Grade III Internal Hemorrhoids and Perceived Rectal Fullness After Hemorrhoidectomy
Grade III internal hemorrhoids do cause a persistent sensation of rectal fullness due to the prolapsed hemorrhoidal tissue mass occupying the anal canal, and hemorrhoidectomy reliably eliminates this sensation by removing the bulky tissue, thereby restoring normal rectal awareness.
Pathophysiologic Basis for Fullness Sensation
Grade III hemorrhoids create a mechanical mass effect through two distinct mechanisms:
Prolapsed tissue volume: Grade III hemorrhoids require manual reduction after prolapsing beyond the anal verge, meaning the hemorrhoidal cushions have enlarged sufficiently to physically occupy space within and beyond the anal canal 1.
Elevated anal resting pressure: Patients with symptomatic internal hemorrhoids demonstrate significantly elevated anal sphincter pressure compared to controls, and this elevated pressure results from the hemorrhoidal mass itself creating overactivity of the internal sphincter 2. This pressure normalizes within one week following hemorrhoidectomy, confirming that the mass—not sphincter dysfunction—drives the sensation 2.
Continuous mucosal prolapse: The abnormal swelling and stretching of suspensory muscles allows rectal mucosa to extend through the anal canal, depositing mucus and creating both chemical irritation and a physical sense of incomplete evacuation 3, 4.
Impact on Normal Rectal Sensation
The chronic presence of grade III hemorrhoids can indeed mask or alter normal rectal fullness awareness:
Baseline fullness: Because grade III hemorrhoids create a constant sensation of tissue in the anal canal—even when manually reduced—patients may lose the ability to distinguish normal rectal distension from the pathologic fullness caused by hemorrhoidal tissue 1, 3.
Mucus deposition: Prolapsed internal hemorrhoids continuously secrete mucus onto the perianal skin, which compounds the sensation of incomplete evacuation and perianal wetness, further distorting normal rectal awareness 3.
Post-Hemorrhoidectomy Resolution
Hemorrhoidectomy definitively resolves the fullness sensation through tissue removal:
Immediate mechanical relief: Conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson technique) achieves a 2–10% recurrence rate for grade III hemorrhoids, meaning 90–98% of patients experience permanent resolution of the prolapsed tissue mass 1.
Normalization of anal pressure: The elevated resting anal pressure documented in hemorrhoid patients drops significantly within one week post-operatively, eliminating the sphincter hypertonicity that contributes to the fullness sensation 2.
Restoration of normal anatomy: By excising the redundant hemorrhoidal tissue and allowing the anal canal to return to its normal caliber, hemorrhoidectomy restores the patient's ability to perceive true rectal distension without the confounding presence of prolapsed cushions 1, 5.
Clinical Implications
Patients should be counseled pre-operatively that the chronic "fullness" or "something there" sensation they have adapted to will resolve after hemorrhoidectomy, and they will regain normal rectal awareness 1. This is a therapeutic benefit, not a complication—the surgery removes the pathologic mass that was masking normal sensation.
Critical Pitfall to Avoid
- Do not attribute post-operative sensations to "lost fullness": If a patient reports new or worsening fullness after hemorrhoidectomy, this suggests a complication (such as hematoma, abscess, or recurrence) rather than loss of the hemorrhoidal "cushion," and requires urgent re-evaluation 1.