After a grade III hemorrhoidectomy, why am I experiencing loss of low‑volume bladder and rectal sensation, and what diagnostic and treatment steps should I take?

Post-Hemorrhoidectomy Sensory Changes: Diagnostic and Treatment Approach

Understanding the Paradox

Your loss of low-volume bladder and rectal sensation after grade III hemorrhoidectomy most likely reflects a combination of pelvic floor muscle guarding (protective spasm) that developed during the pre-operative period and persists post-operatively, rather than direct nerve damage from the surgery itself. 1

The paradox you describe—where diseased hemorrhoidal tissue may have provided sensory cues for bladder/rectal awareness—is not a recognized physiological mechanism. Instead, what likely occurred is:

• Chronic pelvic floor tension patterns developed during the months or years you lived with symptomatic grade III hemorrhoids, creating protective guarding that you became accustomed to 1
• This guarding persists after surgery even though the painful stimulus (hemorrhoids) is gone, a phenomenon well-documented after anorectal procedures 1
• You cannot perceive the ongoing muscle tension because it has become your baseline neuromuscular pattern 1

Why Direct Surgical Nerve Damage Is Unlikely

Hemorrhoidectomy is a superficial procedure confined to the anal canal that does not approach the deep pelvic autonomic nerves responsible for bladder and rectal sensation 1. These nerves (hypogastric plexus, pelvic splanchnic nerves) are located several centimeters away from the surgical field 1.

However, sphincter manipulation during hemorrhoidectomy does cause structural changes:

• Sphincter defects occur in up to 12% of patients after hemorrhoidectomy, documented by ultrasonography and manometry 2, 1
• Excessive retraction and anal canal dilation during surgery are the primary technical factors causing sphincter injury 1
• Incontinence rates of 2–12% reflect functional impairment rather than deep nerve injury 2, 1

Diagnostic Evaluation You Need

Immediate Assessment (Within 2–4 Weeks Post-Op)

• Anorectal manometry to measure resting and squeeze pressures—reduced resting pressure at the high-pressure zone correlates with sphincter dysfunction 3
• Endoanal ultrasound to identify external or internal sphincter defects, which occur in approximately 20% of symptomatic patients 3
• Digital rectal examination by an experienced colorectal surgeon to assess sphincter tone and identify pelvic floor muscle hypertonicity 4

If Initial Tests Are Normal or Equivocal

• Saline infusion test to objectively measure your ability to retain liquid, which is impaired in patients with post-hemorrhoidectomy sensory changes 3
• Urodynamic studies if bladder symptoms predominate, to rule out concurrent bladder dysfunction unrelated to surgery 5

Critical Diagnostic Pitfall to Avoid

Do not assume all symptoms are surgical complications—anal pain and sensory changes can reflect neuropathic pain and dysesthesia rather than structural damage 1. This distinction is crucial because treatment differs fundamentally.

Treatment Algorithm

First-Line: Pelvic Floor Physical Therapy (Start Immediately)

Specialized pelvic floor physical therapy 2–3 times weekly is the cornerstone of treatment for post-surgical guarding and sensory dysfunction 1. This therapy should include:

• Internal and external myofascial release to address persistent muscle tension 1
• Gradual desensitization exercises to retrain sensory awareness 1
• Muscle coordination retraining to restore normal pelvic floor function 1

This approach is effective because pelvic floor muscle tension and protective guarding patterns persist after surgery even when the original painful stimulus is removed 1.

Adjunctive Pharmacologic Management

• Topical lidocaine 5% ointment applied to affected areas for neuropathic pain management 1
• Continue stool softeners (e.g., polyethylene glycol, psyllium husk 5–6 teaspoons with 600 mL water daily) to prevent straining that exacerbates guarding 6
• Avoid topical corticosteroids beyond 7 days to prevent mucosal thinning 6

If Conservative Therapy Fails After 8–12 Weeks

• Botulinum toxin injection into the internal anal sphincter achieves 75–95% cure rates for persistent sphincter hypertonicity with no risk of permanent incontinence or sexual dysfunction 1
• This should be considered before any repeat surgical intervention 1

When to Suspect Actual Surgical Complication

Seek urgent re-evaluation if you develop:

• Severe pain with high fever and urinary retention—suggests necrotizing pelvic sepsis, a rare but serious complication 6
• Progressive fecal incontinence—may indicate sphincter defect requiring surgical repair 3
• Anal stenosis symptoms (difficulty passing stool despite softeners)—occurs in 0–6% of patients and may require dilation or revision 6

Prognosis and Realistic Expectations

• Most patients with post-hemorrhoidectomy sensory changes improve with pelvic floor therapy within 3–6 months 1
• Sphincter defects, when present, may cause permanent functional impairment in approximately 20% of symptomatic patients 3
• Your body is not "damaged" in the way you fear—the guarding is a learned neuromuscular pattern that can be retrained 1

Critical Pitfall: The "Reliance" Hypothesis

Your theory that you "relied on deep sensations of hemorrhoids for bladder/rectal arousal and sleep" is not supported by any physiological mechanism in the literature. What you experienced was likely:

• Chronic pelvic floor hypertonicity that became your baseline 1
• Altered sensory processing due to persistent pain and inflammation 1
• Post-surgical sensory recalibration as your nervous system adapts to the absence of diseased tissue 4

The solution is not to recreate the diseased state, but to retrain your pelvic floor and sensory awareness through specialized physical therapy 1.