Three years after hemorrhoidectomy, the patient reports rectal tightness interfering with orgasm and bladder sensation; what are the likely causes and recommended evaluation and management?

Rectal Tightness After Hemorrhoidectomy: Late Anal Stenosis with Pelvic Floor Dysfunction

Three years after hemorrhoidectomy, persistent rectal tightness affecting orgasm and bladder sensation most likely represents late anal stenosis with secondary pelvic floor dysfunction, requiring urgent anorectal manometry, digital rectal examination under anesthesia if needed, and consideration for lateral internal sphincterotomy or anoplasty combined with pelvic floor physical therapy. 1, 2

Understanding the Pathophysiology

Primary Mechanism: Post-Surgical Anal Stenosis

• Late anal stenosis occurs in 0-6% of patients after hemorrhoidectomy, with emergency hemorrhoidectomy carrying higher risk than elective procedures 3, 2
• The typical presentation window is 3-12 weeks post-operatively, but your patient's 3-year timeline suggests either delayed diagnosis or progressive fibrosis 1
• Anal stenosis develops from excessive tissue excision or circumferential scarring, creating a mechanical narrowing that increases baseline anal sphincter tone 1, 2

Secondary Pelvic Floor Dysfunction

• Elevated resting anal pressure persists long-term after hemorrhoidectomy—studies show mean pressures of 103.6 ± 21.5 mmHg at 12 months post-op versus 73 ± 5.9 mmHg in controls 4
• This chronic hypertonicity can cause referred pelvic floor muscle spasm, explaining the interference with orgasm and bladder sensation 5, 6
• 19% of patients report a sense of anal stenosis at 10-year follow-up, confirming this is a recognized long-term complication 2

Immediate Diagnostic Evaluation

Essential Physical Examination

• Digital rectal examination is mandatory to assess the degree of stenosis—inability to admit the examining finger indicates severe stenosis requiring intervention 1
• Anoscopy with adequate lighting should be attempted to visualize the stenotic ring and rule out recurrent hemorrhoids or other pathology 7, 8
• If examination is impossible due to pain, examination under anesthesia may be necessary to fully assess the stenosis 7

Objective Testing

• Anorectal manometry is the gold standard for documenting elevated resting anal pressure and confirming sphincter hypertonicity 5, 6, 4
• Manometry will likely show resting pressures >100 mmHg (normal 60-80 mmHg), consistent with post-hemorrhoidectomy stenosis 4

Treatment Algorithm

Mild Stenosis (Admits One Finger)

• Start with outpatient anal dilatation performed weekly in clinic, combined with:
  • Bulk-forming laxatives (psyllium husk 5-6 teaspoons with 600 mL water daily) to prevent straining 7
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours to reduce sphincter tone 7
  • Pelvic floor physical therapy to address secondary muscle dysfunction affecting sexual and bladder function 7
• Re-evaluate at 4-6 weeks—if symptoms persist, escalate to surgical intervention 1

Moderate to Severe Stenosis (Cannot Admit One Finger)

• Lateral internal sphincterotomy is the procedure of choice for stenosis with documented sphincter hypertonicity on manometry 1, 4
• This procedure reduces resting anal pressure by approximately 25-30 mmHg, relieving the mechanical obstruction and secondary pelvic floor spasm 4
• Anoplasty (advancement flap) is reserved for cases with significant tissue loss or circumferential scarring where sphincterotomy alone is insufficient 1

Critical Technical Considerations

• Perform "minimal cutting" sphincterotomy to reduce incontinence risk—remember that hemorrhoidectomy itself causes sphincter defects in up to 12% of patients 7
• Never perform aggressive anal dilatation under anesthesia, as this causes sphincter injuries and 52% incontinence rate at long-term follow-up 7
• Avoid repeat hemorrhoidectomy unless there is documented recurrent hemorrhoidal disease on anoscopy 7

Addressing Sexual and Bladder Dysfunction

Mechanism of Symptoms

• Chronic anal sphincter hypertonicity causes reflex pelvic floor muscle spasm, which directly impairs:
  • Pelvic blood flow during arousal (affecting orgasm)
  • Bladder neck relaxation (affecting sensation and emptying) 5, 6
• Resolution of anal stenosis typically resolves these secondary symptoms within 3-6 months 1

Adjunctive Therapies

• Pelvic floor physical therapy is essential even after surgical correction, as muscle dysfunction may persist 7
• Topical muscle relaxants (nifedipine 0.3% with lidocaine 1.5%) can provide interim relief while awaiting definitive treatment 7

Expected Outcomes

Post-Treatment Recovery

• All 27 patients in one series were symptom-free at 3-month follow-up after appropriate treatment for post-hemorrhoidectomy stenosis 1
• No recurrent stricture occurred in patients treated with either sphincterotomy or anoplasty 1
• Resting anal pressure normalizes within 6-12 months after sphincterotomy, with corresponding improvement in pelvic floor symptoms 4

Critical Pitfalls to Avoid

• Do not attribute symptoms to "normal post-operative changes" at 3 years—this represents a complication requiring intervention 1, 2
• Do not perform simple anal dilatation under anesthesia without addressing the underlying sphincter hypertonicity 7
• Do not delay treatment—chronic stenosis leads to progressive pelvic floor dysfunction that becomes harder to reverse 5, 6
• Screen for incontinence risk factors before sphincterotomy (age >60, female sex, prior vaginal delivery) and adjust surgical technique accordingly 7