|An average Indian
patient has "tongue neurosis". He is
not satisfied unless his tongue is examined
properly. In fact many a patient would complain
of coating or burning of the tongue when it looks
plum normal to a specialist! Significantly, an
average Arab does not bother about the tongue.
This population does not clean the tongue with
"tongue-cleaners" like their Indian
As against this, an Arab,
next to sex, is mainly concerned about the
perineum. Many Arabs are known to clean (shave)
perineal area as religiously as our Indians look
after their tongue. They associate sex with
perineum and therefore look after the hygiene of
this area with more enthusiasm.
patient is not satisfied till you have examined
his perineum. (Females are still very shy and do
not expect to be examined for piles routinely.
But I can see that the trend has already started
in Bahraini females and it looks as if it will
spread to others as well). it is interesting to
note that the 'true' or 'apparent' incidence of
piles in Arab females is strikingly less.
patient looks forward to be askeda million
dollar question.... "Did you ever have or do
you have any symptoms of piles?" ("Bavasur"
Most of the times the answer is 'umkin' or
'imkin' which means 'may be'. A very few Arabs
are bold enough to say 'no'! The females
specially fall in this group.
to their habits of diet, or other factors, the
incidence of constipation and piles is much more
common in Arab countries. The problem is
complicated by severe shyness (Hayaa)
on the part of the Arab to talk anything about
the perineum. When you do find two or three
friends sitting together, the talk of the
'perineum' tickles (Dilkhush)
them more than the 'sex talk'. I must hurry to
add that an average 'perineum conscious' mind
does not include testicles (Kaulas).
hates the idea of getting operated for piles. He
therefore, 'hides' the symptoms of piles. He
argues with his doctor, saying 'Please leave the
piles alone and treat me for the rest of my
symptoms'. Strikingly, an Arab's attitude is in
sharp contrast. He has been taught (by whom??)
that piles are responsible for many an "ill
do not forget to look at the perineum of an Arab.
if the patient complains of the following :
the history-taking, he uses the word 'imkin'
which means 'may be' he is suffering from
- He has
symptoms of 'fissure in ano' or 'fistula
in ano' (nasoor)
which he includes with piles.
complains of 'perineal itching' (hakka)
which may be dueto poor hygiene or skin
problems related to excessive sweating.
- Sex weakness
- Low backache
- Pain in the
history of presence of blood in the
stools at present or in the past
(although this may have been only once,
often due to a hard stool!).
in the stool (often due to irritable
especially associated with straining (Zahara)
while passing stools.
discomfort in the perineum.
in the rectum (proctalgia fugax,
tags (external piles) or warts in the
other symptom (e.g. loss of appetite) for
which there is no apparent cause.
does an Arab attribute any "perineum
symptoms" to piles, but he is
also afraid of "piles".
I have seen on more than a hundred occasions,
when a patient religiously follows a long
prescription of a physician and does not respond
to treatment, but becomes asymptomatic as soon as
surgery for piles is done. The happiness has to
be seen on their faces (after the operation) to
be believed! Sex weakness, low backache, aching
legs, etc. are the bug'bear of all the physicians
in private practice. If all these can be relieved
by an operation for piles, is it worthwhile!
difficulty arises in selecting the patient. Not
all Arabs think that piles are bad for health.
Here comes the value of taking history in detail.
You can spot out (from the facial expression)
whether that patient has 'perineum' or 'rectum'
psychosis. The other factors which will influence
your decision would be
of shaving the pubic hair
of smile and satisfaction seen on the
patient's face while the perineum is
amount of relaxation of the anal
sphincter while doing the rectal
to undergo invasive testing by a
a small piece of advice to my surgeon
"toilet" is very important
to an Arab. So much so, if there is
any faecal discharge outside the
anus, an Arab is disqualified from
offering prayers to "Allah".
This is equivalent to menstruation or
presence of few drops of urine at the
glans penis after passing urine.
(some Arabs keep a tissue paper in
the perineum or at the tip of the
glans penis, held in place by the
rubber-band ligation is disliked by
many because post-operative bleeding
occurs from the sloughing and is a
cause of anxiety. And there is
nothing that the surgeon can show
(excised piles) to the patient!!
Incidentally, if the Arab patient is
shown excised piles, he is very happy
is not very well received by an Arab.
It causes profuse discharge
post-operatively, lasting some times
as long as 2-4 weeks. An Arab does
not complain of post-operative pain
but he views the discharge with
suspicion and concludes that the
operation has not been successful!
dilatation or Lord's procedure is not
liked by many an Arab because the
skin tags of piles are still left
best operation therefore is
haemorrhoidectomy or excision of
piles (and dilatation, if there is
associated fissure) with no skin tags
left behindin short, an
operation of "Anal toilet".
though very rare, a pre-operative
check-up to exclude,
colonic-Bilharziasis, or a portal
hypertension due to hepatic
bilharziasis, is essential especially
fact, all fistulous tracts should be
sent for histopathological check-up
to exclude conditions like Kochs or
post-operative prescription of anti-amoebic drugs
is really not indicated. Most of the surgeons
prescribe such drugs to these patients .