External Hemorrhoid Thrombectomy
If a painful blood clot (thrombosis) has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision and drainage,...
Minimally Invasive Procedures
For persistent bleeding or painful hemorrhoids, your doctor may recommend one of the other minimally invasive procedures available. These treatment...
What to Expect from Your Doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time o...
What You Can Do in The Meantime
In the time before your appointment, take steps to soften your stools. Eat more high-fiber foods, such as fruits, vegetables and whole grains, and...
How long does it take for a hemorrhoids to clear up?
Some hemorrhoids do not require treatment and will clear up on their own within a few days. During this time, a person should rest and avoid doing anything that strains or puts pressure on the area.
What to do if you have a hemorrhoids?
The doctor may recommend alternative treatments or run tests to rule out underlying causes. People who experience severe hemorrhoids may need more intensive treatment, including medical procedures.
Why do women get hemorrhoids?
The extra weight that a woman carries during pregnancy may cause hemorrhoids. Hemorrhoids are a common problem during pregnancy. The extra weight that a woman carries during pregnancy may place a strain on the veins in the anus and rectum. As the uterus grows, it also puts pressure on the veins near the rectum.
Why is it so hard for hemorrhoids to heal?
aging muscles. sitting on the toilet for too long. straining while having a bowel movement. having anal intercourse. overusing or abusing enemas or laxatives. Some of the above factors can also make it difficult for hemorrhoids to heal, allowing the problem to persist for longer.
What is the procedure to shrink a hemorrhoid?
Sclerotherapy, during which a doctor injects a chemical medication into the hemorrhoid to shrink it. Doctors may also use heat, light, or freezing temperatures to achieve this. Surgical removal, which doctors only recommend in cases where hemorrhoids do not respond to at-home or in-office methods.
How to get rid of anus pain?
Taking regular showers. Gently washing the anus in the shower after each bowel movement or using moist toilet wipes or water from a bidet. Taking a warm sitz bath to relieve symptoms. Sitting on an ice pack to reduce pain or discomfort.
What are the symptoms of hemorrhoids?
The symptoms of hemorrhoids may vary from person to person, but often include: a lump external to the anus. pain or discomfort. itching, even after wiping the area clean.
How to treat hemorrhoids at home?
You can most often treat your hemorrhoids at home by. eating foods that are high in fiber. taking a stool softener or a fiber supplement such as psyllium. NIH external link. (Metamucil) or methylcellulose (Citrucel) drinking water or other nonalcoholic liquids each day as recommended by your health care professional.
How long does it take for a prolapsed hemorrhoid to go away?
Most often, doctors recommend using over-the-counter products for 1 week. You should follow up with your doctor if the products. do not relieve your symptoms after 1 week. cause side effects such dry skin around your anus or a rash. Most prolapsed internal hemorrhoids go away without at-home treatment.
What is the procedure to remove internal hemorrhoids?
Hemorrhoid stapling. A doctor, most often a surgeon, may use a special stapling tool to remove internal hemorrhoid tissue and pull a prolapsing internal hemorrhoid back into the anus. Your doctor will give you anesthesia for this treatment. Sometimes complications of hemorrhoids also require treatment.
What is the procedure used to treat bleeding or prolapsing internal hemorrhoids?
Office treatments include the following: Rubber band ligation. Rubber band ligation is a procedure that doctors use to treat bleeding or prolapsing internal hemorrhoids. A doctor places a special rubber band around the base of the hemorrhoid. The band cuts off the blood supply.
How to treat a swollen rectum?
sitting in a tub of warm water, called a sitz bath, several times a day to help relieve pain. Applying over-the-counter hemorrhoid creams or ointments or using suppositories—a medicine you insert into your rectum —may relieve mild pain, swelling, and itching of external hemorrhoids.
How does infrared light affect hemorrhoids?
The scar tissue cuts off the blood supply, often shrinking the hemorrhoid. Infrared photocoagulation. A doctor uses a tool that directs infrared light at an internal hemorrhoid. Heat created by the infrared light causes scar tissue to form , which cuts off the blood supply, often shrinking the hemorrhoid.
