After internal hemorrhoidectomy, does removal of the hemorrhoidal cushions cause a direct loss of rectal pressure sensation, how important is that sensation for well‑being, sexual arousal and sleep, and can remaining rectal sensory pathways be trained to compensate?

Direct Answer on Rectal Sensation After Internal Hemorrhoidectomy

Internal hemorrhoidectomy does not cause clinically significant loss of rectal pressure sensation or impair well-being, sexual arousal, or sleep in most patients, though those with pre-existing continence compromise may experience worsening symptoms. 1

Understanding Hemorrhoidal Cushions and Pressure Sensation

The anal cushions are normal vascular structures that contribute 15-20% of resting anal pressure and contain arteriovenous communications that help maintain the anal "seal." 2 However, the primary concern after hemorrhoidectomy is not loss of sensory function but rather changes in continence mechanics. 3

What Actually Happens to Pressure After Surgery

• Patients with symptomatic hemorrhoids have abnormally elevated anal resting pressures (108.4 ± 23 mmHg) compared to healthy controls (73 ± 5.9 mmHg) before surgery. 4
• After hemorrhoidectomy, resting anal pressure decreases but remains higher than normal controls (103.6 ± 21.5 mmHg vs. 73 ± 5.9 mmHg at 12 months). 4
• This pressure reduction is actually beneficial and does not represent a pathologic loss of sensation—it normalizes the previously elevated tone. 2

Impact on Continence and Quality of Life

Overall Population Effects

The majority of patients experience no significant change in continence status after Milligan-Morgan hemorrhoidectomy. 1 In a study of 76 patients:

• Overall preoperative liquid continence test volume was 1130.61 ± 78.35 mL vs. postoperative 991.27 ± 42.77 mL (P = 0.057—not statistically significant). 1
• Wexner incontinence scores showed no significant difference before vs. after surgery (1.68 ± 0.13 vs. 2.10 ± 0.17, P = 0.064). 1

Critical Caveat: Pre-existing Continence Issues

Patients with compromised continence before surgery (liquid continence test < 900 mL) experience significant worsening after hemorrhoidectomy and should avoid this procedure. 1 In this subgroup:

• Retained volume decreased from 858.24 ± 32.01 mL to 574.18 ± 60.28 mL (P = 0.011). 1
• Wexner scores worsened from 2.71 ± 0.30 to 3.58 ± 0.40 (P = 0.003). 1

Well-Being, Sexual Arousal, and Sleep

There is no evidence in the medical literature linking hemorrhoidectomy to impaired sexual arousal or sleep disturbances. The provided guidelines and research focus exclusively on continence outcomes, pain, and functional anorectal physiology. 5

• The major drawback of hemorrhoidectomy is postoperative pain requiring narcotics and 2-4 weeks off work, not sensory or sexual dysfunction. 5
• Complications include urinary retention (2-36%), bleeding (0.03-6%), and incontinence (2-12%), but no sexual or sleep-related adverse effects are documented. 5

Compensatory Mechanisms

Rectal Sensation Pathways

The rectum's ability to perceive stool presence through the rectoanal contractile reflex remains intact after hemorrhoidectomy because this mechanism depends on rectal wall stretch receptors, not the hemorrhoidal cushions themselves. 3

• Damage to endovascular cushions may produce a poor anal "seal" and impaired anorectal sampling reflex, but this affects fine discrimination of gas vs. liquid vs. solid—not global rectal sensation. 3
• The puborectalis muscle and anorectal angle maintenance are independent of hemorrhoidal tissue and remain functional. 3

Sphincter Function Preservation

Both internal and external anal sphincters remain structurally and functionally intact after properly performed hemorrhoidectomy. 5

• Sphincter defects documented by ultrasonography occur in up to 12% of patients, but these result from excessive retraction and dilation during surgery—not from removal of hemorrhoidal tissue itself. 5
• The internal anal sphincter provides most resting pressure, and the external sphincter reinforces during voluntary squeeze; neither is intentionally disrupted during standard hemorrhoidectomy. 3

Clinical Algorithm for Decision-Making

Before proceeding with internal hemorrhoidectomy, assess baseline continence:

1. Perform liquid continence testing or detailed Wexner scoring. 1
2. If retained volume < 900 mL or significant baseline incontinence exists, avoid Milligan-Morgan hemorrhoidectomy and consider alternative treatments (rubber band ligation, infrared photocoagulation). 1, 5
3. If continence is normal (retained volume > 900 mL), proceed with hemorrhoidectomy with confidence that sensory function and quality of life will not be compromised. 1

Common Pitfalls to Avoid

• Never assume hemorrhoidectomy causes loss of rectal sensation—the elevated pressure from hemorrhoids is pathologic, and its reduction is therapeutic. 4, 6
• Do not confuse the anal cushions' contribution to the anal seal (mechanical function) with sensory perception—these are distinct mechanisms. 2, 3
• Avoid excessive anal dilation and retraction during surgery, as sphincter injury from surgical technique—not tissue removal—causes incontinence. 5