The medical dictionary

Papillae are very small cone-shaped or teat-like projections that are found protruding from an encircling ring at the upper end of the anal canal. The ring is a little more than an inch inside the anal opening. Ordinarily, papillae are about half the size of a safety match head and their presence is unknown to the individual and unfelt. Often papillae become bruised, cut, torn, or otherwise injured by the passage of a hard stool, by the presence of some hard particle in the stool (such as a nut shell fragment), or by the insertion of a rectal tube or syringe, etc. They then become acutely inflamed, swollen, enlarged, and very tender. The swollen masses extend into the canal of the rectum like sore thumbs. Subsequent stool passages add to the irritation by rubbing and pushing against the inflamed papillae during passage. As the trouble continues, the papillae increase in size. After the acute inflammation subsides, the swelling usually remains and the papillae become tough and fibrous.

The number of treatments is determined by severity of the hemorrhoidal disease. Treatment may easily be administered on consecutive days with as many as 3 to 4 treatments in a 24-hour period. The typical case with internal hemorrhoids may require 6 to 10 treatments. Side effects may include slight pain and/or bleeding, but the mucosa has no topical pain sensors allowing this treatment to be administered with little or no discomfort.

Pain – one must recall the anatomy of the anorectum when interpreting pain patterns consistent with hemorrhoids. Internal hemorrhoids are usually not painful unless strangulated. When there is pain involved with hemorrhoids it is indicative that the condition originates at or below the anorectal line therefore being consistent with mixed or external hemorrhoidal disease.

We then proceed to examine the anorectum with a Barr-Shuford anoscope.

Adequate lubrication is essential. I inspect for hemorrhoidal disease, anal papilla, rectal polyps, IBS, IBD, Crohn’s disease, etc. and this part of the exam (anoscopy) just takes a few seconds depending upon tolerance and visual findings.

Anoscopy -this is the definitive examination to determine the extent of the hemorrhoidal condition. The use of a disposable anoscope (Hinkel-James) is best when performing this procedure, and at times a topical anesthetic may be indicated to reduce discomfort. Mild straining by the patient at times may help assess the amount of prolapse present. Other conditions, such as hypertrophied anal papilla, rectal polyps, anal fissures etc. may also be disclosed.

Cranford Technique-this procedure consists of anal dilation (manual), fissurotomy/ fissurectomy (surgical excision of the diseased ulcerated tissue) and surgical excision or fulguration of the sentinel pile and/ or all hypertrophied anal papilla. The patient then follows up 3-4 days post-operatively with perianal applications of diltiazem 2% gel tid for 30 days, topical anesthetics and a suitable stool softener.

The advantage of the Cranford Technique is to maintain the integrity of the internal sphincter muscle. I sometimes joke with my patient that I am a “sphincter saver”, as the medical management of acute anal fissure disease is a lateral internal sphincterotomy. The internal sphincter muscle is resected in its entirety, thus reducing the resting potential of said muscle, allowing increased vascularity to the diseased tissue which facilitates healing. The obvious side effect from this procedure is a condition called “wet anus syndrome” or anal leakage. This is a very annoying condition, which could and should be avoided. Dr. Steven G. Cranford has performed between 1200-1500 outpatient “fissure repairs” under local anesthesia at the Sandy Blvd. Rectal Clinic-Portland.

Cryotherapy – this is the destruction of hemorrhoids by freezing with liquid nitrogen (-180 degree C). This technique had a brief window of popularity, but is no longer clinically popular. I had experience with this procedure and found it not practical, as storage of the liquid nitrogen is difficult and instructions in its use says to apply the “probe” to the tissue until it turns white” and then remove. This is not exact enough for the clinician and the amount of tissue that sloughs is somewhat unpredictable.

The following allows the proctologist to establish a baseline for the purpose of discussion of this disease with a nomenclature that is consistent.

no protrusion, but may bulge into the anal canal/ may / may not bleed.

protrudes at the time of BM, but reduces spontaneously, may/ may not bleed.

protrudes at the time of BM, must be manually reduced, may/ may not bleed.

permanent prolapse/ protrusion and cannot be reduced, may/ may not bleed.

Digital exam is the introduction of the examiners index finger into the anorectum. I apply a 10% Lidocaine (topical) which helps to minimize discomfort. One immediately feels for anal muscle tone or lack thereof. If this is painful, then one must adapt to the patient’s response. If there is significant pain, usually there is an anal fissure, possible anal abscess, anal cancer, etc., and a condition that is very common but under diagnosed, anal stenosis (anal narrowing/anal reflexive spasm). In women I check for rectoceles and in men I may I may palpate their prostate. At the anorectal line one may encounter enlarged hypertrophied anal papilla, which are usually present when one has anal fissure disease. Internal hemorrhoids, as mentioned will feel “spongy” and anorectal cancers will be indurated (hard) and fixed. I always look at my examining finger to check for blood.