How to prevent hemorrhoids?
You can help prevent hemorrhoids by. eating foods that are high in fiber. drinking water or other nonalcoholic liquids each day as recommended by your health care professional. not straining during bowel movements. not sitting on the toilet for long periods of time. avoiding regular heavy lifting.
What is the best way to treat a recurring hemorrhoids?
The surgery can be done with local anesthesia combined with sedation, spinal anesthesia or general anesthesia. Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids.
How to treat hemorrhoids?
You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort. With these treatments, hemorrhoid symptoms often go away within a week.
How to remove a hemorrhoid with a rubber band?
To remove a hemorrhoid using rubber band ligation, your doctor inserts a small tool called a ligator through a lighted tube (scope) in the anal canal and grasps the hemorrhoid with forceps. Sliding the ligator's cylinder upward releases rubber bands around the base of the hemorrhoid.
How to treat hemorrhoids in the anal area?
Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent. Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water for 10 to 15 minutes two to three times a day.
How long does it take for a hemorrhoid band to fall off?
The hemorrhoid withers and falls off within a week. Hemorrhoid banding can be uncomfortable and cause bleeding, which might begin two to four days after the procedure but is rarely severe.
What is the procedure called when you have to remove a hemorrhoids?
This procedure, called stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. It is typically used only for internal hemorrhoids. Stapling generally involves less pain than hemorrhoidectomy and allows for earlier return to regular activities.
What to do if you have a hemroid?
Medications. If your hemorrhoids produce only mild discomfort, your doctor might suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients such as witch hazel, or hydrocortisone and lidocaine, which can temporarily relieve pain and itching.
How long does it take for a hemorrhoid to heal?
Most mild hemorrhoids resolve on their own within a few days. Sometimes, they may take up to a week. Larger hemorrhoids might last longer, and since they’re more prone to complications, sometimes they’ll not resolve on their own and you’ll need to visit a doctor.
How often do hemorrhoids recur?
With non-surgical treatment techniques (usually used for mild, grade 1), hemorrhoids can return at a rate of 10-50% in a 5-year period.
How long do thrombosed hemorrhoids last?
Thrombosed hemorrhoids last for around 7-9 days but can be prolonged up to a few weeks. A thrombosed hemorrhoid is one that has developed a clot inside it. External hemorrhoids (or those that stick out of the anal canal) are more likely to get thrombosed, which can potentially lengthen their duration.
Why do veins weaken when you cough?
The brief increase in intra-abdominal pressure associated with coughing or sneezing can cause vein walls to weaken, allowing hemorrhoids to develop. Heavy physical labor. Much like straining with bowel movements, straining to lift or push heavy objects can result in hemorrhoids as well. Genetics.
What is it called when your veins are swollen?
What Hemorrhoids Are. Hemorrhoids are a condition affecting the veins that move deoxygenated blood away from the tissues of the anus and rectum. If excessive pressure is applied to these veins, they become swollen. This creates the condition we call hemorrhoids .
Why do hemorrhoids happen?
Why Hemorrhoids Happen. Normally, the veins of the lower gastrointestinal tract are not dilated, as they are with hemorrhoids. However, when there is force or pressure applied to the outer walls of these veins, they will swell and expand, causing the vein to bulge outwards and cause hemorrhoids to occur.
What are the risk factors for hemorrhoids?
These include obesity, inflammatory bowel disease, prolonged sitting on the toilet, liver disease, a family history of hemorrhoids, spinal cord injury, and long-term diarrhea. Some of these can be treated to reduce the risk of future hemorrhoid development.
What is the most common nonsurgical treatment for hemorrhoids?
Rubber band ligation is the most common nonsurgical treatment, and it involves your doctor tying a tight band around the base of the hemorrhoid to cut off the blood supply. Eighty percent of people who receive treatment for hemorrhoids have this type of treatment.
How to treat a hemmorhoids flare up?
Follow these tips: Eat the recommended amount of high-fiber foods and drink plenty of fluids to keep your stools soft and prevent straining during bowel movements. You can also speak with your doctor about taking a stool softener.
