Dear Dr. Roach: Do you know anything about injection sclerotherapy for hemorrhoids? Are there any other new treatments?
A: Hemorrhoids are a normal part of our anatomy, but they cause problems such as bleeding and itching, and they can develop blood clots. Hemorrhoids may be internal or external. External hemorrhoids rarely need more than conservative treatment, except when they develop a blood clot, which can be very painful. Large internal hemorrhoids can prolapse (that is, push through the anus).
Internal hemorrhoids are graded 1 through 4 based on degree of prolapse: grade 1 do not prolapse; grade 2 prolapse during a bowel movement but reduce (i.e., go back in) spontaneously; grade 3 can be reduced; and grade 4 cannot. Treatment of internal hemorrhoids depends on their classification.
Grade 1 and external hemorrhoids usually are treated conservatively with a high-fiber diet. Psyllium (such as Metamucil) or methylcellulose (such as Citrucel) can be used if a person's diet is inadequate in fiber, as many are. Additional conservative treatments include creams and ointments that relieve symptoms, such as Anusol or Preparation H, and sitz baths, a chair-style bath in which the buttocks and hips are immersed in water. Hydrocortisone-based creams should not be used for longer than a week. Thrombosed external hemorrhoids might need immediate treatment to remove the blood clot.
Grade 1 and 2 hemorrhoids also can be treated with "minimally invasive" office-based treatments, such as sclerotherapy. This is the injection of a medication that causes "sclerosing" (from the Greek word for "stone"), a shrinking and fibrosis of the hemorrhoidal tissue. Other options include banding (placement of a rubber band around the hemorrhoidal tissue), laser and cryotherapy, all of which cause the hemorrhoid to shrink. The choice is up to the patient and the surgeon or gastroenterologist performing the procedure.
Some grade 3 hemorrhoids can be treated with these minimally invasive techniques, but other grade 3 and grade 4 hemorrhoids will need definitive surgical therapy. There are several surgical options, including open and closed hemorrhoidectomy, stapled hemorrhoidopexy and lateral internal sphincterotomy. I seldom send patients to the surgeon for these procedures anymore, but a minority of people still need them if the office-based procedures don't work.
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One newer technique is ligation of the hemorrhoidal artery. One study showed that this procedure resulted in less pain than open hemorrhoidectomy.
Dear Dr. Roach: When I was 64, a cyst was found in my bladder. When the cyst was removed, it was found to be cancerous. My urologist wants me to continue to have an annual cystoscopy, which I do.
I'm now 76 and in good health. Do you feel the annual cystoscopy is still necessary?
A: Now that more people have had successful treatment of cancer, we are starting to learn about the risks they face in subsequent years. The risk of another cancer is generally higher, but it's the exact form of cancer that determines how much risk there is, and consequently, how aggressive follow-up must be.
In the case of bladder cancer, I have read some studies that the risk is quite small after five years. However, the American Urologic Association has clear guidelines: Because of the increased risk for recurrence, it recommends annual cystoscopy indefinitely. Cystoscopy is a pretty safe procedure, so I think your urologist's recommendation is reasonable.