Tempis Fugit they say. And for those not inclined toward the
Latin side of things, Time Flies. In keeping with that theme, I believe Herman
and I became acquainted about 18 years ago, and while time is always flying,
the relationship Herman and I have maintained through the years has been less
than agreeable. I have, in fact, wanted to end that relationship many times,
but Herman has continued to be an unwelcome companion. I visited a professional
9 years ago to see what I could do about severing our connection, and the
professional suggested a less-than-satisfactory solution. She was fully capable
of administering a final solution, so to speak, but because she was concerned
that the aftermath of the cure might endanger those who have entrusted their care to me, she was unwilling at that time. She
therefore performed only a partial exorcism, and the relationship diminished in
intensity…..for a while. In far too soon a period, Herman was back in his
ever-presently annoying manifestation. Herman, you see, is a hemorrhoid. We
have become so close that I have felt justified in using his Christian name
even though nothing would have made me happier than to do away with his
existence.
For those of you who may not understand the problem that a
hemorrhoid can be, I will attempt to briefly acquaint you with pain in the backside
that they are. My first understanding of hemorrhoids was when my mother became
afflicted. I was but a young boy, certainly less than 10 years old, and was
concerned when she went away to the hospital. She had only done that previously
when she was pregnant, and she always came home with a sister, but in this
instance, she came home without a bundle of joy in her arms. In fact, I
remember her coming home with only a little white vinyl life preserver. I
remember that she was decidedly uncomfortable, but other than that I only
remember that Metamucil became a standard item in the contents of the kitchen
cupboard, and that she was completely committed to its consumption.
I, of course, learned about hemorrhoids in my professional
training, but had no real-life experience with them until I was in my General
Practice Residency. I was assigned to a Family Practice physician and was
privileged to spend two weeks with him. I distinctly remember a patient who was
maybe 30 years old, who was on the examination table with the goods exposed. I
had never imagined that anyone could look so miserable. His hemorrhoids were
ringing his orifice and swollen hugely, red and bloody and I could only wonder
how he managed to take care of business. In fact, he was having difficulty
taking care of business, but because it was a follow up visit, I could only
assume that there had been improvement. I could barely imagine what they must
have looked like in the first place.
The doctor assured me that this was not an unusual problem
and that, while there had been improvement, the patient would need more
definitive treatment. He would be joining my mother in the ranks of those who,
having suffered for their physical impairment and surgical resolution, would
heal…..in time.
While my hemorrhoids had never been in a crisis state like
the young man’s had, they were uncomfortable. Some sufferers complain of pain,
itching and bleeding. I had only ever experienced occasional bleeding with use
of standard toilet paper. My anal comfort had long been a priority, so I did my
very best to keep our relationship as agreeable as possible. When on a hunting
trip, one of my companions returned from his own visit to the facilities and
remarked to me, “Baby wipes are wonderful.” A little slow on the uptake, I
didn’t understand his reference, but as time went on I began to appreciate his
opinion completely, and it became my own.
My wife and I traveled to Israel and Egypt several years ago
and were amused to see that every toilet had a water jet built into the toilet
that would wash the wall opposite if the seat wasn’t occupied. We quickly
discovered that its purpose was truly genius from a hygiene perspective. We
were almost immediately enamored of its usefulness, and when we returned home
it became my mission to add such a contrivance to our own toilet. As it turned
out, an addition was readily and inexpensively available. It was called a
bidet, which it is not, but we have since lovingly referred to it as our “booty
washer”. We tried to interest our children in the concept and, in fact, gifted
one to each of them the following Christmas. We have been puzzled to find that
only 1 of the six has seen use. My suspicion is that as they notice the
inevitable march of time affecting their very own bodies, the others may be
employed as well.