What is the best way to soften a stool?
Ask your doctor about taking a stool softener or a fiber supplement, such as psyllium (Metamucil) or methylcellulose (Citrucel). A tablespoon of mineral oil added to food can also help soften stools. Keep the anal area clean.
How to stop bowel movement?
You should also drink plenty of water to help relieve constipation and reduce straining during bowel movements. Here are some additional things that may help relieve symptoms: Minimize the time you sit on the toilet. When you feel the urge to move your bowels, go as soon as possible.
How to get rid of anal swollen hemroids?
Use a sitz bath or sit in a warm tub for a few minutes to bathe the anal area. You may also try using over-the-counter (OTC) topical medications to ease discomfort, such as phenylephrine hemorrhoidal gel (Preparation H). These products are used if the hemorrhoids are bulging and inflamed.
How many people had hemorrhoids in 2004?
in 2004 compared the rate of recurrence of hemorrhoids in 231 people. Some of the study participants received treatment at home, and others had surgery to remove their hemorrhoids. Hemorrhoids recurred in 6.3 percent of the people who had surgery and in 25.4 percent of the people who received at-home treatment.
How common are hemorrhoids?
Hemorrhoids are very common. Seventy-five percent of people will have hemorrhoids at some point. Hemorrhoids are more common in people between the ages of 45 and 65. Explore the interactive 3-D diagram below to learn more about external and internal hemorrhoids.
How long does it take for a hemorrhoids to clear up?
One in 20 Americans have hemorrhoids, and nearly half of adults over 50 have them. At-home care and treatments can usually clear up hemorrhoids in about a week. After that time, you can talk to your doctor about other options.
What to do if you still have hemorrhoids?
Surgery. If you still have hemorrhoid pain after a week or are bleeding during or after bowel movements, your doctor might have to perform surgery to remove the hemorrhoids. They elect to perform surgery based on the following criteria: Other anorectal issues that require surgery. Internal hemorrhoids are strangulated.
How long does it take for a thrombosed hemorrhoid to go away?
The pain of thrombosed hemorrhoids may improve within 7-10 days without surgery and may disappear within two to three weeks.
What is the best treatment for internal hemorrhoids?
Doctors choose the procedure after talking to you and determining what you can tolerate and the best treatment. A closed hemorrhoidectomy is the most common treatment for internal hemorrhoids. The doctor removes the hemorrhoids with a scalpel, laser, or electrocauterization and then sutures the wound.
What is a pile of veins called?
Hemorrhoids are enlarged, swollen veins in the lowest part of the rectum and anus. These veins bulge and get irritated, especially when the patient defecates, and cause bleeding. Hemorrhoids are also commonly called piles. It is one of the most common causes of rectal bleeding.
What is a hemorrhoidectomy?
A hemorrhoidectomy is a procedure for the surgical removal (excision) of hemorrhoids. Stapled hemorrhoidopexy involves stapling the last section of the large bowel, which reduces the supply of blood to the hemorrhoids and causes them to gradually shrink.
How do you know if you have hemorrhoids?
If you have hemorrhoids, you might feel some of the following symptoms: Itching. Burning. Pain when sitting. Lumps on your anus. Bleeding. Hemorrhoid prolapse. If you’ve ever had hemorrhoids, you know that they can be very painful and irritating. If you haven’t, do your best to prevent them from happening.
How long does it take for a hemorrhoid to heal?
Most mild cases will clear up in around three to four days without treatment but larger ones can take a few weeks. Prolapsed hemorrhoids are troubling since they can persist for months at a time and may not go away without surgical intervention.
What is the procedure to remove hemorrhoids?
A hemorrhoidectomy is the surgical removal of the affected tissue and can be done under a local or full anesthetic depending on technique and preference. Another surgical option is stapling, which is similar to a band ligation but involves medical staples on an internal hemorrhoid.
How to make bowel movements go easier?
Increase your fiber and water intake in order to make bowel movements go more easily. Take a sitz bath to help soothe the anal area and reduce swelling. More information on sitz baths for hemorrhoids can be found here. In cases of external hemorrhoids, an ice pack or a cold compress can help reduce swelling.
