itching. When we treat hemorrhoids, it dries up the area and decreases the amount of mucus secretion from the hemorrhoids.
“And the biggest thing is adding psyllium fiber. By adding psyllium fiber and getting a long, solid, soft, clean bowel movement, when we wipe, there’ll be nothing there. Nothing will come out later, and the itching will improve a lot because there is no irritant to the skin. And if the itching is really bad, use a prescription hydrocortisone ointment at 2.5%, which you can get at the doctor’s office from a proctologist like myself.”
Dr. David Rosenfeld
Yes. Too little fiber or water causes hard stools and straining, which can lead to hemorrhoid symptoms and diverticular disease. Foods you don’t tolerate well can cause gas, bloating and sticky stools.
“Absolutely. Diet plays a big role in our stool consistency and what our bowels are like. If we are eating unhealthy, with not enough fiber (try to get at least 30 grams of fiber a day) and not drinking 32 to 64 ounces of water a day, our stools can become very rock- and pellet-like. We have to strain to get them out, and that puts pressure on the anus and creates hemorrhoid symptoms.
“The colon squeezing really hard to get the stool out can also lead to diverticular disease, which is pouches of the colon. That can lead to diverticulitis, which is an infection of the pouch, or diverticular bleeding. And if we’re eating a lot of foods that we don’t tolerate very well, we don’t digest them as well. We get gas and bloating, we get mushy, sticky stool, and we just feel uncomfortable.”
Dr. David Rosenfeld
Any time you have rectal pain, discomfort or swelling. A specialist can find the cause, from a thrombosed hemorrhoid or an abscess to cancer, with an exam that isn’t painful.
“Any time someone has rectal pain or discomfort, it’s best to go in to see a specialist to find out exactly what the problem is. If it is a thrombosed hemorrhoid, the time I will operate on it is if it comes back in the same spot. If someone has an abscess and we wait too long, it just gets more and more painful. Anal cancer and rectal cancer are always a concern.
“So my philosophy is that any time there’s anorectal pain, discomfort or swelling, that’s the time to see a specialist. We are trained to do exams that are not painful.”
Dr. David Rosenfeld
Small, abnormal growths in the colon. Precancerous polyps can lead to colon cancer, and the only way to know which kind you have is to remove them and send them to a pathologist.
“Colon polyps are growths in the colon that are abnormal little bumps. They come from the cell’s DNA changing, and that change leads to an abnormal cell that divides. We get more and more abnormal cells dividing in the same area, and it leads to a small bump. That bump can continue to grow.
“Polyps are not normal. Typically they come from the food that we eat. The thought is that there are a lot of poisons and toxins in our food that are affecting our DNA. Also, a lot of the foods that we eat kill good bacteria, so we get a bacterial imbalance. The bad bacteria bind to the colon cells and create a lot of inflammation that can change the DNA of the cell. Precancerous polyps can lead to colon cancer. Non-precancerous polyps will not lead to colon cancer, but there is no way to know what they are until you remove them and send them to the pathologist.”
Dr. David Rosenfeld
Not if they’re removed. Precancerous polyps that are left in place keep growing and can eventually become cancer.
“Colon polyps themselves are not dangerous if we remove them. If colon polyps aren’t removed and they are of the precancerous type, those polyps will continue to grow. They double about every two and a half years, and eventually they will become cancer.”
Dr. David Rosenfeld
Exercise every day, even just a one-mile walk; eat a diet low in saturated fat with fruits, vegetables and grains; add psyllium fiber; and drink 32 to 64 ounces of water.
“The best lifestyle changes, even beyond diet, would be to exercise every day, even if it’s just walking a mile. That improves our digestion, because the more active we are, the better our bowels function. Then, having a diet low in saturated fats and high in polyunsaturated fats like olive oil and avocado, and foods that have antioxidants like fruits, vegetables and grains. Adding psyllium fiber to the diet will help bind bile and waste, so that lowers cholesterol.
“Drink 32 to 64 ounces of water, because water is a very important ingredient to our bowel movements. The more water we drink, the softer the stool is. The colon is a six-foot-long water slide: when we drink a lot of water, the colon is lubricated just like the slide, and the stool slides through the colon easier. So dietary changes and exercise changes are the best way to improve colon and anorectal health.”
Dr. David Rosenfeld
Fiber from the seed shells of the psyllium plant. Its insoluble and soluble fiber help form a long, soft, easy bowel movement, and the soluble fiber binds bile and helps pull out cholesterol.
“Psyllium is a plant. The plant creates thousands of seeds, and the shells of those seeds have tremendous amounts of fiber, both the insoluble that does not dissolve and the soluble that does dissolve. Those fibers help create a long, large, soft, easy bowel movement. The soluble fiber forms a slurry and binds bile and pulls out cholesterol. So the psyllium plant is just a plant. It’s not a vegetable, but the seeds it makes create tremendous amounts of fiber.”
Dr. David Rosenfeld