Management of Grade 3 Hemorrhoids After Previous Hemorrhoidectomy and Fistulotomy
Direct Answer
Pelvic floor therapy alone is insufficient for grade 3 hemorrhoids with your surgical history—you need evaluation by a colorectal surgeon for definitive treatment, as grade 3 hemorrhoids typically require procedural intervention (rubber band ligation) or repeat surgical hemorrhoidectomy when conservative measures fail. 1
Understanding Your Current Situation
Your grade 3 hemorrhoids represent internal hemorrhoids that prolapse through the anus during bowel movements but require manual reduction. 1 Given your history of previous hemorrhoidectomy and fistulotomy, this likely represents either:
- Recurrent hemorrhoidal disease (2-10% recurrence rate after conventional hemorrhoidectomy) 1
- Residual hemorrhoidal tissue not addressed in the initial surgery 1
- New hemorrhoid formation from ongoing risk factors 1
Critical point: Pelvic floor dysfunction may contribute to straining and worsen hemorrhoids, but it does not treat the hemorrhoidal disease itself. 1
Why Pelvic Floor Therapy Alone Is Not Enough
While pelvic floor physiotherapy has a role in hemorrhoid management, it serves as an adjunctive measure, not primary treatment for grade 3 disease:
- Pelvic floor exercises may help with associated urinary or fecal leakage and reduce straining 2
- Cognitive behavioral therapy and Kegel exercises can decrease anxiety and lower urinary tract symptoms 2
- However, no evidence supports pelvic floor therapy as definitive treatment for grade 3 hemorrhoids 1
The American Gastroenterological Association clearly states that grade 3 hemorrhoids require either office-based procedures (rubber band ligation) or surgical intervention when conservative management fails. 1
Who You Should Contact and Treatment Algorithm
1. Colorectal Surgeon (Priority Referral)
This is your essential next step. A colorectal surgeon should evaluate you for:
- Rubber band ligation (first-line procedural treatment for grade 3 hemorrhoids, 70.5-89% success rate) 1
- Repeat hemorrhoidectomy if rubber band ligation fails or is not feasible given your surgical history 1
- Assessment for complications from previous surgeries (anal stenosis, sphincter defects occur in up to 12% after hemorrhoidectomy) 1, 3
Why this matters with your history: Previous anorectal surgery increases complexity—the surgeon needs to evaluate for:
- Scar tissue that may complicate banding 1
- Sphincter integrity (previous fistulotomy may have affected sphincter function) 3
- Whether mixed internal/external components exist requiring surgical rather than office-based treatment 1
2. Gastroenterologist (If Not Already Involved)
Essential for ruling out other causes of bleeding:
- Hemorrhoids alone do not cause positive fecal occult blood tests 1
- Colonoscopy is mandatory if you have rectal bleeding with risk factors for colorectal cancer or if bleeding pattern is atypical 1
- This is especially important given your surgical history—never attribute all symptoms to hemorrhoids without proper evaluation 1
3. Continue Pelvic Floor Therapy (As Adjunct Only)
Your pelvic floor provider should coordinate with your colorectal surgeon, focusing on:
- Reducing straining during defecation (the most important modifiable risk factor) 1
- Managing any associated pelvic floor dysfunction 2
- Postoperative rehabilitation if you undergo procedures 2
Comprehensive Treatment Plan You Need
Conservative Measures (Foundation, Not Cure)
These should already be in place but won't resolve grade 3 hemorrhoids:
- Dietary fiber: 25-30 grams daily (psyllium husk 5-6 teaspoonfuls with 600 mL water daily) 1
- Adequate hydration to soften stool 1
- Avoid straining during bowel movements 1
- Sitz baths for symptom relief 1
Topical Treatments (Symptomatic Relief Only)
- Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks (92% resolution rate for thrombosed hemorrhoids, may help with pain) 1
- Short-term corticosteroids (≤7 days maximum) for inflammation—never longer due to tissue thinning risk 1
- Flavonoids may relieve symptoms but have 80% recurrence within 3-6 months after cessation 1
Important: Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or prolapse. 1
Definitive Treatment Options Your Surgeon Will Discuss
Option 1: Rubber Band Ligation (Preferred Initial Procedure)
- Success rate: 70.5-89% for grade 3 hemorrhoids 1
- Advantages: Office-based, no anesthesia required, lower pain and complication rates than surgery 1
- Technique: Band placed ≥2 cm above dentate line to avoid severe pain 1
- Limitations: Higher recurrence rate than hemorrhoidectomy; may not be suitable if extensive external component exists 1
Your surgical history consideration: Previous hemorrhoidectomy may have altered anatomy—surgeon must assess if adequate tissue exists for banding. 1
Option 2: Repeat Hemorrhoidectomy (If Banding Fails or Not Feasible)
- Indications: Failure of office-based procedures, mixed internal/external hemorrhoids, patient preference after discussion 1
- Success rate: 90-98% with 2-10% recurrence rate 1, 3
- Techniques available:
Recovery expectations: Narcotic analgesics typically required, 2-4 weeks before returning to work 1, 3
Complications to discuss: Urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), incontinence (2-12%) 1
Critical Pitfalls to Avoid
Never assume all symptoms are from hemorrhoids—anal fissures, abscesses, or fistulas may coexist (fissures occur in up to 20% of hemorrhoid patients) 1
Do not delay evaluation if you have:
Avoid prolonged conservative management for grade 3 hemorrhoids—these typically require procedural intervention 1
Never use corticosteroid creams >7 days—causes perianal tissue thinning and injury risk 1
Beware of recurrent disease in same location—may indicate inadequate initial surgery or ongoing risk factors not addressed 1
Special Considerations Given Your Surgical History
Your previous hemorrhoidectomy and fistulotomy create unique considerations:
- Sphincter function assessment is critical—fistulotomy may have compromised sphincter integrity, increasing incontinence risk with repeat surgery 1, 3
- Scar tissue evaluation—may limit options for rubber band ligation 1
- Anal stenosis screening—occurs in 0-6% after hemorrhoidectomy and would complicate further procedures 1
- Document baseline continence—essential before any intervention given surgical history 3
Your colorectal surgeon should perform:
- Digital rectal examination assessing sphincter tone and scar tissue 1
- Anoscopy to visualize hemorrhoids and rule out other pathology 1
- Possibly anorectal manometry if continence concerns exist 3
Bottom Line Action Plan
- Schedule consultation with colorectal surgeon immediately (this is non-negotiable for grade 3 hemorrhoids) 1
- Continue pelvic floor therapy as adjunctive treatment focusing on reducing straining 2
- Implement all conservative measures (fiber, hydration, avoid straining) while awaiting surgical evaluation 1
- Consider gastroenterology referral if you haven't had recent colonoscopy, especially if bleeding present 1
- Discuss with surgeon: Your preference between office-based ligation (less invasive, higher recurrence) versus repeat hemorrhoidectomy (more definitive, longer recovery) 1, 3
The evidence is clear: grade 3 hemorrhoids require procedural or surgical intervention when conservative measures fail—pelvic floor therapy alone, while beneficial as an adjunct, will not resolve your hemorrhoidal disease. 1