9 years ago I visited a colorectal surgeon for a colonoscopy
and pointed out that I was unhappy with the state of my sphincter. It seems
that an internal hemorrhoid (there are internal and external versions of the
specie) that grows large enough in size will prolapse (hang out), and while it
can be pushed back inside, has a definite desire to see more of the world. She
said that definitive care would be excision, but that I could not work while
taking narcotic pain medications, so I would have to wait until I could take 2+
weeks off. In the meantime, she suggested an infrared treatment that would burn
the hemorrhoid and that as it scarred on healing, would shrink and become more
manageable. She did perform this treatment and there was improvement for a
while, but recurrence was inevitable and so it has recurred.
Baby wipes and the “Booty Washer” had become my mainstay and
only when forced to use toilet paper extensively would I see enough bleeding to
concern me, but my view was that I would rather deal with the problem at 61
years old while it was less severe than at 71 when it was a real problem. Following a recent colonoscopy, I once again
suggested that the ultimate solution might be indicated, and the doctor agreed
and referred me once again to a colorectal surgeon.
The surgeon examined my anal appendages and informed me that
they were more severe than I gave them credit for. On a grading system of 1 to 4,
I scored a 4. While I have always been competitive, I did not view this as an
achievement. He explained treatment options, but the only permanent solution
was excision, and that was what I had expected anyway. I told him that my
partner could cover the practice for whatever period was necessary, and he was
pleased to schedule the surgery.
On my way to the surgery center today, I mentioned to my
wife that maybe this was a bit extreme. I had been living with the problem for
a long time, and I was voluntarily submitting myself to a procedure that would
leave me miserable for somewhere between 2 and 6 weeks. For entertainment
purposes only, I looked up blogs that described the aftermath of
hemorrhoidectomy, and they were not encouraging. My favorite suggested that the
first bowel movement following surgery felt like it was razor blades dipped in
tabasco sauce with glass shards mixed in. I couldn’t wait.
I arrived at the surgery center 10 minutes early and was
taken to pre op almost as soon as I had signed consent for everything from
anesthesia, surgery, payment, and assignment of benefits from the insurance
company. The nurse was very sweet and competent, and was moonlighting. Her
full-time job was in labor and delivery. Almost the right terrain anyway. She
had me undress completely and put on the shortest OR gown I had ever seen. Not
that I wear a Teddy, but you can imagine…..Anyway, she gave me lovely purple
socks to keep my feet warm and the standard green OR hat, started the IV and
put the EKG leads on, and then I was left to wait a few minutes.
My wife was brought back and she began working on some salt
clay ornaments she plans to give to our children for the grandkids to hang on
the Christmas tree. I told her that I was sure she was the only one who had
ever thought to work clay in the pre op treatment room, but everyone who came
in was interested, proving that variety keeps people engaged.
The surgeon came in dressed in scrubs and a matching hat and
we had a pleasant conversation. He reminded me that we would not be friends
after the anesthetic began wearing off, but was very reassuring about the
procedure. The anesthesiologist came in
for more consent, and we agreed on deep sedation with Fentynl, Versed, and
Propofol rather than endotracheal intubation. He injected the first drug into
the IV to give me a taste of what was to come. He told me I would have to scoot
over to the OR table when we got to the OR. I suppose I did, but I wouldn’t
know if they had brought in a crane to move me. I was out.
After the surgery and in recovery, I felt great. The surgeon
had told me that he would he would use a long-acting local anesthetic
(Marcaine) at the end of the procedure so I could expect it to be numb for4-6
hours. In fact, I didn’t feel particularly numb, as in a fat lip after a dental
nerve block, but was extremely comfortable. I chatted with the nurse for a few
minutes and she said her fiancé had undergone the same surgery two weeks before
and he was acutely uncomfortable in recovery. I was gratified to think I
wasn’t. In fact this gave me hope that my recovery would be much easier that that
poor fellows.
I got dressed and went to visit a friend in the same building
and stopped for chicken feed on the way home. The nurse had given me 2 Percocet
tablets before I left and I felt fine. The prescription for the Percocet
(narcotic pain killer) said 1 or 2 every 4-6 hours, and I planned to stay on
that schedule. My experience with taking out wisdom teeth had taught me not to
let the pain get ahead of the pain meds or it would be much harder to control.
