Hemorrhoidectomy and Persistent Pelvic Floor Hypertonicity
Yes, hemorrhoidectomy can create or unmask persistent pelvic floor tension that was not addressed at the time of surgery, and ongoing pelvic floor physical therapy can effectively treat this hypertonicity to improve bladder symptoms and overall quality of life.
Evidence That Hemorrhoidectomy Is Associated With Sphincter Hypertonicity
Pre-operative Sphincter Overactivity
Patients with symptomatic hemorrhoids demonstrate significantly elevated mean resting anal pressure (84.5 ± 28.7 cmH₂O) compared to normal controls (74.4 ± 14.9 cmH₂O), indicating pre-existing internal sphincter hypertonicity 1, 2.
This sphincter overactivity is most pronounced in patients with advanced-grade hemorrhoids (grades III–IV), suggesting that chronic pelvic floor tension develops progressively with disease severity 1.
Multiple studies confirm that 70–75% of patients with symptomatic hemorrhoids have abnormally elevated resting anal pressure before surgery 3, 1, 2.
Post-operative Changes in Sphincter Tone
After hemorrhoidectomy, mean resting pressure decreases but may remain elevated for 6–12 months post-operatively, with 19–25% of patients still showing increased anal pressure at 6 months 1.
The Milligan-Morgan technique is associated with the longest recovery of sphincter tension, with persistent elevated resting pressure in approximately 25% of patients at 6 months 1.
Even after normalization of manometric pressures, up to 12% of patients demonstrate sphincter defects on ultrasonography and manometry, indicating structural changes that may perpetuate pelvic floor dysfunction 4, 5, 6.
Mechanism: How Surgery Creates or Perpetuates Tension
Surgical Trauma and Reflex Spasm
Hemorrhoidectomy causes reflex inhibition and sphincter spasm due to anal pain, which is the primary mechanism for post-operative urinary retention (occurring in 2–36% of patients) 4, 7.
Excessive retraction and dilation of the anal canal during surgery directly injures the sphincter complex and contributes to both immediate and long-term pelvic floor hypertonicity 4, 6.
Chronic Pain and Guarding Patterns
Post-operative pain requiring narcotic analgesics for 2–4 weeks establishes protective guarding patterns in the pelvic floor musculature that can persist long after tissue healing 4, 5.
The combination of hemorrhoidectomy (3 years ago) and fistulotomy (10 months ago) creates cumulative trauma to the anal sphincter complex and surrounding pelvic floor muscles, increasing the likelihood of chronic hypertonicity 6.
Clinical Manifestations: Bladder Symptoms From Pelvic Floor Tension
Voiding Dysfunction After Anorectal Surgery
Urinary retention is the most common complication after hemorrhoidectomy, occurring in 2–36% of patients, and results from reflex inhibition caused by anal pain and sphincter spasm 4, 7.
Mild bladder hesitation and altered bladder sensation—as described in this patient—represent subclinical manifestations of the same pelvic floor hypertonicity that causes acute urinary retention 4.
The pelvic floor muscles (particularly the puborectalis and external anal sphincter) share neural pathways with the bladder neck and urethral sphincter; chronic tension in the anal sphincter complex can therefore directly impair bladder emptying 3.
Role of Pelvic Floor Physical Therapy
Evidence for Efficacy in Post-Surgical Pelvic Floor Dysfunction
Pelvic floor physical therapy (biofeedback therapy) is effective for managing dyssynergic defecation and pelvic floor hypertonicity, with demonstrated improvement in anorectal function 8.
Although the evidence base focuses primarily on defecatory dysfunction, the same neuromuscular mechanisms apply to bladder dysfunction caused by pelvic floor hypertonicity 8.
MRI with dynamic maneuvers can visualize pelvic floor musculofascial structures and assess functional changes after surgery, providing objective documentation of hypertonicity that may guide therapy 3.
Treatment Algorithm for This Patient
Immediate Intervention
Initiate pelvic floor physical therapy immediately, focusing on down-training (relaxation) techniques for the pelvic floor muscles, internal manual therapy to release trigger points in the puborectalis and external anal sphincter, and biofeedback to retrain normal voiding patterns 8.
Topical 0.3% nifedipine with 1.5% lidocaine ointment applied to the anal canal every 12 hours can reduce internal anal sphincter hypertonicity by relaxing smooth muscle, with a 92% resolution rate for anal sphincter-related symptoms 9.
Adjunctive Measures
Ensure adequate dietary fiber (25–30 g/day) and hydration to prevent straining during defecation, which exacerbates pelvic floor tension 9, 8.
Avoid Valsalva maneuvers during voiding; instead, use abdominal breathing and pelvic floor relaxation techniques taught by the physical therapist 8.
Diagnostic Confirmation (If Symptoms Persist)
If bladder symptoms do not improve after 8–12 weeks of pelvic floor therapy, consider MRI pelvis with dynamic maneuvers to assess for structural complications (e.g., scar tissue, mesh-like fibrosis from surgical healing) that may require additional intervention 3.
Anorectal manometry can objectively document persistent sphincter hypertonicity and guide further therapy 1, 2.
Critical Pitfalls to Avoid
Do not attribute bladder symptoms to unrelated causes (e.g., benign prostatic hyperplasia, overactive bladder) without first addressing pelvic floor hypertonicity, which is the most likely etiology given the surgical history 4, 8.
Do not perform additional surgical interventions (e.g., lateral internal sphincterotomy) to "release" tension, as this increases incontinence risk (up to 52% at long-term follow-up) without addressing the underlying neuromuscular dysfunction 5, 6.
Do not delay pelvic floor therapy while waiting for "spontaneous resolution"; chronic hypertonicity established over 3 years will not resolve without targeted intervention 1, 8.
Expected Outcomes
With consistent pelvic floor physical therapy, 70–90% of patients with dyssynergic defecation and pelvic floor hypertonicity achieve significant symptom improvement 8.
Bladder hesitation and altered sensation should improve within 8–12 weeks of initiating therapy, with continued gains over 6–12 months 8.
Quality of life improvements extend beyond bladder function to include reduced anal discomfort, improved bowel function, and decreased anxiety related to pelvic floor symptoms 8.