Q. I am a T8 complete para, 12 years post-injury. Lately I’ve been noticing some bleeding when I do my bowel program. Other wheelers I hang out with say it is probably hemorrhoids. This has me worried. A friend’s hemorrhoids got so bad he needed to have them surgically removed and it took over two weeks of bed rest to recover.
What are hemorrhoids? Are they more common in people with SCI? Can they be prevented or managed to avoid surgery?
A. Steve, hemorrhoids are swelling of veins in the rectum and around the anus. When they swell too much, they lose their elasticity and bulge out in sac-like protrusions. Unfortunately hemorrhoids are extremely common in people with SCI, and the longer you have been injured, the more likely you are to get them. Clinicians I spoke with say that in people with SCI, the main cause seems to be chronic minor irritation or trauma that happens during a bowel program.
Although a major sign of hemorrhoids in people with SCI is bleeding during a bowel program, never assume that this is the cause. It is extremely important to notify your doctor of any new or unexplained rectal bleeding and get an exam to identify the cause. It could be a symptom of a more serious condition, including cancer.
Although SCI and neurogenic bowel management make it more likely to develop hemorrhoids, there are options that may reduce your chances of developing them or help with symptoms.
Dianna Elledge, R.N., of the Craig Hospital SCI Nurse Advice Line, explains that stool consistency is important. If it is too loose, it can cause accidents; too firm means constipation, which can cause and/or aggravate hemorrhoids. Elledge says the proper amount of fiber is key for this balance because it provides bulk and keeps things moving. “We recommend 20-25 grams of fiber a day,” says Elledge. She says to also be sure to drink enough water — 8-12 cups of water a day is recommended, but be sure to balance this amount with how you manage your bladder.
Nutritionist Joanne Smith, co-author of Eat Well, Live Well with Spinal Cord Injury, in her 26th year as a para, agrees with Elledge. She says good sources of fiber are legumes (peas and beans), vegetables and whole grains. In addition she recommends 1 tablespoon of whole husk psyillium fiber mixed in a glass of warm water per day.
Smith also suggests taking a probiotic supplement with a minimum of 15 billion active micro-organisms each night to help keep things moving through the intestines. And she recommends foods and supplements that have been shown to relieve hemorrhoids by strengthening the veins, including:
Flavonoid-rich foods — strawberries, blueberries, blackberries, cabbage, onions and tomatoes.
Foods rich in vitamin C — dark berries, broccoli, Brussels sprouts, kale and red peppers. And a daily 2,000 mg vitamin C supplement.
It is also important to keep your weight in check. Excess fat around the midsection can put pressure on veins that cause hemorrhoids, says Elledge. She says Craig Hospital recommends, if possible, to keep your bowel program under an hour because sitting on the commode leaves the rectum unsupported and can increase pressure on hemorrhoids. Be gentle when doing digital stim and limit it to no more than two or three minutes at a time. Use plenty of lube and keep the total time of digital stim to 20 minutes or less because it creates irritation that can cause and/or inflame hemorrhoids.
Soaking in a warm tub after a bowel program can help shrink hemorrhoids, says Elledge. If they are external hemorrhoids, putting ice in a moist wash cloth or sock and applying it for 10-15 minutes may help.
Anecdotally, an option that helped me is the Peristeen system manufactured by Coloplast (see resources). The system introduces tap water into the colon via a rectal hydrophilic catheter with a Foley balloon. The water loosens stool and acts as a mild irritant, causing peristalsis — wave-like colon contractions that move and evacuate stool. The system empties the colon in an average time of 30 minutes — and empties two-thirds of the entire colon.
I started using Peristeen last year to deal with chronic constipation. I was also experiencing hemorrhoidal bleeding. Within a few months of using the system, the bleeding stopped and hasn’t returned. Before using the system, I was doing a digital stim bowel program every day, sometimes twice a day to prevent accidents. The Peristeen system empties me out so well that now I only need to do a bowel program every other day.
In November CMS granted a Medicare reimbursement code for Peristeen. For further information contact your physician, rehab center and/or Coloplast.
If conservative measures aren’t working, how does a person decide to go to the next level and treat them? Dr. Bard Cosman, a colorectal surgeon board-certified in spinal cord injury medicine, is professor of clinical surgery at UC San Diego, based at the San Diego VA Medical Center. He explains that there are three main reasons for treating hemorrhoids: bleeding that is annoying, which is common; heavy bleeding that is dangerous, which is very rare; and hygiene — hemorrhoids that make a mess or get so big that they cause bowel care difficulties. Cosman clarifies that hemorrhoids never get to the point where they obstruct the anus or rectum.
If hemorrhoids get to the point where something needs to be done, Cosman explains there is an easy fix called hemorrhoid banding, also called rubber band ligation, a procedure where the hemorrhoid is grasped with an instrument and a tight rubber band is placed at the base, which cuts off the blood supply. “The hemorrhoid that has been banded falls off within two to 10 days and leaves an open wound that heals as a scar in six to eight weeks. The scar sticks to the sphincter muscle, which is what you want,” says Cosman. “It is a simple, quick office procedure that was invented here in California in the 1950s and is the world’s most common procedure for dealing with hemorrhoids,” he says. “Banding works well on folks that don’t have sensation. If you could feel it, it would hurt. In the non-SCI population we only do banding on internal hemorrhoids where there isn’t sensation.”
Cosman has been doing a weekly SCI colorectal clinic for 19 years, and he routinely does hemorrhoid bandings. He explains that hemorrhoid banding for people with SCI isn’t a cure for hemorrhoids; it is more like a maintenance procedure, downsizing them enough that they aren’t a problem for a while, but eventually they will come back, and you do the procedure again.
There are a myriad of tissue-destructive office treatments that are similar to banding, says Cosman (see resources). The most common one is called infrared photocoagulation — an intense beam of infrared causes scar tissue and cuts off blood supply to the hemorrhoid, which works just as well as banding.
The next level up is hemorrhoidectomy, an inpatient surgical procedure, explains Cosman. Expect about two weeks of downtime in bed to recover, and light eating at first. “The ratio of bandings to hemorrhoidectomies I do is somewhere around 15 to 1,” he says. “The rare person with SCI that I have to perform a hemorrhoidectomy on is someone who has truly enormous hemorrhoids that I can’t band, or more commonly, has an incomplete injury, sensation and symptoms.”
• Craig Hospital Bowel Problem Module: www.craighospital.hostworks.net/repository/documents/HeathInfo/PDFs/706.Bowel.Problems.NOD.pdf
• “Peristeen: New Option for Bowel Management”: www.newmobilitycom/2014/04/peristeen-for-bowel-management/
• Banding and other tissue-destructive outpatient treatments: www.asge.org/assets/0/71312/71314/145aeb14-9e9d-43d9-8a51-80ff3bde20a4.pdf