Is the distress after my hemorrhoidectomy (removal of hemorrhoid tissue) due to altered sensation at the surgical site or the lack of hemorrhoid tissue itself, considering my history of hemorrhoidectomy and fistulotomy (surgical procedure for fistula)?

Post-Hemorrhoidectomy Distress: Altered Sensation vs. Tissue Loss

The distress after hemorrhoidectomy is primarily caused by altered sensation at the surgical site—specifically pain from sphincter spasm, wound inflammation, and nerve irritation—rather than the absence of hemorrhoid tissue itself. 1

Understanding the Source of Distress

The hemorrhoid tissue itself does not contribute to normal sensation or function in a way that would cause distress when removed. Rather, the surgical site changes create the problem:

Primary Pain Mechanisms After Hemorrhoidectomy

• Sphincter hypertonicity and spasm is the dominant cause of post-hemorrhoidectomy pain, as the internal anal sphincter reflexively contracts in response to surgical trauma 1
• Wound inflammation and nerve irritation at the excision sites cause significant discomfort, particularly during the first 2-4 weeks when most patients cannot return to work 1, 2
• Reflex inhibition from anal pain creates a cycle where pain triggers more sphincter spasm, which generates more pain 2

Why It's Not About Missing Tissue

• Hemorrhoids are pathologically enlarged vascular cushions—their removal restores normal anatomy rather than creating a deficit 3
• The corpus cavernosum recti (normal vascular tissue) remains intact after proper hemorrhoidectomy and continues to contribute to fine continence 4
• Successful hemorrhoidectomy has 90-98% patient satisfaction with only 2-10% recurrence, indicating the tissue removal itself is therapeutic, not harmful 3

Evidence-Based Management of Post-Operative Distress

Immediate Red Flags to Rule Out

Before attributing distress to normal post-operative changes, exclude serious complications:

• Check vital signs immediately: fever >38.5°C, tachycardia >100 bpm, or hypotension suggests necrotizing pelvic sepsis requiring emergency surgical consultation 1
• Assess for urinary retention (occurs in 2-36% of patients): the triad of severe pain, high fever, and urinary retention indicates necrotizing pelvic sepsis 1, 2
• Evaluate for significant bleeding: hemodynamic instability, dizziness, or anemia symptoms require immediate CBC 1
• Rule out anal stenosis: inability to pass stool despite adequate softening suggests early stricture formation requiring urgent dilation 1

Multimodal Pain Management Protocol

Implement an "around-the-clock" regimen rather than as-needed dosing:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours achieves 92% resolution rate by relaxing internal anal sphincter hypertonicity, with no systemic side effects 1
• Oral metronidazole 400mg three times daily reduces postoperative pain through unclear mechanisms, possibly by reducing bacterial load and inflammation 1, 5
• Scheduled NSAIDs and opioids as needed, combined with the above topical therapy 1
• Flavonoids (diosmin-hesperidin 450mg/50mg twice daily) provide additional symptom relief and can be safely combined with other analgesics 1

Critical Stool Management

Preventing straining is the primary trigger for reducing postoperative pain:

• Psyllium husk 5-6 teaspoonfuls with 600mL water daily prevents straining which directly triggers pain at the surgical site 1
• Osmotic laxatives (polyethylene glycol or lactulose) if psyllium alone is insufficient, with the goal of achieving soft, bulky stools that pass without straining 1

Non-Pharmacological Adjuncts

• Warm sitz baths 3-4 times daily for 15-20 minutes reduce inflammation and provide symptomatic relief 1

Special Consideration: Your Fistulotomy History

Given your history of both hemorrhoidectomy and fistulotomy, there are additional considerations:

• Fistulotomy carries a 20% risk of continence deterioration, with the majority representing minor incontinence 6
• Combined procedures (hemorrhoidectomy + fistulotomy) increase the risk of sphincter defects documented by ultrasonography and manometry in up to 12% of patients 2
• If you're experiencing soiling or minor incontinence, this represents altered sensation from sphincter injury rather than missing hemorrhoid tissue 7

Long-Term Continence Concerns

• Impaired anal continence affects 2-12% of patients after hemorrhoidectomy alone, and this risk increases with combined procedures 2
• Female sex and operations for hygienic problems are associated with higher risk of post-operative incontinence 7
• The sensation of incomplete closure or altered perianal sensation is more likely related to sphincter changes from your fistulotomy than from hemorrhoid tissue removal 6, 8

Expected Timeline and When to Seek Help

• Pain should improve progressively over 2-4 weeks, with most patients returning to work by 4 weeks 1
• Reassess for complications (infection, anal stenosis, sphincter injury) if pain worsens or fails to improve within 1-2 weeks 1
• Avoid topical corticosteroids beyond 7 days, as prolonged use causes perianal tissue thinning and increased injury risk 1

Common Pitfall to Avoid

Do not assume all post-operative distress is "normal healing"—the specific pattern matters. Severe pain with fever and urinary retention is necrotizing pelvic sepsis until proven otherwise, particularly in immunocompromised patients (uncontrolled diabetes, AIDS, neutropenia) who have a 5-fold increased risk 1. Progressive worsening rather than gradual improvement warrants immediate surgical re-evaluation 1.