What is the likely cause of a 67-year-old patient's trouble passing stool and urine one week after hemorrhoid surgery, with symptoms including constipation, urinary retention, abdominal distension, and passing wind, while taking medication that may be exacerbating constipation, and what management strategies can be employed to address these issues?

Post-Hemorrhoidectomy Urinary Retention and Constipation

Most Likely Diagnosis

This patient has postoperative urinary retention secondary to hemorrhoidectomy, compounded by opioid-induced constipation. The clinical triad of difficulty voiding (passing minimal urine despite drinking 6 glasses of water), needing to pass stool before urinating, and constipation one week post-hemorrhoidectomy is pathognomonic for urinary retention with overflow 1. The medication (likely opioids) is exacerbating both the urinary retention and constipation 2.

Immediate Assessment Required

You must rule out necrotizing pelvic sepsis immediately. The clinical triad of severe pain, high fever, and urinary retention suggests this rare but life-threatening complication requiring emergency examination under anesthesia with radical debridement 1. However, the absence of fever in this patient makes this less likely but does not exclude it entirely 1.

Critical Red Flags to Assess Now:

• Check temperature immediately - any fever with urinary retention and severe pain mandates emergency surgical consultation 1
• Verify vital signs for hemodynamic stability - tachycardia or hypotension suggests sepsis or significant bleeding 3
• Assess for immunocompromise - uncontrolled diabetes, immunosuppressive medications, or AIDS increase necrotizing infection risk 1

Immediate Management Algorithm

Step 1: Address Urinary Retention (Most Urgent)

Bladder catheterization is indicated now. Urinary retention occurs in 2-36% of post-hemorrhoidectomy patients and requires prompt drainage 4, 5. The patient's inability to void despite adequate fluid intake (6 glasses of water) with only minimal output indicates significant retention 1, 5.

• Insert Foley catheter immediately to measure residual volume and provide relief 2, 1
• Expect 300-800mL or more of retained urine 5
• Plan for early catheter removal (within 24-48 hours) to prevent urinary tract infection 2

Step 2: Manage Opioid-Induced Constipation

Stop or dramatically reduce opioid analgesics immediately. Opioid-induced constipation is the most frequently reported side effect and is exacerbating both the constipation and urinary retention through increased pelvic floor tension 2.

Switch to multimodal non-opioid analgesia:

• Acetaminophen 1000mg every 6 hours for baseline pain control 2
• NSAIDs (ibuprofen 400-600mg every 6-8 hours) if not contraindicated 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied to perianal area every 12 hours for local pain relief (92% effective for hemorrhoid pain) 3

Step 3: Aggressive Bowel Regimen

Initiate osmotic laxatives immediately - these are safe and effective for post-surgical constipation 3, 6:

• Polyethylene glycol (MiraLAX) 17g daily in 8oz water 3, 6
• Continue until soft, formed stools achieved 7, 6

Add stool softener:

• Docusate sodium 100-200mg twice daily to prevent hard, dry stools 7
• This generally produces bowel movement within 12-72 hours 7

Increase dietary fiber and fluids:

• 25-30 grams fiber daily (can use psyllium husk 5-6 teaspoonfuls with 600mL water daily) 3
• Adequate water intake to soften stool 3

Step 4: Sitz Baths for Pain and Healing

Prescribe warm sitz baths 3-4 times daily for 10-15 minutes to reduce inflammation, improve comfort, and promote healing 3.

Why This Happened

The primary mechanism is sphincter trauma from surgery causing reflex bladder inhibition, compounded by opioid effects 1. Excessive retraction with anal canal dilation during hemorrhoidectomy causes sphincter injury contributing to voiding dysfunction 1. The opioids prescribed for postoperative pain cause both constipation (slowing GI motility) and worsen urinary retention through autonomic effects 2.

Epidural or spinal anesthesia increases risk - if this patient had regional anesthesia, urinary retention rates are significantly higher (odds ratio 2.43 for general vs. spinal) 5, 8. The severity of hemorrhoids (likely grade III-IV requiring surgery) is also an independent predictor of urinary retention 5.

Critical Pitfalls to Avoid

• Never attribute severe pain, fever, and urinary retention to "normal postoperative course" - this triad mandates immediate evaluation for necrotizing pelvic sepsis 1
• Never continue opioids when multimodal analgesia is available - opioids are the primary driver of postoperative constipation and worsen urinary retention 2
• Never allow prolonged urinary retention - bladder overdistension can cause permanent detrusor dysfunction 2, 5
• Do not perform rectal examination if necrotizing sepsis suspected - this requires examination under anesthesia in the operating room 1

Expected Timeline for Resolution

• Urinary retention should improve within 24-48 hours after catheterization and opioid cessation 1, 5
• Constipation should resolve within 12-72 hours with osmotic laxatives and stool softeners 7, 6
• If no improvement in 48-72 hours, urgent surgical consultation required to evaluate for complications 3

When to Escalate Care Immediately

Call surgeon emergently if:

• Any fever develops (suggests infection/sepsis) 1
• Severe worsening pain (suggests abscess, ischemia, or necrosis) 1
• Inability to catheterize (may need suprapubic catheter) 2
• Rectal bleeding with hemodynamic instability (suggests delayed hemorrhage) 3, 4