Post-Hemorrhoidectomy Sexual Dysfunction and Urinary Urgency at 1 Year
Most Likely Diagnosis
This patient is experiencing recognized long-term complications of hemorrhoidectomy, specifically internal anal sphincter dysfunction and possible pudendal nerve injury, which are causing reduced sexual function and altered urinary urgency sensation. These complications occur in 2-12% of patients after hemorrhoidectomy and are particularly associated with electrosurgical techniques like LigaSure 1, 2.
Understanding the Pathophysiology
Sexual Dysfunction Mechanism
Pudendal nerve injury during hemorrhoidectomy causes sexual dysfunction in 10-35% of patients after pelvic/anorectal surgery 3. The pudendal nerve provides sensory innervation to the genitals and motor control to pelvic floor muscles, and can be damaged during hemorrhoidal excision, particularly with deeper dissection or thermal injury from electrosurgical devices 3.
LigaSure hemorrhoidectomy, while effective for bleeding control, generates thermal spread that can affect adjacent neurovascular structures 1, 2. The sexual dysfunction rate varies based on surgical technique and extent of tissue injury 3.
Urinary Urgency Without Incontinence
Altered rectal urge sensation and internal sphincter dysfunction are documented complications of LigaSure hemorrhoidectomy 4. One study found significantly reduced rectal urge sensation (173 mls vs 284 mls) and thinner internal sphincter (1.88 mm vs 2.5 mm) after conventional diathermy compared to LigaSure 4.
This altered sensation likely reflects changes in pelvic floor proprioception and sphincter function rather than true bladder pathology 4. The urgency sensation without actual incontinence suggests sensory nerve dysfunction rather than structural bladder or sphincter damage 5.
Diagnostic Workup
Essential Initial Evaluation
Perform urodynamic studies (multichannel filling cystometry) to determine if detrusor overactivity or other urodynamic abnormalities are present before considering invasive treatments 5. This is critical because the AUA/SUFU guidelines recommend urodynamic testing when invasive or irreversible treatments are being considered for urgency symptoms 5.
Assess post-void residual (PVR) to identify urinary retention or incomplete bladder emptying 5. Elevated PVR may indicate bladder outlet obstruction or detrusor underactivity 5.
Document a voiding diary for at least 3 days to objectively measure frequency, volume per void, and urgency episodes 6. Patient recall is unreliable; objective documentation is essential 6.
Specialized Testing
Consider anorectal manometry and endoanal ultrasound to assess sphincter anatomy and function 4. These tests can document internal sphincter thickness changes and functional deficits that explain the altered sensation 4.
Evaluate for anal stenosis, fissures, or residual hemorrhoidal tissue 1, 2. These occur in 3.6%, 1%, and 2% of patients respectively after LigaSure hemorrhoidectomy and can contribute to pelvic floor dysfunction 2.
Management Algorithm
Step 1: Conservative Management (First-Line for All Patients)
Urinary Urgency Management:
Initiate bladder training as first-line therapy for urgency symptoms 5. This is a strong recommendation with moderate-quality evidence from the American College of Physicians 5.
If bladder training fails after 6-8 weeks, add pharmacologic treatment with antimuscarinic agents or beta-3 agonists 5. Base the choice on tolerability, adverse effect profile, ease of use, and cost 5.
Avoid systemic pharmacologic therapy if stress incontinence component is present 5. The ACP strongly recommends against systemic drugs for stress urinary incontinence 5.
Sexual Dysfunction Management:
Refer for multidisciplinary management including psychological counseling, as sexual dysfunction after pelvic surgery requires psychological, pharmacological, and sometimes surgical therapy 3. This is essential because the dysfunction has both organic and psychological components 3.
Consider phosphodiesterase-5 inhibitors (sildenafil, tadalafil) for erectile dysfunction if male 3. These are standard first-line pharmacologic therapy for post-surgical sexual dysfunction 3.
Step 2: Specialist Referral Indications
Refer to urology if:
Urodynamic studies show detrusor overactivity or bladder outlet obstruction requiring invasive treatment 5. The AUA/SUFU guidelines recommend urodynamic testing before invasive or irreversible treatments 5.
Symptoms fail to improve with 3 months of conservative management 6. Persistent symptoms despite optimal medical therapy warrant specialist evaluation 6.
Elevated PVR (>150-200 mL) suggests significant retention 5. This may indicate bladder outlet obstruction requiring intervention 5.
Refer to colorectal surgery if:
Anal stenosis is suspected (difficulty with bowel movements, thin stools) 2. This occurs in 3.6% of LigaSure hemorrhoidectomy patients and may require anoplasty 2.
Anal fissure or fistula develops 2. These occur in 1% and 0.2% of patients respectively and require surgical management 2.
Recurrent hemorrhoidal symptoms develop 2. The recurrence rate is 4.8% after LigaSure hemorrhoidectomy 2.
Step 3: Advanced Interventions (Only After Conservative Failure)
For refractory urinary urgency:
- Consider percutaneous tibial nerve stimulation or sacral neuromodulation only after failure of behavioral and pharmacologic therapy 5. These are invasive options reserved for refractory cases 5.
For sexual dysfunction:
Consider vacuum erection devices, intracavernosal injections, or penile prosthesis for refractory erectile dysfunction 3. These represent escalating levels of invasive therapy 3.
Refer to sexual medicine specialist or pelvic floor physical therapist for comprehensive evaluation 3. Specialized expertise is often needed for optimal management 3.
Critical Pitfalls to Avoid
Do not assume urinary urgency is due to overactive bladder without urodynamic confirmation 5. The absence of detrusor overactivity on a single urodynamic study does not exclude it, but testing is essential before invasive treatment 5.
Do not attribute all symptoms to hemorrhoidectomy without ruling out other pathology 7. Perform anoscopy and consider colonoscopy if symptoms suggest inflammatory bowel disease or malignancy 7.
Do not overlook medication review 6. Many commonly prescribed drugs (anticholinergics, diuretics, alpha-blockers) can worsen urinary symptoms 6.
Do not delay referral for psychological support 3. Sexual dysfunction has significant psychological impact and requires early intervention 3.
Prognosis and Patient Counseling
Minor incontinence (flatus) occurs in 1.7% of LigaSure hemorrhoidectomy patients at long-term follow-up 1. This is generally stable and does not progress 1.
Sphincter defects documented by ultrasound and manometry occur in up to 12% of patients after hemorrhoidectomy 4. However, most are asymptomatic or cause only minor symptoms 4.
Sexual dysfunction after pelvic surgery improves in many patients with appropriate management, but complete resolution is not guaranteed 3. Setting realistic expectations is essential 3.
Urinary urgency symptoms often improve with bladder training and pharmacologic therapy in 50-70% of patients 5. However, symptoms may persist despite optimal management 5.