How do you know if you have hemorrhoids?
Hemorrhoids have a few specific symptoms that can make it easier for your doctor to make a formal diagnosis: Bleeding bright red blood during a bowel movement. You likely won’t notice this is happening until you see red in the bowl or on toilet paper. Itching, irritation, discomfort, or pain from the anal area.
Why do hemorrhoids stick around longer?
People who suffer from chronic constipation will find that their hemorrhoids stick around longer due to constant straining.
How to clean anus after bowel movement?
After a bowel movement, blot the anus with toilet paper that has been moistened with water or cleansing agents. Alternatively, you can use a bidet to clean and then pat dry the area. Avoid pre-moistened toilet wipes unless they are alcohol and perfume-free. These can dry out the area and aggravate your symptoms.
What causes a hemorrhoid?
Causes Of Hemorrhoids. A hemorrhoid can be caused by anything that results in increased pressure in the anal canal. This includes: Chronic diarrhea or constipation (from straining) Obesity. Pregnancy. Anal intercourse . Prolonged sitting . Straining during bowel movements.
How long does it take for a small hemorrhoids to clear up?
Even without treatment, the symptoms of small hemorrhoids might clear up in just a few days. Chronic hemorrhoids, however, can last weeks with regular symptom flare-ups. Keep reading to learn how to treat hemorrhoids that won’t go away and when to see a doctor.
How to treat hemorrhoids?
Following diagnosis, your doctor might recommend treating chronic hemorrhoids with lifestyle changes, including: incorporating more high-fiber foods in your diet. increasing your daily consumption of water and other nonalcoholic beverages. limiting your time sitting on the toilet.
What is the procedure to remove a prolapsed hemorrhoid?
This procedure is also called hemorrho id stapling. Hemorrhoidectomy. A surgeon surgically removes prolapsed hemorrhoids or large external hemorrhoids.
What is a strangulated hemorrhoid?
A strangulated hemorrhoid is a prolapsed hemorrhoid with the blood supply cut off by the muscles around your anus. A thrombosed hemorrhoid is a clot (thrombus) that forms after blood pools in an external hemorrhoid. If you have hemorrhoids, you’re not alone.
Why do hemorrhoids bleed?
Like internal hemorrhoids, external hemorrhoids can bleed, but because there are more nerves in the area, they tend to create discomfort. Conditions commonly associated with chronic hemorrhoids include the following: A prolapsed hemorrhoid is an internal hemorrhoid that gets bigger and bulges outside the anal sphincter.
What is the procedure called when you have a hemorrhoids?
In-office procedures. Your doctor may suggest: Rubber band ligation. Also called hemorrhoid banding, this procedure is used for prolapsing or bleeding hemorrhoids. Your doctor places a special rubber band around the base of the hemorrhoid to cut off its blood supply.
What is the best way to shrink a hemorrhoid?
Electrocoagulation. Your doctor uses a special tool to deliver an electric current that shrinks a hemorrhoid by cutting off its blood supply. It’s commonly used for internal hemorrhoids. Infrared photocoagulation. Your doctor uses a tool that delivers infrared light to shrink a hemorrhoid by cutting off its blood supply.
Overview
- Also known as piles, hemorrhoids are swollen or inflamed veins, usually in the anus or lower rectum. They normally develop as a result of exerting too much pressure during bowel movements. The increase in pressure on these delicate veins explains why some women develop them during their pregnancy. You may develop external or internal hemorrhoids. They cause dis…
- A hemorrhoidal skin tag is a soft, fleshless mass or skin flap that forms as a result of existing hemorrhoid. The shape of skin tags in and around the anus. People do not even know they have hemorrhoidal skin tags unless they feel them while wiping up after a bowel movement.