I ate lunch (my patented fried salad) figuring the bulk was
exactly what the doctor ordered….so to speak. He had mentioned that laxatives
that liquefy the stool were a mistake because the injured muscular ring has got
to stretch regularly. Otherwise, scarring occurs and the ability of the
sphincter to stretch becomes greatly diminished leading to all sorts of
complications…..like chronic constipation and fecal incontinence. I wasn’t
going there, so I planned to eat my normal salad diet.
There is a trade-off….or maybe two…. With the pain meds.
Narcotics kill pain pretty well, but they are also constipating which, in my
situation, would be excruciating. Narcotics also can cause profound nausea if
taken on an empty stomach, or to excess. I was fighting the constipation enemy,
and quite frankly, disregarded nausea complication.
By late afternoon, the numbness was 80% gone, and the pain
monster was starting to rear its ugly head. Sitting, standing, walking and
pretty much any other normal activity were difficult. Like….worse than
difficult. The doctor had said that relief might be found in a warm bath and I
was ready to believe him. I ran water into the tub and lowered my tenderest
parts into it, and miraculously, it felt much better….for 20 minutes or so.
Then the throbbing and aching resumed. I watched half a movie trying to take my
mind off my problem, and not for the first time reminded myself that this was
ELECTIVE surgery. I got out and dried off, dressed for bed and whined to my
loving wife. She had no magic bullet for me either, though, and went to bed
about 11PM. I lay down on my front on the living room floor and began
memorializing this experience.
November is National Novel Writing Month, and for the third
year in a row, I am writing my own Great American Novel. On November 15, I was
roughly half way done and expected that my recovery period would give me plenty
of time to finish. This story, on the other hand, is one that must be told for
posteriority (the number of lame jokes about this situation is almost amazing).
So instead of writing my novel and keeping up with my word counts, I have now taken
on another task.
Day 2
By
1 AM I had taken another dose of the Percocet and was overcome with waves of
nausea. I could not walk, crawl, or even stand up for fear of becoming a
spewing fountain of vomit. The best I could do was put my head on the ground lying
very still, and nap. In an hour, I believed I felt somewhat better and
endeavored to crawl to the bedroom. I got as far as the closet where I once
again lay as still as I could and tried to nap. Closer to 3, I crawled into
bedroom, miserable with pain, dizziness, and the fear of leaving an indelible
mark on our newly cleaned carpet. Beverly got up to take care of her own
business, and she sweetly got me a hot pack, plugged in the charger for the
computer, and unable to help any more, went back to bed.
An
hour later I raised myself sufficiently as to crawl into the bed, climbed under
the covers and unhappily slept until 5 when my rear set off a wake-up call.
Still dizzy, I pulled my clothes off and ran more water into the tub where I
enjoyed another spate of temporary relief. I stayed in the bath for perhaps an
hour, dried and dressed again, and crawled back into bed for another 2 hour
nap.
Because
of the nausea, I took my last dose of the pain meds at 11PM last night, so at
the moment I am appreciating what the sequelae of having deeply tender surgery
in one of the most private of places without the benefit of pain medication.
Some might call that going “Cold Turkey”, and I wouldn’t disagree with them.
I
fixed more salad at about 8 AM, and have found that if I sit on a living room
couch with my hips far back and the laptop computer on my lap, I can write for
a while. The writing making the position marginally endurable. The sweet nurse
from the surgery center called to ask how I was doing, and having had no pain
relief since 11PM the previous night, I told her I wasn’t doing well. The
feeling of a lava pot bubbling in my drawers was constant. She suggested
anti-nausea medication and a change to Hydrocodone from Oxycodone. My lovely
wife rushed off to fill the prescription for the hydrocodone and I have now
taken both meds, along with carrot soup for lunch, and was able to steal a nap
on the couch. The nausea is, at present, minimal. As I woke up, I was pleased
that the pain seemed to have abated…..until I moved…..and it came back with a
vengeance. Medical professionals like to be able to quantify pain, and on a
scale of 1 to 10, I estimate the discomfort at 6.5 to 7.
