In an adult after internal hemorrhoidectomy who now has mild urgency, occasional leakage, and altered rectal sensation, can pelvic‑floor therapy enable other rectal structures to compensate for the loss of hemorrhoidal cushion function?

Pelvic‑Floor Therapy for Post‑Hemorrhoidectomy Anorectal Dysfunction

Pelvic‑floor therapy cannot restore the lost hemorrhoidal cushion function, but it can improve compensatory mechanisms in patients with mild urgency, occasional leakage, and altered sensation after internal hemorrhoidectomy.

Understanding the Pathophysiology

The hemorrhoidal cushions normally contribute 15–20% of resting anal tone and serve as a fine‑tuning mechanism for continence, particularly for liquid and gas discrimination 1. After hemorrhoidectomy, this contribution is permanently lost 1. The resulting symptoms—urgency, occasional leakage, and altered rectal sensation—reflect both the loss of cushion function and potential sphincter injury during surgery 2, 3.

Sphincter defects occur in up to 12% of patients after hemorrhoidectomy, documented by ultrasonography and manometry 1, 2. These injuries arise from excessive retraction or dilation of the anal canal during surgery 2. Even without frank sphincter injury, hemorrhoidectomy reduces basal and squeeze pressures, though typically from abnormally high preoperative levels to normal postoperative values 4.

Evidence for Pelvic‑Floor Therapy

Anorectal biofeedback therapy is effective for managing fecal incontinence and can help patients develop compensatory strategies when anatomical structures are compromised 5. The therapy works by:

• Strengthening residual sphincter function through targeted exercises that improve voluntary squeeze pressure 5
• Improving rectal sensory awareness to compensate for altered sensation after cushion removal 5
• Teaching behavioral strategies such as timed defecation and urgency suppression techniques 5

Biofeedback is particularly valuable when combined with bowel modifiers tailored to the specific symptoms—in this case, agents that reduce stool liquidity and frequency to minimize demands on the compromised continence mechanism 5.

Realistic Expectations and Limitations

Pelvic‑floor therapy cannot regenerate excised hemorrhoidal tissue or reverse sphincter defects, but it can optimize the function of remaining structures 5. Patients with preoperative compromised continence who undergo hemorrhoidectomy may experience further deterioration 6. In one study, patients with preoperative liquid retention volumes below 900 mL showed significant worsening after surgery (858 mL preoperatively vs 574 mL postoperatively, P = 0.011), along with increased Wexner incontinence scores (2.71 vs 3.58, P = 0.003) 6.

The degree of improvement depends on baseline sphincter integrity. Patients with external sphincter injuries (detected in 20% of symptomatic post‑hemorrhoidectomy patients in one series) have reduced ability to hold liquids compared with healthy controls (P = 0.004) 3. These structural defects limit the potential benefit of pelvic‑floor therapy alone 3.

Practical Treatment Algorithm

Step 1: Initial Conservative Management (First 2–3 Months)

• Initiate bulk‑forming agents (psyllium husk 5–6 teaspoons with 600 mL water daily) to produce soft, formed stools that are easier to control 1
• Increase dietary fiber to 25–30 g daily and ensure adequate fluid intake 1
• Avoid straining during defecation, which can worsen sphincter dysfunction 1
• Use topical lidocaine 1.5–2% for residual anal discomfort that may trigger urgency 1

Step 2: Pelvic‑Floor Physical Therapy (If Symptoms Persist Beyond 3 Months)

Refer to a pelvic‑floor physical therapist for structured biofeedback therapy, which is now the primary delivery mechanism for this treatment 5. The therapy should include:

• Manometric biofeedback to improve voluntary squeeze pressure and coordination 5
• Sensory retraining to improve rectal perception and urgency thresholds 5
• Behavioral strategies including timed defecation and urgency suppression 5

Step 3: Adjunctive Pharmacotherapy

• Consider oral flavonoids (phlebotonics) to improve venous tone in residual vascular tissue, though 80% of patients experience symptom recurrence within 3–6 months after cessation 1
• Use antidiarrheal agents (loperamide) judiciously if loose stools contribute to leakage 5

Step 4: Advanced Interventions (If Conservative Measures Fail After 6–12 Months)

• Sacral neuromodulation is a minimally invasive option for refractory fecal incontinence 5
• Anal dextranomer injection can augment the anal canal when structural deficits persist 5
• Colostomy or sphincteroplasty are rarely required but may be considered in severe cases 5

Critical Pitfalls to Avoid

Do not attribute all post‑hemorrhoidectomy incontinence to cushion loss alone—always consider sphincter injury, which occurs in 2–12% of patients and is the primary driver of severe symptoms 1, 2. A thorough digital rectal examination can detect sphincter defects, and endoanal ultrasound or manometry should be performed if symptoms are severe or progressive 3.

Never delay evaluation for other anorectal pathology. Anal fissures coexist in up to 20% of hemorrhoid patients, and new‑onset pain or bleeding after hemorrhoidectomy may indicate fissure, abscess, or stenosis rather than simple cushion loss 1.

Avoid attributing anemia or significant bleeding to residual hemorrhoidal disease without colonoscopic evaluation to exclude proximal colonic pathology 1.

Prognosis

Most patients with mild post‑hemorrhoidectomy symptoms improve with conservative management and pelvic‑floor therapy, particularly when baseline sphincter function is preserved 5, 4. However, patients with preoperative compromised continence or significant intraoperative sphincter injury have a less favorable prognosis and may require advanced interventions 6, 3.