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.

An Arab 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.

Every Arab patient looks forward to be asked—a million dollar question.... "Did you ever have or do you have any symptoms of piles?" ("Bavasur" or "Bavasir"). 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.

Whether due 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).

An Indian 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 health"

Therefore do not forget to look at the perineum of an Arab. if the patient complains of the following :

1. During the history-taking, he uses the word 'imkin' or 'umkin' which means 'may be' he is suffering from piles.
2. He has symptoms of 'fissure in ano' or 'fistula in ano' (nasoor) which he includes with piles.
3. He complains of 'perineal itching' (hakka) which may be dueto poor hygiene or skin problems related to excessive sweating.
4. He complains of
   1. Sex weakness
   2. Low backache
   3. Pain in the legs.
5. A 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!).
6. Mucous in the stool (often due to irritable colon).
7. Constipation, especially associated with straining (Zahara) while passing stools.
8. Any discomfort in the perineum.
9. Pain in the rectum (proctalgia fugax, discussed elsewhere).
10. Skin tags (external piles) or warts in the perineum.
11. Any other symptom (e.g. loss of appetite) for which there is no apparent cause.

Not only 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!

The 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—

1. Pattern of shaving the pubic hair
2. Degree of smile and satisfaction seen on the patient's face while the perineum is being examined
3. The amount of relaxation of the anal sphincter while doing the rectal examination
4. Willingness to undergo invasive testing by a proctoscope ("mandaar" or"nidur").
5. Finally, a small piece of advice to my surgeon colleagues.

1. Anal "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 underwear).
2. Baron's 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 and satisfied.
3. Cryohaemorrhoidectomy 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!
4. Anal dilatation or Lord's procedure is not liked by many an Arab because the skin tags of piles are still left behind.
5. The best operation therefore is haemorrhoidectomy or excision of piles (and dilatation, if there is associated fissure) with no skin tags left behind—in short, an operation of "Anal toilet".
6. Finally, though very rare, a pre-operative check-up to exclude, colonic-Bilharziasis, or a portal hypertension due to hepatic bilharziasis, is essential especially in Yemenis.
7. in fact, all fistulous tracts should be sent for histopathological check-up to exclude conditions like Kochs or Bilharziasis.

Pre- or post-operative prescription of anti-amoebic drugs is really not indicated. Most of the surgeons prescribe such drugs to these patients .