- A sitz bath (a bathing style where only the buttocks and hips are immersed in water) is one of the best way to use Epsom salt in treating hemorrhoids and other related genital or anal problems. This is done by mixing a given proportion of this salt with a certain amount of water, after mixing the water with your own hands, you will need to sit in the basin or bathtub containing the solutio…
Treatment
- Dramatic relief for most hemorrhoid symptoms can be found with simple, home remedies for hemorrhoids. To avoid occasional flare-ups, try the following. Take time. When you feel the urge to defecate, go to the bathroom immediately; don't wait until a more convenient time. Stool can back up, leading to increased pressure and straining. Also, schedule a set time each day, such a…
- Doctors arent sure what exactly causes the veins to swell, but they think that straining to pass stool, constipation, diet, pregnancy, and aging can all be reasons for hemorrhoids developing. Hemorrhoids can last from a few days to many weeks. Usually, you can relieve the painful and itchy symptoms of hemorrhoids by making dietary changes and using home treatments to reliev…
- Treatment of external hemorrhoids usually addresses the hygiene issue, where excess skin tags makes it difficult to properly clean the anus area after a bowel movement. If this becomes a significant issue, surgery can be considered to remove the hemorrhoid. Laser therapy: Laser therapy can be used to scar and harden internal hemorrhoids. Stapled hemorrhoidectomy: Stapl…
- The treatment of choice for hemorrhoids usually depends on its severity. It is possible to treat hemorrhoids solely with lifestyle changes in milder cases. In fact most hemorrhoids resolve on its own without any treatment. However, the recurrence rate is usually higher without medical treatment. Severe hemorrhoids may require surgery. If left untreated the repeated bleeding can c…
Cause
- The lower part of the rectum and anus contains blood vessels, and too much pressure on these can cause them to bulge and become swollen to form hemorrhoids. According to Dr. Benjamin Wedro on eMedicineHealth.com, increased pressure in the anus resulting in piles can be caused by excessive straining during a bowel movement, pregnancy, obesity, or sitting for too long. The…
- There are a number of causes of hemorrhoids most of which involves an increase in pressure within the rectum and anus. The raised pressure may affect the veins in different ways, like slowing down the blood flow within the veins. This can cause the vein to become engorged and compromise the supportive tissue that holds it in place. It is also more likely to occur in older pe…
- The foregoing notwithstanding, there are different factors which can contribute to the healing. These include the following:-
Signs And Symptoms
- There are two kinds of hemorrhoids: internal hemorrhoids, which occur in the lower rectum, and external hemorrhoids, which develop under the skin around the anus. External hemorrhoids are the most uncomfortable, because the overlying skin becomes irritated and erodes. If a blood clot forms inside an external hemorrhoid, the pain can be sudden and severe. You might feel or see …
- Internal hemorrhoids occur further inside the rectum. Because there are few pain sensory nerve cells, internal hemorrhoids dont usually cause any pain. The only symptom may be rectal bleeding. However, if the hemorrhoid breaks through the anus (prolapse), this could result in pain and discomfort. Most of the symptoms of hemorrhoids are noticed when you have external hem…
- Once these blood vessels become inflamed, swollen, prolapsed (protruding) or thrombosed (obstructed with a clot) then we experience symptoms that we refer to as hemorrhoids or piles. In fact the terms is often incorrectly used to describe any anal discomfort when it may not always be due to hemorrhoids. These symptoms include anal itching, burning anus, pain in the anus or rect…
Diagnosis
- Hemorrhoids can usually be diagnosed from a simple medical history and physical exam. External hemorrhoids are generally apparent, especially if a blood clot has formed. Your clinician may perform a digital rectal exam to check for blood in the stool. She or he may also examine the anal canal with an anoscope, a short plastic tube inserted into the rectum with illumination. If there's …
- Although hemorrhoids arent dangerous and usually go away in a few weeks, it is always advisable to see a doctor if you have any kind of bleeding from the anus. The doctor will perform a full examination to rule out the possibility of a more serious condition. Rectal bleeding is also a symptom of some types of cancers. Also, if its difficult to get rid of hemorrhoids completely usi…
- If there is concern that significant bleeding has occurred, a complete blood count (CBC) to measure blood hemoglobin and hematocrit levels, and platelet count is obtained. If the patient is on warfarin (Coumadin), a prothrombin time (PT) or INR may be done to measure the blood clotting levels.
