Can pelvic‑floor physical therapy help with persistent pain, sphincter spasm, or altered sensation after a hemorrhoidectomy once the surgical wound has fully healed?

Can Pelvic‑Floor Physical Therapy Help with Persistent Post‑Hemorrhoidectomy Pain?

Pelvic‑floor physical therapy is a reasonable adjunctive treatment for persistent sphincter spasm, myofascial pain, or altered sensation after hemorrhoidectomy once the surgical wound has fully healed, though direct evidence specific to post‑hemorrhoidectomy pain is limited. 1

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Evidence for Pelvic‑Floor Physical Therapy in Anorectal Dysfunction

• Pelvic‑floor physical therapy (PFPT) is a first‑line conservative treatment for hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia, with robust evidence showing improvement or cure of symptoms. 1

• PFPT works by functional retraining to improve pelvic floor muscle strength, endurance, power, and—critically—relaxation in patients with pelvic floor dysfunction. 1

• Although the evidence base for PFPT focuses primarily on urinary incontinence, pelvic organ prolapse, and fecal incontinence, the same principles of muscle relaxation and myofascial release apply to post‑surgical sphincter spasm and chronic pelvic pain. 1

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Pathophysiology of Persistent Post‑Hemorrhoidectomy Pain

• Anal sphincter spasm is a primary driver of pain after hemorrhoidectomy, caused by reflex inhibition and excessive retraction or dilation of the anal canal during surgery. 2

• Up to 12 % of patients develop internal or external anal sphincter defects after hemorrhoidectomy, which can manifest as persistent pain, altered sensation, or fecal soiling. 3

• Postoperative pain is typically managed with narcotic analgesics, topical nifedipine with lidocaine, and sitz baths, but these address acute pain rather than chronic myofascial dysfunction. 2

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When to Consider Pelvic‑Floor Physical Therapy

Refer for PFPT evaluation if any of the following persist beyond 6–8 weeks after complete wound healing:

• Persistent anal or pelvic pain that is not explained by wound complications, infection, or recurrent hemorrhoids. 1

• Sphincter spasm or hypertonicity causing pain with sitting, defecation, or digital examination. 2

• Altered sensation, dyspareunia, or pelvic floor myofascial pain that interferes with daily activities or sexual function. 1

• Fecal soiling or mild fecal incontinence that may reflect sphincter injury or dyssynergia rather than frank sphincter defect. 3

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Adjunctive Pharmacologic Strategies for Sphincter Spasm

While awaiting PFPT evaluation or as a bridge to therapy, consider:

• Topical 0.3 % nifedipine with 1.5 % lidocaine ointment applied every 12 hours to reduce anal sphincter spasm and associated pain. 2

• Topical diltiazem (another calcium‑channel blocker) applied three times daily has been shown to accelerate wound healing after hemorrhoidectomy by reducing sphincter hypertonicity, with mean healing time of 22.3 days versus 27.4 days for placebo (p = 0.012). 4

• Avoid prolonged use of topical corticosteroids (> 7 days), as they cause irreversible thinning of perianal tissue and do not address sphincter spasm. 2

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Critical Pitfalls to Avoid

• Do not attribute all persistent pain to "normal postoperative recovery" without excluding wound complications, abscess, anal fissure, or recurrent hemorrhoids. 2

• Do not perform repeat hemorrhoidectomy or aggressive dilation in patients with mild fecal incontinence or sphincter injury, as this will worsen incontinence. 3

• Do not delay referral for PFPT beyond 8–12 weeks if pain persists despite pharmacologic management, as chronic pain syndromes become more difficult to treat over time. 1

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Limitations of Current Evidence

• There are no randomized trials specifically evaluating PFPT for post‑hemorrhoidectomy pain, so recommendations are extrapolated from evidence in other hypertonic pelvic floor disorders. 1

• Standards of PFPT treatment protocols vary widely, and larger well‑designed trials are needed to show long‑term effectiveness in this specific population. 1

• Conflicting evidence exists regarding perioperative PFPT before or after pelvic floor surgery, so PFPT is best reserved for patients with persistent symptoms after wound healing. 1

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Practical Algorithm for Post‑Hemorrhoidectomy Pain Management

Weeks 0–6 (Acute Phase):

• Standard postoperative care: narcotic analgesics, topical nifedipine/lidocaine, sitz baths, stool softeners. 2

Weeks 6–8 (Wound Healing Phase):

• Assess for complete wound healing, resolution of pain, and return to normal bowel function. 2
• If pain persists, evaluate for wound complications, abscess, fissure, or recurrent hemorrhoids. 2

Beyond 8 Weeks (Chronic Phase):

• If sphincter spasm, myofascial pain, or altered sensation persists despite complete wound healing, refer for pelvic‑floor physical therapy evaluation. 1
• Continue topical calcium‑channel blockers (nifedipine or diltiazem) as adjunctive therapy. 2, 4