Notes from a Doctor's Practice

There are no dumb questions, but occasionally embarrassing ones. Many of you sheepishly bring up issues during your visit with the doctor thinking you are alone and you are not alone. Here are the most common awkward questions I am asked about.

1)  Bright red blood with your poops. This is so common we call this Bright Red Blood Per Rectum or BRBPR.  One drop of blood in the toilet turns the whole toilet red and that's what brings many people to the emergency room and to the doctor's office.

What is it? By far the most common cause is hemorrhoids. These can be internal where you don't see them or external where you can see and feel them. Helpful hint: Internal hemorrhoids are generally painless while external hemorrhoids cause burning, itching and pain with a bowel movement. More unusual causes of BRBPR are anal fissures (crack or tear) or mass in the rectum (cancer) and your doctor can help you rule out. 

What can we do about it? To help alleviate BRBPR from hemorrhoids use stool softeners, over the counter hemorrhoid remedies (Anusol HC, Preparation H) and follow up with your doctor.

2)  I'm passing a lot of gas. The amount of gas you pass depends on a number of factors including diet. Excessive gas may give you loud, smelly flatus, abdominal distension and rumbling stomach.

What is it?  Lactose intolerance, sudden change in diet (adding more fiber) and an upset in the natural bacteria in your gut are common culprits.

What can we do about it? Limiting, but not excluding, dairy products, beans, vegetables, fruit, dried fruits, garlic and beer may help. Probiotics found in live/active culture yogurt (Activia by Dannon, Columbo, Horizon, Stonyfield among others) at two tablespoons a day may also help.

3)  Itchy butt or "Pruritus ani." Itching of the anus and the skin around it that is worse at night is a common but annoying problem that many of you will sheepishly bring up.

What is it? Dietary factors and fecal soilage from diarrhea or loose bowel movements are the most common causes. Your doctor will also want to rule out abscesses, infections like pinworms, skin conditions like psoriasis, and hemorrhoids among other things.

What can we do about it? Conservative treatment will work 90% of the time. Start by avoiding food and beverages known to exacerbate pruritus ani such as coffee, tea, cola, chocolate, citrus fruits and tomatoes. Your next goal is to keep the skin around the anus clean and dry without excessive wiping or use of astringent cleaners. If you can bathe after a poop it's helpful.  Following a bath, the area can be dried by dabbing with a soft towel or using a hair dryer and unmedicated talcum powder will also help keep it dry. Finish it off with a 1 % hydrocortisone cream applied twice a day to help the area heal.

4)  "I can't get a boner." Erectile Dysfunction is the name for this common complaint from men of all ages who can't acquire or sustain an erection.

What is it? Common offenders in older men are cardiovascular disease and medication side effects. In younger men (as many as 30% complain of this at some point) psychosocial factors, medication side effects (antidepressants) and bicycling (more than 3 hours a week) are the most common causes. Depression, performance anxiety and loss of sensate focus (being distracted by financial concerns, etc) explain the majority of psychosocial problems.

What can we do about it? Counseling and communicating with your partner are the obvious first steps. Yes, you can give the medications a try (Viagra, cialis, levitra) and see if they will help. Helpful hint: to sort out whether your ED is psychological pay attention to the presence of spontaneous erections (middle of the night or early morning). The absence of spontaneous erections steers us away from a psychological cause and toward a more organic cause of your ED.

5)  Bad breath: What brings most of you to complain about this is a report from your partner/father/sister/mother that you have bad breath or Halitosis.

What is it? The oral cavity is the source 85% of the time. This is largely the result of bacterial breakdown of certain amino acids from proteins present in food debris, saliva, or postnasal drip in the oral cavity. Bad breath from the mouth comes from bacterial accumulation between the teeth, and from the posterior part of the tongue.

What can we do about it? Treatment is proper dental care and oral hygiene. Specifically, gentle cleaning of the posterior portion of the tongue (with a plastic tongue cleaner), rinsing and deep gargling with a mouthwash, eating fibrous foods, brief gum chewing if the mouth is dry or after meals (5 minutes) and sufficient water intake will help your bad breath.

6) Excessive sweating in armpits, palms or soles. Idiopathic hyperhidrosis is the name for this common and distressing complaint. This isn't just your armpits getting sweaty once in a while this is focal, visible, excessive sweating of at least six months duration without apparent cause which stops during sleep.

What is it? With Idiopathic Hyperhidrosis, the actual sweat glands are normal. Rather, the cause of hyperhidrosis appears to be an abnormal or exaggerated response of the glands to normal emotional stress. It usually occurs before the age of 25, there is often a family history and it impairs daily activities.

What can we do about it?  We start with topical agents such as prescription strength antiperspirants like 20 percent aluminum chloride in ethanol (Drysol) or 6.25 percent aluminum tetrachloride (Xerac). These may provide adequate therapy for patients with mild to moderate symptoms. Beta-blockers or benzodiazepines may be useful in treating symptoms directly related to emotional stress. The newest proven therapy is botulinum toxin (BTX) which can be injected into the axilla, palm and soles. Painful, but it works.

7)  Excess hair growth in women: Hirsuitism is excess facial hair and is a problem 10% of females of reproductive age experience.

What is it? While it is hard to really define what "excess" hair growth is since it varies with ethnicity, hair growth on the chin or lip will be the most common complaint for women with Hirsuitism. Too much androgen (male hormone) is the source and Polycystic Ovary Syndrome (PCOS) is the number one cause with Idiopathic hirsuitism (idiopathic meaning we have no idea why it happens) being number two.

What can we do about it? Nonpharmacologic therapy consists of shaving or waxing but my recommendation is for laser hair removal.  Laser treatment, although expensive, is effective and often results in permanent reduction in hair growth especially in women with lightly pigmented skin and dark hairs. A new topical option is Vaniqa which inhibits new hair growth and works fairly well. Hormonal options include combination estrogen-progesterone oral contraceptives which will slow hair growth in 60-100% of women. Spironolactone is another option which has been shown to be highly effective in women with moderate to severe hirsuitism.    

8) Butt Acne: Men and women often awkwardly ask me about red bumps that may itch or even hurt that come and go on their butt cheeks and is a source of embarrassment.

What is it? This isn't really acne but rather a folliculitis. Folliculitis is a superficial bacterial infection of the hair follicles (you can also see it on the thighs or beard area in men). The most common cause is Staph Aureus infection followed by Pseudomonas Aeruginosa which comes from contaminated water (this is often called Hot tub folliculitis). You will notice the lesions like to crop up if you've been sweating and sitting around a lot.

What can we do about it? "Butt-acne" typically resolves on its own with warm compresses but if lesions persist we can prescribe topical antibiotics like Bactroban and in very resistant or recurrent cases we use an oral antibiotic.

Dr O.