- Physical examination should include an abdominal examination, inspection of the perineum, digital rectal examination, and anoscopy. Digital rectal examination alone can neither diagnose nor exclude internal hemorrhoids; anoscopy is required. On anoscopy, internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, gl…
Prognosis
- Depending on where you have hemorrhoids and the severity of them, they could last for one or two days or up to a few months.
- A thrombosed external hemorrhoid may resolve on its own; however, this condition often needs medical care. Bleeding with a bowel movement is never normal and should prompt a visit to a health-care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons for bleeding including inflammatory bowel diseas…
- There is no single direct answer to this question. In some people, the symptoms will begin easing after some few weeks while in others the symptoms remain the same and in others they keep getting worse. If not treated, the condition may worsen to the extent of requiring surgical treatment. Because there is always some degree of pressure exerted on the veins during norma…
- The decision to remove hemorrhoidal skin tags through surgery should not be taken lightly. Any operation in the anus area tends to cause postoperative pain during the recovery process, which often includes other restricted activities. Full recovery time may take weeks. Finally, while people often confuse them with cancerous tumors, Acrochordons are benign and present no serious he…
Prevention
- Exercise. Moderate aerobic exercise, such as brisk walking 2030 minutes a day, can help stimulate bowel function.
- Anybody who has had hemorrhoid before will tell you that an ounce of prevention is worth a pound of cure. This literally means that it is easier to stop something from happening in the first place than to repair the damage after it has happened. What then do you need to do to prevent hemorrhoids from happening? Preventing hemorrhoids involves keeping you stool soft, this way…
- One can maintain regular bowel movement and lessen the risk of hemorrhoids by including more fiber in his or her diet, about 30 grams per day, Husain said. Laxatives, aside from bulk-forming laxatives like Fiberall and Metamucil, can lead to diarrhea, and should be avoided because they can worsen hemorrhoids. Also, one should avoid exerting too much pressure during bowel move…
- The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips: 1. Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids. Add fiber to your diet slowly to avoi…
Management
- Some hemorrhoids can't be managed with conservative treatments alone, either because symptoms persist or because an internal hemorrhoid has prolapsed. Fortunately, a number of minimally invasive hemorrhoid treatments are available that are less painful than traditional hemorrhoid removal (hemorrhoidectomy) and allow a quicker recovery. These procedures are g…
- Medical management is appropriate for grade 1 hemorrhoids. All patients with hemorrhoids should maintain soft bulky stools that can be passed without straining. This is also important after surgery because straining and passage of hard stools increase pain and bleeding, and delay healing. Adequate intake of fluid and fiber helps soften the stool. A metaanalysis of seven rando…
Preparation
- Myrtle oil can be mixed with an ounce of cold cream and applied to the hemorrhoid. You must dilute it before application application of undiluted essential oils often cause allergic reactions and skin irritation.
- Instead of bathing in an Epsom solution, some people have reported quick relief of the symptoms by directly applying a paste of the Epsom salt. The paste is achieved by mixing a considerable amount of Epsom salt say two tablespoons in a cup of clean warm water.
- Clean your anus gently using a moistened toilet paper after every bowel movement. You can use water or cleansing liquid like Balneol to moisten the toilet paper or you can also use pre-moistened towels or baby wipes. Avoid rubbing the area or using perfumed soap because this will cause more irritation. Instead of wiping, you can opt to wash with a bidet or wash in the shower. …
Diet
- Get more fiber. Add more fiber to your diet from food, a fiber supplement (such as Metamucil, Citrucel, or Fiber Con), or both. Along with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids. High-fiber foods include broccoli, beans, wheat and oat bran, whole-grain foods, and fresh fruit. Fiber supplements help decrease hemorrhoidal …
- Eat fiber-rich foods. Vegetables are great sources of fiber. Ideally you'll want to eat those recommended for your individual nutritional type. Consuming a wide variety of vegetable fiber will provide the bulk needed for your stool to pass comfortably through your intestines. If you need extra fiber, I suggest whole organic flaxseeds. Grind them in a coffee grinder and add one or tw…