The Hemorrhoids-Day of Surgery

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 5^th day.

                I was told at the outset that the 5^th 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.