Diana Ziser Rego, an adult-gerontology nurse practitioner with expertise in lower GI disorders, describes efficient routes to identifying hemorrhoids and anal fissures, offering tips on what questions to ask, straightforward management plans and guidance on when to refer. Find out why you need to distinguish external hemorrhoids from internal ones.
My name is Diana Ziser. Um I also go by Diana Zer Rego and, and um I am from the Bay Area. I, I grew up out here, I was a nursing assistant out here first. Uh where my first nickname as the gentle wiper started. And so that's when I really should have known that I was going to be in cool surgery here. I am. I was a cardiothoracic nurse for five years where I could make anybody poop on any amount of opioids. And then in 2016, I started at a colorectal surgery clinic in Michigan and I just freaking loved it this picture because I think that is exactly what everyone pictures whenever they come to you guys with, with pain. Um The biggest things that I sort of talked to people about and explain is that where, where are you, where when with anal pain, I gotta talk about what's going on on the inside of your butt and what's going on on the outside. So like, so this is any anal pain, most, most anal pain, most pain, hemorrhoids, fish or even fous abscesses is what are your bowel movements doing? So, what's going on on the inside and what is going on on the outside? So what are those muscles doing? What are the internal Sphinx are doing? External Sphinx are doing? Um, you know, are they contracted? Are they too? I mean, you're not gonna be able to tell that obviously on the Zoom appointment, but it's gonna be really, really important to get a sense when someone says my, my butt hurts getting those details about, uh, you know, do your bowels feel complete, obviously? Are you having bleeding? Are you having pain? Because it makes a difference in how and where I'm gonna kind of go with my diagnosis, particularly between a hemorrhoid and a fissure. So, hemorrhoids are a normal part of your anatomy, right? Like when I was pregnant, I used to walk around in patient rooms and being like my fetus has hemorrhoids and they would be like, that's disgusting and weird. But it's, but it's true. And so, but they're, they're a normal part of anatomy. And so oftentimes people are like, I got this and I'm like, nope, you've had it forever and, you know, there's, they're basically blood vessels, we've named, we've, we, and they get tired if the inside of your butt and the outside of your butt are not working appropriately. Um And so that's why if somebody is sitting and straining on the toilet and they have for years or they have, you know, and, and, and actually even a history of sexual abuse because then you can get pelvic floor dysfunction and it really freezes up your pelvic floor. And so you will be all of those hemorrhage and figures will really get um layered with that. The difference is between external and internal hemorrhoids is ex the way I describe it is internal, are almost always painless and they bleed a ton. And then there's kind of the mixed component which are the ones that live on. Like what I like to say, the ones that live on the edge right there, that skin and then the external ones are the ones that people are like, oh my God, I feel this like really horrible painful lump. And that is because this there's nerves right here. So like for example, one an intervention I do in clinic is something called banding, which they, which we only use for internal hemorrhoids because people like, can you ban an external hemorrhoid? And the answer is no, the only thing you can do for external hemorrhoids with lumps, bombs, thrombo hemorrhoids. All that jazz is either you leave it the hell alone, which is most of mostly what I recommend or an excisional hemorrhoidectomy. Um Yeah, so that, so that's where, so that's the difference between internal and external hemorrhoids, internal. So pa painless bleeding for internal hemorrhoids and external hemorrhoids are more painful. They, they're, they're feeling more lumpy. So when someone's talking to you about my guess is that you guys will get in it like a virtual appointment for either rectal bleeding or pain and it'll hemorrhoid symptoms are typically itching and that's because your internal hemorrhoids are like draining a little, they're irritated for whatever reason. Um, they'll, you'll feel prolapse of tissue and again, that's those mixed component internal hemorrhoids that are, um, swelling because of either something's something's going on whether it's a bad bowel movements, pelvic floor dysfunction, maybe it's a tumor. We don't know, um, painless bleeding, hard lumps near the anus that are sore, tender and pain or ache, especially when you sit and that's gonna really come from again if you remember the, where the nerves are, that's that external stuff. So the big deal with hemorrhoids and any and with fissures, it is typically straining, irregular bowel habits. I'm sitting on, I take my phone into the bathroom when I'm on the toilet for 25 minutes. Um, and I'm, the other thing is with the itching, you're using wipes, you're using prep H all the time. Um All of those things will, can, can cause worsening hemorrhoids if you're using a lot of prep h which people do because if you have chronic constipation, your hemorrhoids are always irritated. So then people go to over the counter stuff and they use that every day for years and that can actually make things worse because as a steroid, it can really thin your skin. Um, so management is gonna be about bowel management, staying hydrated, sits, baths, heating pad tubs, baths and I would say tropical lidocaine. Um, let's talk a little bit about fiber. Um Every, everyone gets real nervy, pervy about it. And so it's, or people think it's Metamucil, oftentimes patients mix up Metamucil and uh Miralax. And so my favorite fiber is benefiber because