I
still have far more experience with widom tooth extraction pain than I do the
present complaint, but the advice I have always given is to use cold packs the
first day to limit swelling, no packs the second day while the wound is
maturing, and hot packs the third day to increase circulation and take away the
swelling. The surgeon’s advice for me was to let the bathtub become my best
friend for a few weeks, taking 3 or 4 soaks per day. I’m not sure what my own
patients did after receiving my advice to them, but my recent experience is
that I would try anything for improvement. This meant alternating between ice
packs and hot packs, hot baths, and showers. I haven’t tried to sit with my
rear exposed in the snow, but the thought has occurred to me. Surprisingly,
except for the fact that I had to stand, the shower gave the most continuous
pain relief. The bath for a while and the same for the cold and hot packs.
I
tried to watch a couple of shows with Beverly and while I would like to say
that the pain meds made me keep falling asleep, she would counter that sleeping
while watching TV is just normal behavior. I finally made the trek to the bed
and comfortably lay down. I slept until 1, waking with real pain. I got up and
walked around, took more drugs, and then went back to bed until 3 when the need
to urinate called to me.
Urination
is another subject that is impacted by the trauma. I suspect that the female
urethra, all of an inch long, does not have the same complications that the
male does. The edema and change in sensation make draining the bladder a
decidedly difficult matter. In order to operate the urethral sphincter, the
anal sphincter is also activated which results in a decidedly negative
experience. Sort of like swallowing with an exquisitely sore throat. During the
first day, it was painful to start the stream, but not to maintain it. By this
evening it was no longer painful and that bit of blessed relief had continued
since.
The Third Day
This
morning, I was finally ready to commit to my first bowel movement since the
surgery. I quoted from a post-hemorrhoidectomy blog earlier about razor blades,
tabasco sauce and glass shards. You can imagine I was not looking forward to
the experience. I had taken my pain med dose at about 6:30AM and the doctor had
prescribed topical 5% lidocaine ointment for use “before and after bowel
movements”. I dutifully applied the ointment and then sat back (or actually
forward) to let nature take its course. I wanted to experience as
atraumatically an evacuative event as possible, but I so wanted to be able to
write, “What about the fishhooks…I know there were fishhooks in there!”
Fortunately, I am mostly happy to report that the experience was only somewhat
unpleasant. I have to credit my salad diet and the addition of psyllium to
creating a shaped but soft stool. The real difference between the stool I
created and my normal construction had only to do with girth. The length
similar, but there were two of them only half the normal diameter. This is, of
course, only an estimate. I asked my wife to get a caliper but she declined.
I
went from the toilet to the shower and then dressed in my recovery uniform of
pajama bottoms and an REI polar fleece shirt. If the theory is that stretching
the orifice is necessary to ensure normal dimensions after healing has
occurred, I have to report that there must have been stretching, because the
discomfort in the hours after was notably greater. I sit tipped back in a
recliner with a hot pack strategically placed feeling only somewhat
uncomfortable. Imagine what your thumb feels like a few hours after hitting it
with a hammer in an attempt to drive a nail. Except it’s not my thumb.
Breakfast
this morning was fried salad again followed by a soda, ginger tea, and ice
cream for lunch. Sometimes you have to live a little. I wrote at my novel,
looked for and failed to find something to watch on the television, and before
I knew it, I was ready for bed. I had watched, or mostly watched, the two
episodes of Castle that I had missed in the preceding weeks, and my bed was
calling for me. I stopped by the hygienic facility to urinate, and I found
where the fishhooks were hiding! I could feel a certain heaviness in my lower
bowel, and with a lifetime of experience, decided that I might be ready for
another bowel movement. I applied the topical anesthetic, but my level of
systemic analgesic was probably minimal at that point. “Everything was going so
well,” I thought, “that I should be back to normal in only a day or two.”
From
this point in the future, I look back with a sad smile at my naiveté. I sat for
a few moments with nothing happening and decided that a little force might be
in order. I began to strain.
