An open letter: Why Primary Care Physicians Should Prevent Hemorrhoids Through Proactive Screening

Dr. Robert Cutler, our founder and product developer, penned this open letter to increase patient-provider dialogue on the issue of hemorrhoids. Early screening can prevent surgical intervention and other complications. Examples of quick and easy hemorrhoid intervention opportunities can be found below.

With an estimated 75% of Americans expected to encounter hemorrhoid issues at some point in life, and a 23% expected increase in demand for treatment over the next 20 years¹, we can assume there will be ample opportunities to address hemorrhoids with patients.

Patients are often apprehensive when it comes to reporting hemorrhoid symptoms to their physician, which makes a proactive approach to hemorrhoid care even more important. Physicians are in a key position to prevent their patients’ hemorrhoids from progressing to a more serious condition. If we were to increase screening for early signs of this condition, this would better serve patients by avoiding or reducing the potential need for surgery and other invasive procedures in the future.

The Current State of Hemorrhoid Care

Current medical standards tend to be geared more towards identifying and treating problematic hemorrhoids rather than preventing them from becoming a painful problem for the patient. Because of this, and the fact that patients can be wary of sharing hemorrhoid symptoms with their doctor, hemorrhoids may go undiagnosed, which can lead to more invasive treatments in the future that can be painful and costly for the patient.

Diagnostics

Among the list of diagnostic procedures currently performed during an annual physical examination, the only item typically related to anorectal health is a colonoscopy. While a doctor might incidentally discover hemorrhoids during the colonoscopy or a prostate exam, a more proactive approach is the best way to prevent more issues in the future.

Surgical Treatment

Surgery is generally reserved for painful prolapsed internal hemorrhoids, multiple thrombotic external hemorrhoids, or hemorrhoids with significant bleeding.² Surgery may only address a hemorrhoid issue in one area, but there are three major areas where hemorrhoid issues develop, along with a few other minor areas. These minor areas can account for secondary rectal issues, stemming from the development of post-op collateral circulation.

How to Prevent Hemorrhoids with Routine Doctor Visits

With so many clinics under extreme time constraints, prevention of hemorrhoids with screenings can be under prioritized. Nonetheless, finding a few minutes to address hemorrhoid prevention carries the potential to save hours on invasive procedures and surgeries. Here are some examples of hemorrhoid intervention opportunities that will fit easily into existing time constraints.

Identify the Common Risk Factors During Annual Physicals

Risk factors can be pulled from patient history, family history, and routine procedures (such as taking weight). Identifying key risk factors in patients is a valuable opportunity to resolve hemorrhoid issues before they become common anorectal problems, which result in a variety of uncomfortable and often scary symptoms. If a doctor encounters an at-risk patient, they can strongly recommend that the individual schedules a follow-up exam to evaluate the hemorrhoids. An opportunity for a rectal exam may be found during an annual physical (especially with a prostate check for men). If a rectal exam can be offered during an annual physical for an at-risk patient, this better serves the patient. Additionally, hemoccults can be provided to patients at an early age.

Integrating the following checklist of hemorrhoid risk factors into an annual physical allows doctors to qualify patients for a preventative rectal exam.

• Heredity – Does the patient have a family history of hemorrhoids?
• Lifestyle – Does the patient lift heavy objects often (bodybuilders, laborers, etc.)
• Bowel Habit Irregularity – Does the patient have frequent bouts of diarrhea or
• constipation?
• Age – Is the patient at that age when a colonoscopy is needed?
• Pregnancy – Is the patient in the later stages of pregnancy or have they recently
• delivered a baby?
• Obesity – Is the patient’s weight putting more strain on anorectal vasculature?
• Liver Issues – Is the patient’s risk for hemorrhoids being increased by portal
• hypertension caused by Cirrhosis?

Obstetricians

Up to 50% of pregnant women will develop hemorrhoid problems.³ These flare-ups may not present themselves until the third trimester or postpartum, but obstetricians are in a unique position to intervene early. Obstetricians can both examine for hemorrhoids along with pelvic exams during routine pregnancy checkups, and recommend hemorrhoid prevention self-care. With pregnancy being one of the chief hemorrhoid causes, doctors have the opportunity to improve women’s health care by outlining what they can do to mitigate hemorrhoid flare-ups including the temporary use of pregnancy-safe medications.

Leveraging Technology

A traditional in-person consultation is generally preferred, but thanks to improvements in telemedicine, it’s not the only way to communicate with patients. Some doctors are requiring their patients to use a patient portal as part of their care procedure. Doctors can leverage patient engagement within the portal by communicating recommendations for hemorrhoid prevention and advising when they should schedule a rectal exam. Likewise, patients can use the portal to securely and privately message their practitioner with any immediate questions.

Guide Patients on Prevention

An at-risk patient who is diagnosed with asymptomatic hemorrhoids or is currently presenting hemorrhoids can then receive noninvasive intervention measures such as lifestyle modifications and a take-home “How to Prevent Hemorrhoids” guide. Below are some suggested recommendations for this plan.

• Increase fiber intake
• Reduce consumption of caffeine, dairy, and other products that trigger irregular bowel movements
• Drink sufficient water
• Regular exercise that doesn’t strain anorectal muscles
• Daily Kegel exercise⁴

The Future of Hemorrhoid Care

As hemorrhoidectomies continue to trend downward, we can reassure patients that being forthcoming with hemorrhoid symptoms isn’t likely to result in surgery. Incorporating additional diagnostics into existing, routine examinations is a small but crucial step towards avoiding more invasive and costly procedures. As doctors screen for breast cancer, diabetes, etc., they could also screen for signs and symptoms of hemorrhoids with a simple anoscopic examination and asking a few questions.

Additionally, performing hemoccult tests on younger individuals could identify people who have microscopic bleeding caused by internal hemorrhoids. This would then be confirmed by performing anoscopy and reassessed after medication treatment. When we take steps to identify risk factors and treat hemorrhoids that are abnormal but have not yet become symptomatic, we can prevent the potential development of hemorrhoids and complex issues that often require the use of more complicated and repetitive procedures or surgeries in the future

References

1. Sandler, R. and Peery, A., 2019. Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol. Jan;17(1):8-15.
2. Lohsiriwat V, 2015. Treatment of hemorrhoids: A coloproctologist’s view. World J Gastroenterol. Aug 21;21(31):9245-52.
3. Office on Women’s Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services, 2019. Body Changes and Discomforts.
4. Ali, Z., El-Sayed, N. and Taha, N., 2011. Effect of Conservative Measures in Improving Hemorrhoid Stages and Relieving Symptoms among Patients with Hemorrhoid. Journal of American Science, 7(9), pp.53-64.