The same as above but including either nitroglycerine (0.2% glyceryl trinitate ointment) applied to the perianus tid or diltiazem 2% gel applied tid. I prefer the diltiazem as the nitroglycerine can cause severe headache.

• After 3-4 days patient then applies to the perianus topical diltiazem 2% gel tid for 30 days. This compounded medication is a calcium channel blocker which helps to relax the internal sphincter muscle, improving blood flow to the area, thus resulting in healing. Appropriate stool softeners (psyllium, flax seed) are also prescribed.

Surgical hemorrhoidectomy – this procedure is reserved for the most severe cases of hemorrhoidal disease. When one has internal hemorrhoids 3 or 4 degree and coexistent prolapsus, closed hemorrhoidectomy may be the only option. In my practice it is unusual to see a clinical situation where hemorrhoidectomy is necessary, but when indicated this may be the patients only viable option. The procedure is just a matter of dissecting the diseased tissue from the anal verge up to the anorectal ring and then closing the wound. There are usually 3 incision sites located in the right posterior, right anterior and left lateral quadrants. Bleeding is controlled by electrotherapy and running sutures. Needless to say, this procedure is post-surgically one of the most painful experiences an individual will even endure. Complications are bleeding, intense post-operative pain and scar tissue formation, which may lead to proctostenosis, or a narrowing of the ano-rectal canal. Sometimes the opposite occurs where division or inadvertent muscle/ neurological damage may lead to incontinence or wet anus syndrome. When possible, it is clearly obvious that one should resort to all non-surgical options prior to submitting to surgical hemorrhoidectomy.

Hemorrhoids can be defined in a couple of different ways. The “not so clinical definition” is they are merely varicose veins located in the anorectum. A more recent study has described the presence in the anal canal/lower rectum of specialized highly vascular “cushions” or “pads” consisting of discrete masses of thick submucosa which contain blood vessels, smooth muscle and elastic and connective tissue. It is suggested that hemorrhoids are nothing more than sliding downward of this part of the anal canal lining. Such cushions are present in everyone, and it is suggested that the term “hemorrhoids” be confined to situations where these cushions are abnormal (enlarged, inflamed) and cause symptoms. The cushions or pads are located in three constant sites; right anterior, right posterior, and left lateral, and upon examination, this is where the examiner will see the presence of hemorrhoidal disease. This is also called the “Surgical Y”.

Bleeding – 75% of all bleeding from the large bowel is caused by hemorrhoidal disease. Bleeding associated with hemorrhoids will be bright red and the amount will be dependent upon the severity of this condition. Anemia is not uncommon and at times hospitalization is necessary due to blood loss.

Pain – one must recall the anatomy of the anorectum when interpreting pain patterns consistent with hemorrhoids. Internal hemorrhoids are usually not painful unless strangulated. When there is pain involved with hemorrhoids it is indicative that the condition originates at or below the anorectal line therefore being consistent with mixed or external hemorrhoidal disease.

Protrusion/ Prolapse – if the hemorrhoidal disease has progressed then there is frequently protrusion, which is most noticeable during defecation. If the protrusion is constant (4 degree hemorrhoids) then mucosal leakage and fecal soiling is more common (wet anus syndrome). This frequently causes persistent pruritus/ itching as a common symptom.

Anal / genital warts are caused by the Human papillomavirus (HPV) which is the most common sexually transmitted infection in the United States and is spread by skin to skin contact. Condyloma acuminatum refers to an epidermal manifestation attributed to HPV. It is not usually a serious condition unless it goes untreated.

Infared Photocoagulation (IRPC) – this is the application of a laser like devise that emits infared light that causes destruction of the diseased tissue. It is applied in bursts of 0.5 to 3 seconds per site and is effective on 1, 2 and 3 degree internal hemorrhoids. Side effects are similar to other treatments; bleeding, pain and rectal stricture. I had extensive experience with this procedure and the biggest problem was equipment failure. The disposable tips were very expensive and the power generator spent more time at the manufacturer that in my office.

Internal hemorrhoids; symptomatic, exaggerated submucosal vascular tissue located above the anorectal line and are covered by transitional and columnar (mucosal) epithelium.

Pain – one must recall the anatomy of the anorectum when interpreting pain patterns consistent with hemorrhoids. Internal hemorrhoids are usually not painful unless strangulated. When there is pain involved with hemorrhoids it is indicative that the condition originates at or below the anorectal line therefore being consistent with mixed or external hemorrhoidal disease.