I
digress to talk about the dentate line. If you have bothered to look at a
diagram of the anal mechanism and not just rely on my poor description, you may
have noticed something called the dentate line. It is where the tissue of the
rectum meets the tissue of the anus. Internal hemorrhoids are products of
tissue above the dentate line, and external hemorrhoids are formed below the
dentate line. There are no teeth involved. This is important because there are
no pain fibers in the nerves above the dentate line. There are buckets of pain
fibers in the tissue below the dentate line. If a doctor offers to “band” your
internal hemorrhoids, he is saying he will place a rubber band around the
internal hemorrhoid at its base to strangulate it, and when it becomes
gangrenous and falls off, it is gone. Or most of it is gone. Because that takes
place above the dentate line, there is little or no pain. Hemorrhoidectomy
involves excising all that tissue and the excision runs through or below the
dentate line and therefore pain becomes a factor.
Getting
back to the situation at hand, because of the swelling, there is really very
little normal feeling of whether the rectum is ready to bear foul fruit….or
not. My poor interpretation led me to strain, which was uncomfortable, but not
unmanageable. I received little compensation for my effort. The aftermath,
however, is uncomfortable to recall. Surgeons speak about a bowel being “boggy”,
and this I understand to mean “swollen, unmoving, turgid, and uncomfortable.” I
believe that the word boggy might be applied to that swollen tissue that I was
now dealing with. With the buckets of nerve endings carrying millions of volts
of high energy pain. I got up from the toilet unhappy with my production and
realized that I was about to die. The fishhooks had been lanced through my
tenderest tissues and I could not get away from them. I imagine that is what
women feel like when they finally realize that the baby is coming out and there
is nothing they can do about it except go along for the ride.
I
could do nothing except go along for the ride. I applied more topical in a Hail
Mary attempt to relieve the discomfort, to no avail. I took a double dose of
the Hydrocodone, and as I was chewing it, started the shower. I wanted
Morphine. NOW. I didn’t get it. The shower helped, but the boggy feeling
remained. Finally, as the pain meds were beginning to kick in, I crawled in to
bed and prayed for sleep. I woke 3 times to urinate, but decided that putting
that boggy tissue in a dependent (hanging down) attitude was unwise and stood
to relieve myself. The lesson I had learned was not to be an overachiever.
Trust the bulky diet. Trust the body to tell you that it is time to use the
toilet Right Now, or there will be a messy reward. I vowed to proceed on that
premise for the duration.
Day 4
While
I was up during the night, I continued to take the pain meds, and by morning
was feeling better. Normal is still a ways off, but better. The thing is, I
feel fine. Mind and body are functioning normally, with one exception. And that
exception becomes quite uncomfortably painful if the pain meds are not on
board. A second rule to live by for the near future is to not let the pain meds
run clear out. Just like I used to tell my own surgery patients, stay ahead of
the pain. It’s really difficult and quite uncomfortable to try and overcome
pain when it is already established.
Let
me tell you about hygiene. The bidet is great, and many have suggested the
Squatty Potty as an adjunct. I believe it is useful, mostly for people with
shorter legs. My legs are long and sitting normally, my knees are higher than
my hips, so the Squatty Potty is uncomfortable for me to use. I have one that I
received from my daughter last Christmas who knows how Bowel-Aware I am, and I
am grateful for her thoughtfulness, but my wife finds it more useful than I do.
Panty
liners, however, have been something the girls have been keeping to themselves
for far too long. I could see that with external hemorrhoids, one could avoid
having stained underwear all the time, but post surgically, they are nothing
but a blessing. I asked the doctor how much bleeding I could expect and he said
that he basically left an open wound inside of my anus. I could expect bleeding
after a bowel movement, and seepage at other times. He was correct, and the
panty liner that I stole from my wife has kept me from having blood-soaked
underwear most of the time. I should use the plural, as in liners, because I
have changed them.
My
salad breakfast still has fed me well as has the psyllium mixture I have
supplemented my diet with several times a day. Throughout the day, I felt my
lower bowel giving the gassy signs of potential evacuation, and I, with
justifiable fear and trembling, ignored them. I was going to steadfastly adhere
to my new Rule #1. And finally, just before dinner time, I knew that I could
only ignore the prompting at my peril, so I made my way to the porcelain altar.
