Three years after an excisional hemorrhoidectomy I still have persistent abnormal rectal sensation; what diagnostic and therapeutic options are available?

Persistent Abnormal Rectal Sensation Three Years After Hemorrhoidectomy

Three years after excisional hemorrhoidectomy, persistent abnormal rectal sensation most likely represents permanent sphincter injury, which occurs in up to 12% of patients and can be definitively diagnosed with anal endosonography. 1, 2

Understanding the Problem

Your persistent sensory changes are not normal postoperative healing—they represent a chronic complication. After hemorrhoidectomy, most recovery occurs within 2-4 weeks, and any symptoms persisting beyond 8-12 weeks warrant investigation. 3, 1 At three years, you are well past the window where spontaneous improvement would be expected.

Why This Happens

• Sphincter injury occurs when excessive retraction or dilation of the anal canal during surgery damages the internal sphincter, external sphincter, or both 1, 4
• Up to 12% of patients develop sphincter defects documented by ultrasound and manometry after hemorrhoidectomy, even without obvious incontinence 3, 1
• The internal sphincter contributes to 55-85% of resting anal tone and provides fine sensory discrimination; damage explains altered sensation 5
• Scar tissue formation can also disrupt the normal sensory nerve network in the anal canal 4

Diagnostic Workup You Need

First-Line Investigation

• Anal endosonography is the gold standard test—it directly visualizes sphincter defects and has a very high yield in symptomatic post-hemorrhoidectomy patients 2
• In one study, endosonography found abnormalities in 75% of symptomatic patients after hemorrhoidectomy, including internal sphincter defects (most common), external sphincter defects, or combined defects 2
• This test is non-invasive, office-based, and provides immediate structural information 2

Additional Testing

• Anorectal manometry measures sphincter pressures and can detect functional impairment even when anatomy appears normal 5
• Post-hemorrhoidectomy patients often show significantly decreased resting pressure compared to normal (mean 63.7 vs 74.4 cmH₂O), which correlates with altered sensation 5
• Digital rectal examination by an experienced colorectal surgeon can detect palpable defects, scarring, or stenosis 6

Rule Out Other Causes

• Anoscopy to exclude recurrent hemorrhoids, fissures, or stricture formation 3
• If you have any fecal incontinence symptoms (even minor soiling), this strengthens the case for sphincter injury 2
• Exclude inflammatory bowel disease or other systemic conditions if you have additional bowel symptoms 3

Treatment Options Available

Conservative Management

Unfortunately, at three years post-surgery with persistent symptoms, conservative measures are unlikely to provide significant improvement, but they remain first-line:

• Pelvic floor physical therapy or anorectal biofeedback therapy can help retrain sphincter coordination and improve sensory awareness 6
• Biofeedback is effective for dyssynergic defecation and can help patients adapt to altered sensation 6
• Dietary optimization with 25-30 grams fiber daily and adequate hydration to maintain soft, formed stools reduces strain on the damaged sphincter 7, 3

When Conservative Therapy Fails

• If endosonography confirms a significant sphincter defect causing functional impairment, anal sphincteroplasty (surgical repair) may be considered, though this is now rarely performed and reserved for severe cases 6
• Sacral neuromodulation is a minimally invasive option that can improve sphincter function and sensation in select patients with sphincter dysfunction 6
• Anal dextranomer injection is another minimally invasive option for improving continence, though its role in isolated sensory dysfunction is less established 6

What NOT to Do

• Never undergo repeat hemorrhoidectomy or additional anal procedures without first documenting the exact nature of your problem with endosonography 2
• Avoid anal dilation—this outdated procedure causes sphincter injuries and 52% incontinence rate at long-term follow-up 3, 1
• Do not accept reassurance that "this is normal" three years after surgery—it is not, and you deserve proper investigation 2

Critical Next Steps

1. Request referral to a colorectal surgeon (not a general surgeon) who specializes in anorectal physiology and has access to endosonography 2, 6
2. Obtain anal endosonography as the definitive diagnostic test 2
3. Consider anorectal manometry if endosonography is normal but symptoms persist 5
4. Trial of pelvic floor physical therapy while awaiting specialist evaluation 6

Realistic Expectations

• If a sphincter defect is confirmed, complete restoration of normal sensation is unlikely 2
• However, identifying the specific problem allows targeted therapy to maximize function and quality of life 6
• Many patients with documented sphincter defects remain asymptomatic or minimally symptomatic with conservative management 5
• The goal is functional improvement and adaptation, not necessarily complete resolution 6

Common Pitfall to Avoid

The most critical error is attributing persistent symptoms to "normal postoperative changes" without proper investigation. At three years, your symptoms represent a chronic complication that warrants thorough evaluation. 2 Occult sphincter injury as a cause of altered sensation can frequently be demonstrated on endosonography, and this finding fundamentally changes management. 2