The hemorrhoid treatment Dr. Cranford administers is called the “Keesey Technique” or negative galvanic treatment. It is the use of a special electrode that conducts a very low voltage, low milliamperage electrical current into the diseased hemorrhoidal tissue causing electrochemical destruction. Simply stated, the electronic action causes the hemorrhoid to shrink and shrivel up. This is accomplished with little or no pain and treatment usually takes less than 15 minutes.

The number of treatments is determined by severity of the hemorrhoidal disease. Treatment may easily be administered on consecutive days with as many as 3 to 4 treatments in a 24-hour period. The typical case with internal hemorrhoids may require 6 to 10 treatments. Side effects may include slight pain and/or bleeding, but the mucosa has no topical pain sensors allowing this treatment to be administered with little or no discomfort.

Negative galvanic treatment/ “Keesey” treatment – this type of non-surgical treatment is the application of a negative galvanic current by way of a disposable metallic electrode to the diseased hemorrhoidal tissue. It was first discovered by WE Keesey who published an article in 1934 on its clinical application. The negative galvanism causes NaOH (sodium hydroxide) to form at the contact point of the negative electrode, thus causing thrombogenesis and destruction of the hemorrhoidal vascular bed, leading to reduction and removal of internal hemorrhoids. The amount of current is usually somewhere between 15 to 18 Ma for approximately 5-7 minutes per treatment site. The number of treatments is determined by the severity of the hemorrhoidal disease. Treatment may easily be administered on consecutive days with as many as 3 to 4 treatments in a 24-hour period. The typical case with internal hemorrhoids 2-3 degrees may require 8-12 treatments. Side effects include pain and bleeding, but remember that the mucosa is void of somatic sensory enervation allowing this treatment to be administered with little or no discomfort. I have used a variety of the aformationed non-surgical treatments (ligation, IRPC etc.) and the negative galvanic (Keesey) technique is the best tolerated, most effective and has the least likelihood of initiating unwanted side effects (pain, bleeding, infection etc.). In my 37 years of practice at the Sandy Blvd. Rectal Clinic-Portland I have administered approximately 80,000 (Keesey) treatments with few complications and very good outcome. This treatment offers to patient a great alternative to conventional surgical procedures with a predictable outcome that is quite satisfactory.

COL-EZE is a prodefecatory / stool softener consisting of natural botanicals, hydrophilic and cleansing agents designed by Dr. Cranford. There are many stool softeners/bowel cleansers on the market, but COL-EZE contains a unique blend of naturally occurring substances that provide a soothing effect on the irritated bowel and relief for the individual with a history of constipation or “lazy bowel syndrome”. Many people who suffer from chronic constipation use harmful laxatives (Cascara sagrada, Senna) which, over the long term, can cause a “laxative dependency”.

Correction of the existing rectal disorder generally relieves constipation and in many cases entirely eliminates it. However, habitual use of laxative or cathartic drugs moves you that much farther from permanent relief and may even contribute to many rectal diseases.

Mixed hemorrhoids – a combination of both internal and external hemorrhoids. Clinically these are hemorrhoids that usually occur in the confines of the anal canal and are covered by modified stratified squamous epithelium.

Pain – one must recall the anatomy of the anorectum when interpreting pain patterns consistent with hemorrhoids. Internal hemorrhoids are usually not painful unless strangulated. When there is pain involved with hemorrhoids it is indicative that the condition originates at or below the anorectal line therefore being consistent with mixed or external hemorrhoidal disease.

Proctosigmoidoscopy – this procedure is used to best assess the condition of the rectum and the lower bowel. The flexible sigmoidoscope allows the examiner to readily view the status of the bowel mucosa (Crohns disease, ulcerative colitis, IBS etc.) and exclude or confirm the presence of colorectal cancer.

Rubber band ligation – this is the use of a device called a “Baron’s ligator” where a constricting rubberband is placed around the prolapsing hemorrhoid, restricting its blood flow and constricting the tissue until it becomes necrotic. The “dead” hemorrhoidal tissue sloughs and is replaced by minimal scar tissue. This type of treatment is best for internal hemorrhoids grades 1 degree, 2 degree and early 3 degree

Sclerotherapy – this is the injection of 5% phenol in vegetable oil submucosally above the hemorrhoid. Usually 3-5cc are placed at each hemorrhoid site. This is a procedure that has its origin in Great Britain. It causes fixation, retraction and partial atrophy of the hemorrhoidal disease. It is indicated in 1and 2-degree internal hemorrhoids and is very effective. Possible side effects are scar tissue formation and rectal stricture, which usually occur if there are excess amounts of the phenol and oil solution is injected. It is contra-indicted in patients with ulcerative colitis, leukemia, lymphoma or portal hypertension. For some reason, this technique has lost clinical popularity, and is not readily available.