it's real easy to take. It is a soluble fiber. You can, I throw it in my coffee every morning. I don't even know it's there no matter what is going on with these patients, you can start them on a tiny amount of benefiber. Um, like one teaspoon a day for a week to see if we can help regulate their bowels and then they can increase to another teaspoon. Never tell them to start what's on the back of the box because that is always too much. Always, always, it's always like a heaping tablespoon and maybe that's where they'll get. But if you take a constipated person who's not drinking very much water and add a heaping tablespoon of fiber, it's gonna make their constipation worse. They're not gonna be compliant with the fiber. Um I wouldn't be um, another thing if they're already on Metamucil, if they're on Acacia powder, all kinds of other stuff that's fine too. But if they're still having the symptoms, I would switch it up. Um, you can get hemorrhoids from diarrhea as you imagine because if it's dysfunctional bowel, that poor skin is just like losing its mind. Um So doing like one or 2 mg of Imodium as long as you've ruled out CD and other causes of diarrhea that you know, are and you know, are contraindicated with Imodium. Drinking water sits, baths, heating pads, tub, tub, bath. Um I had a surgeon. I once worked with who I still ii I love very much. She's one of my best friends and she was like, I need my patients to do 66 baths a day when their hemorrhoids are flared. And I was like, if somebody told you to do that, shanker, you would laugh enough because nobody has to time to do that. And people get are, are very sensitive about that. So the idea behind a sits bath and it is heat, it's relaxing your pelvic floor. Go back to this anatomy. I need to relax these muscles so that this poor little anoderm gets a break, right. So that's where that comes from. And topical lidocaine is pretty benign. But if you have someone that has like an acute thrombo toroid, uh it, it's helpful. It just, it's, I mean, it's been, it's kind of benign management until you can get them fissure will cut in there. Typically fissures are going to come from constipation and pelvic floor dysfunction. So my, one of my top people that I see in my clinic is our young tech dudes who are very stressed out and carry their stress in their pelvis. And so they're like all of it and they're typically not constipated, but they are poor little internal sphincter. Men in particular, young and men have longer internal sphincters and, and kind of thicker internal sphincters. So if you carry your stress in that pelvis, you're sitting all the time, that's constantly contracted. As you can imagine that poor anoderm is really suffering under that. And so at some point, you, your body hits a point where that anoderm is gonna rip and break. So that's pelvic floor dysfunction. And when you're asking about that for patients, you know, it's oh no. Oh, here they are whoopsies. Um It's frank bleeding like I feel like glass is I'm passing glass. Um hemorrhoids that are bleeding do not typically drip, but visions like to drip. Um They'll, there's also what we call a sentinel pile associated. So it'll be like, oh my God, I have this glass like pain and I feel this new little bump that's right there. And that is because when you have a cut right there, your skin is trying to peel it right, like it's trying to, to close it and it can't get there because there's spasming muscle underneath. Um And so that extra sting, it makes these what we call these little sentinel tags and people often times are like, that's the thing that hurts and it's actually the fish are kind of like underneath it, that hurts the other thing is that you'll have a lot of throbbing post bowel movement. So it's like, oh my God, I poop and I, and I, it takes me two hours to recover from a poop. And that is because you're, you're, you have a cut it and it makes the sphincter spasm which makes the cut hurt, which make the sphincter spasm, which make the cut. So it's this awful cycle. So the things that we do, sorry, I think I skip, I went to that page a little bit but the thing that we do for them and you can even start this if you're not sure if this is, this is a thrombo temporary, which is a fissure. You can start Nifedipine lidocaine. It's pretty, it's Nifedipine, it's Nifedipine 0.4% or excuse me, 0.3% and lidocaine 4% and you need to do a compound pharmacy. If you guys are in San Francisco, there's only two that do it. There's Cush Pharmacy and then there's 4129 Walgreens. There's a reason I have to, I see these every, every day, all the time. I have to have this memorized. Those are the only two compounding pharmacies in the city that'll make this um depending on the patient's insurance, it's, they're really expensive. It's like $100 cream which is a little bit of a bummer. Um I, I if you're fairly certain this is a fissure. So, meaning that like I'm passing my bowel movements and they sh sh sometimes they have most of the times they have constipation with this, but like I'm, it's the pain, it's dripping glass, blah, blah, blah. You can start the Nifedipine night. You're doing a bowel management program like you would with the hemorrhoids, baths, heat, relaxing that pelvic floor. Remember, go back to your anatomy and then if it's refractory to any all of this medical management over the next like three or four weeks, refer to us because then I will do a Botox injection into um an internal sphincter so that this, so it relaxes a little bit so that, that spasm can stop. So those are your big kind of interventions. The sit, you know, sits bath or heat. I oftentimes tell people like, look if you can't do a sits bath, like at least on a heating pad, like whatever is gonna help relax your pelvic floor. Um And there's that, that's what benefiber looks like over the counter lidocaine and then water. And that's, that's the, that what questions do you guys have?
