In a patient with grade III internal hemorrhoids and an associated anal fissure, how does hemorrhoidectomy affect sexual arousal and what are the associated risks?

Hemorrhoidectomy and Sexual Arousal: Risk Assessment

Hemorrhoidectomy does not directly affect sexual arousal mechanisms, but carries a significant 2–33% risk of anal sphincter injury and incontinence that can profoundly impact sexual quality of life and intimate function. 1, 2, 3

Direct Impact on Sexual Arousal Physiology

• Hemorrhoidectomy does not involve structures directly responsible for sexual arousal—the procedure targets hemorrhoidal tissue above and below the dentate line, not the neurovascular bundles or erectile tissues involved in sexual response. 1
• The surgery does not alter hormonal pathways, genital blood flow, or central nervous system arousal mechanisms. 1

Indirect Effects Through Sphincter Injury and Incontinence

Sphincter Damage During Surgery

• Inadvertent removal of anal sphincter muscle occurs in 12–16% of hemorrhoidectomy cases, with smooth muscle fibers found in 80.5% of these injuries and striated muscle in 19.5%. 4, 1
• Open (Milligan-Morgan) hemorrhoidectomy carries the highest risk of sphincter defects, documented by ultrasonography and manometry in up to 12% of patients. 1, 2
• These sphincter injuries can lead to varying degrees of fecal incontinence, ranging from minor soiling to complete loss of control. 1, 3

Long-Term Incontinence Rates

• Long-term studies show that 33% of patients report impaired anal continence after Milligan-Morgan hemorrhoidectomy, with 29% of affected patients directly attributing their incontinence to the surgery. 3
• Female sex is associated with significantly higher risk of postoperative incontinence (p = 0.005). 3
• At 17-year follow-up, incontinence rates remain substantial, indicating permanent functional impairment in a significant subset of patients. 1, 3

Impact on Sexual Quality of Life

• Fecal incontinence profoundly affects intimate relationships and sexual confidence, creating anxiety about bowel control during sexual activity, fear of embarrassment, and avoidance of intimacy. 3
• Patients with incontinence often experience psychological distress, body image concerns, and relationship strain that indirectly suppress sexual desire and arousal. 3
• The need for protective padding, frequent bathroom access, and hygiene concerns can make spontaneous sexual activity difficult or impossible. 3

Risk Mitigation Strategies

Surgical Technique Selection

• Closed (Ferguson) hemorrhoidectomy may offer slightly better outcomes than open technique, though both carry sphincter injury risk. 2
• Stapled hemorrhoidopexy produces significantly less postoperative pain and may reduce sphincter trauma, but lacks long-term efficacy data. 1, 2
• The surgeon must meticulously preserve anal pad tissue and avoid excessive sphincter manipulation during dissection. 5

Contraindicated Procedures

• Never perform lateral internal sphincterotomy as an adjunct to hemorrhoidectomy—randomized studies show no benefit and it increases incontinence risk. 2, 6
• Anal dilatation must be avoided entirely due to 52% incontinence rate at long-term follow-up and direct sphincter injuries. 1, 2

Special Considerations for Your Patient

• The presence of a concurrent anal fissure requires careful surgical planning—performing both hemorrhoidectomy and sphincterotomy in the same setting compounds sphincter injury risk. 1
• If the fissure is acute (<8 weeks), consider treating it conservatively with topical 0.3% nifedipine plus 1.5% lidocaine while addressing only the hemorrhoids surgically. 1
• If the fissure is chronic (>8 weeks), perform a minimal, controlled sphincterotomy rather than aggressive sphincter division to reduce cumulative incontinence risk. 1

Critical Counseling Points

• Explicitly discuss the 12–33% risk of some degree of fecal incontinence and its potential impact on intimate relationships and sexual quality of life before surgery. 1, 4, 3
• Explain that while hemorrhoidectomy does not directly impair arousal physiology, the functional consequences of sphincter injury can profoundly affect sexual confidence and relationship intimacy. 3
• Female patients face higher incontinence risk and warrant particularly thorough preoperative counseling. 3
• Most patients require 2–4 weeks off work for recovery, during which sexual activity should be avoided to allow complete wound healing. 1, 2

Postoperative Monitoring

• Assess sphincter function at 1,3,6, and 12 months postoperatively using validated incontinence scoring systems. 6
• Recovery of anal sphincter tension may take up to 6 months after Milligan-Morgan hemorrhoidectomy, with some patients showing persistent hypertension even at 6 months. 6
• If incontinence develops, early referral to a pelvic floor specialist can improve outcomes through biofeedback, sphincter exercises, and other conservative measures. 1