I had premedicated with narcotics, applied the topical anesthetic, delayed as
long as practical, and finally sat to contemplate nature. Relaxation and a
clear conscience were rewarded, and with little fanfare, I produced a now “normal”,
half-size manifestation embodied in twin corpuses. I went immediately to the bathtub
for a soak and the bogginess was present, but with far less discomfort than I
had the misfortune to experience the previous evening.
The
rest of the evening was spent with my loving companion serving me dinner in
front of the television while the recliner with a seat warmer was applying its
own loving touches to my tenderest parts.
And
evening and morning and…..
The 5th day.
I
was told at the outset that the 5th day would likely be the worst,
but I had completely forgotten the threat until I was looking back over the
day. We had gotten 8-10 inches of snow overnight, and I successfully ignored it
for most of the day. Fried Vegetable Salad for breakfast with increments of
Psyllium and water contributed to my smooth character, and I felt none of the
constipating effects I had been warned about from the narcotic meds. When I
could tell that the urge to be productive was inexorable, I had already been
well-dosed with the appropriate meds and retired to the throne to once again
contemplate nature. With little fanfare, the contemplation seemed a success. A problem
with the swollen and surgically impaired tissue is that it is a poor feedback
mechanism for when the task is complete, but sitting there with that tender
tissue in a dependent attitude becomes quickly uncomfortable, and I hurried,
perhaps too much, to rise. I pulled off my clothes and stepped into the shower
and enjoyed the sensation of the gentle warm spray anointing those hallowed
parts, when I suddenly became aware that I needed to revisit the porcelain
altarpiece. Soaking wet but for a towel on my face, I two-stepped to the toilet
and felt lightened by the experience. I moved back to the shower and resumed my
ministrations when I felt the exact same calling, and repeated the exercise.
Finally, I dried completely, reapplied the topical, and went on about the day.
Unlike before, I did not feel completely debilitated by a normal, natural and
universal human function.
I
want to address the topical anesthetic for a moment. 5% lidocaine, when applied
to a moist mucous membrane, is an effective medicament. In my professional
experience, ideal contact time is about 5 minutes. The label on the bottle says
that it is to be applied before and after bowel movements, as well as when needed.
The problem is that where it is needed is within the sphincter and below the
dentate line. External application is only somewhat useful, at best. Placement
in the most important region with a digit is problematic……and painful. A small
applicator, like a q-tip, might be possible, but when you need it, there is competition
for the space as other things are on the threshold of leaving. And did I mention that expanding that healing
muscle ring is painful.
The
take-away message is not that the topical is useless, but that keeping it in
contact in the right region for 5 minutes before there is competition for the
area requires plenty of pre-planning, early application, and stoical ability to
ignore the discomfort in favor of its placement.
As
much as I really didn’t want to plow the road in the afternoon before it got
dark, I walked around outside and discovered that the snow was deeper than I
had expected. I got the plow truck started after charging the battery for
several hours, and then successfully cleared the area around the house, the two
switchbacks, and began to address the steeper part of the driveway despite
taking pain medication and being only somewhat uncomfortable. On my last pass
before the steepest section, I noticed a black line in the snow extending from
the rear of the vehicle. Viewing that as perhaps emblematic of my own
experience of the last few days, I stopped the engine and got out to look. It
was obvious that engine oil was leaking from something at a great rate. I was
.4 miles from the house and it was uphill all the way. I was not going to walk in my debilitated
condition. I tried to call my wife and was unable to get her at first.
Mercifully, she finally answered the phone and I asked her to bring a
flashlight and a gallon of oil. She did, I refilled the oil pan, started the
engine and drove the massively leaking truck back to the entrance of the garage
where it now sits waiting for appropriate diagnosis and treatment.
We
watched two movies late in the evening, went to bed at a ridiculous hour, and
getting up only twice for urine calls, I slept until 9 AM. No pain meds since 9
PM the previous night.