There is a pathology that is consistent with the fissure disease and chronicity usually dictates its extent. It is not uncommon to see hypertrophied anal papilla (can be multiple), sentinel pile of Brodie (fibrous inflamed tissue located at the base of the ulcer), internal sphincter spasm (may lead to anal stenosis and develop an “overshoot” or increased resting potential of the surrounding musculature) and very small amounts of suppuration (see illustration). The etiology of the fissure disease is usually passage of a large stool or prolonged straining over a period of time (chronic constipation). The clinician usually finds a patient with a fiber-depleted diet, which may be more susceptible to this condition. The typical set of symptoms for anal fissure disease is post-defecatory pain, frank bleeding, sentinel pile, constipation/obstipation and even dysuria. When you examine this patient you must be quite careful, as there will be predictable apprehension because of the pain. It is important to use topical anesthetics (lidocaine 5%) prior to such examination and in some cases perianal infiltration (posterior midline) of 1-2 cc’s of bupivacaine may be required. Digital exam will quickly allow the physician to determine the extent of sphincter spasm/ anal stenosis, which along with the other clinical findings, is vital to dictating an appropriate treatment protocol.

Usually a source of acute embarrassment for the prospective patient. One can diffuse that by simple explanation and reassurance. After a brief discussion about relevant health history, both constitutional and specifics relating to the anorectum, the patient is placed in the left lateral Sims position (laying on one’s left side).Visual inspection is the initial step which reveals an abundance of data to the clinician. One must be diligent to observe the perianus, gluteal crease and the perineum. Often times the condition that is responsible for the patient’s symptoms is very apparent. Some of the more common conditions that are usually visible are external hemorrhoids (thrombosed or non-thrombosed), pruritus ani (anal itching), skin tags, HPV (anogenital warts), perianal fistula, sebaceous cyst, Crohn’s disease, anal cancer, anal fissures, etc. The list is very long. Palpation of the surrounding tissue is imperative as tissue density varies with different conditions. Anorectal cancers are indurated masses that will feel like your “forehead”. Hemorrhoids will be more “spongy” like ones chin.

The advantage of the Cranford Technique is to maintain the integrity of the internal sphincter muscle. I sometimes joke with my patient that I am a “sphincter saver”, as the medical management of acute anal fissure disease is a lateral internal sphincterotomy. The internal sphincter muscle is resected in its entirety, thus reducing the resting potential of said muscle, allowing increased vascularity to the diseased tissue which facilitates healing. The obvious side effect from this procedure is a condition called “wet anus syndrome” or anal leakage. This is a very annoying condition, which could and should be avoided. Dr. Steven G. Cranford has performed between 1200-1500 outpatient “fissure repairs” under local anesthesia at the Sandy Blvd. Rectal Clinic-Portland.

Anal stenosis has traditionally been treated by simply cutting through one side of the sphincter to relieve the tension. Called a sphincterotomy, it simply defeats the action of a sphincter muscle (which is to close), and has the side effect of fecal incontinence or leaking of fecal matter.

Strangulated hemorrhoids – these are a combination of both internal and external hemorrhoids, which are characterized by mucosal and anal prolapsus, intense spasms of the internal and external sphincter muscle group, cutting off the blood supply and usually contains multiple blood clots. Because of the vascular abnormality due to the muscle spasm and if allowed to progress, this type of hemorrhoidal disease can progress to become necrotic and gangrenous.

Protrusion/ Prolapse – if the hemorrhoidal disease has progressed then there is frequently protrusion, which is most noticeable during defecation. If the protrusion is constant (4 degree hemorrhoids) then mucosal leakage and fecal soiling is more common (wet anus syndrome). This frequently causes persistent pruritus/ itching as a common symptom.

The advantage of the Cranford Technique is to maintain the integrity of the internal sphincter muscle. I sometimes joke with my patient that I am a “sphincter saver”, as the medical management of acute anal fissure disease is a lateral internal sphincterotomy. The internal sphincter muscle is resected in its entirety, thus reducing the resting potential of said muscle, allowing increased vascularity to the diseased tissue which facilitates healing. The obvious side effect from this procedure is a condition called “wet anus syndrome” or anal leakage. This is a very annoying condition, which could and should be avoided. Dr. Steven G. Cranford has performed between 1200-1500 outpatient “fissure repairs” under local anesthesia at the Sandy Blvd. Rectal Clinic-Portland.