In an adult patient after hemorrhoidectomy, can pelvic‑floor physical therapy improve postoperative urinary retention and pudendal‑nerve‑related pain or hypersensitivity?

Pelvic Floor Physical Therapy After Hemorrhoidectomy

Pelvic floor physical therapy (PFPT) can effectively treat postoperative urinary retention and pudendal nerve-related pain after hemorrhoidectomy, particularly when pelvic floor hypertonicity or overactivity is the underlying mechanism. 1, 2, 3

Understanding Post-Hemorrhoidectomy Complications

Urinary Retention Pathophysiology

• Urinary retention occurs in 2–36% of patients after hemorrhoidectomy, making it one of the most common postoperative complications 1
• The primary mechanism is reflex inhibition of detrusor muscle contraction caused by anal-region pain and internal sphincter spasm 1
• Excessive retraction or dilation of the anal canal during surgery can injure the internal sphincter, further contributing to urinary retention 1
• Narcotic analgesics administered for postoperative pain impair bladder sensation and detrusor contractility, increasing retention risk 1

Nerve Pain and Sensitivity

• Pudendal nerve-related pain after hemorrhoidectomy often manifests as pelvic floor hypertonicity—a disabling condition with urological symptoms, sexual problems, and chronic pelvic pain 3
• Pelvic floor overactivity (hypertonic dysfunction) can paradoxically coexist with weakness, creating mixed-type pelvic floor dysfunction 4

Evidence for Pelvic Floor Physical Therapy

Efficacy for Urinary Retention and Pelvic Floor Dysfunction

• PFPT has robust evidence-based support as a first-line treatment for most pelvic floor disorders, including voiding problems and pelvic pain 2
• PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction 2
• An individualized PFPT program aimed at normalizing pelvic floor function (as opposed to pure Kegel strengthening) can reduce urinary symptoms and pelvic pain 4

Efficacy for Hypertonicity and Nerve-Related Pain

• PFPT appears efficacious in patients with chronic pelvic pain syndrome, vulvodynia, and dyspareunia—conditions sharing the same hypertonicity mechanism as post-hemorrhoidectomy nerve pain 3
• Three of 4 randomized controlled trials found positive effects of PFPT compared to controls on pain, pelvic floor muscle tone, sexual function, symptom scores, and quality of life 3
• Patients with pelvic floor overactivity demonstrated statistically significant decreased pelvic pain (p < 0.001) after individualized PFPT that included relaxation training 4

Guideline Support

• The American Society of Clinical Oncology (ASCO) states that pelvic floor physiotherapy may be beneficial for patients experiencing symptoms of potential pelvic floor dysfunction, including persistent pain and urinary leakage 5
• The AUA/SUFU guideline recommends pelvic floor muscle training as first-line therapy for overactive bladder and urinary symptoms 5
• Cognitive behavioral therapy and pelvic floor (Kegel) exercises may be useful to decrease anxiety and discomfort and lower urinary tract symptoms 5

Treatment Algorithm for Post-Hemorrhoidectomy Complications

For Urinary Retention (Within 6–8 Hours Postoperatively)

1. Assess for catheter reinsertion if unable to void within 6–8 hours 1
2. Initiate PFPT consultation if retention persists beyond 24 hours or recurs after catheter removal 1, 2
3. Focus on pelvic floor relaxation techniques rather than strengthening, as hypertonicity is the likely mechanism 4, 3

For Nerve Pain or Hypersensitivity (Persistent Beyond 2 Weeks)

1. Refer to pelvic floor physical therapist for individualized assessment to determine whether underactive, overactive, or mixed-type dysfunction is present 4
2. If hypertonicity is identified, prioritize relaxation training (manual therapy, biofeedback, breathing exercises) before any strengthening 4, 3
3. If mixed-type dysfunction, treat with combination of relaxation training followed by strengthening 4
4. Continue PFPT biweekly for 8–12 weeks, as this duration showed significant improvement in multiple studies 6, 3

Adjunctive Measures

• Combine PFPT with topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours to reduce anal sphincter spasm and associated pain 1
• Maintain bulk-forming laxatives and adequate hydration to prevent straining that exacerbates pelvic floor tension 1, 7
• Limit narcotic analgesics when possible, as they worsen urinary retention 1, 8

Critical Pitfalls to Avoid

• Do not assume all post-hemorrhoidectomy voiding difficulty is solely due to the anorectal procedure—systematically assess for medications, fluid status, or pre-existing bladder dysfunction 1
• Never prescribe pure Kegel strengthening exercises without first assessing for hypertonicity, as strengthening an already overactive pelvic floor worsens pain and urinary symptoms 4, 3
• Avoid attributing persistent pain (>2 weeks) to "normal postoperative healing" without evaluating for pelvic floor dysfunction, as early PFPT intervention prevents chronic pain 1, 3
• Do not delay PFPT referral beyond 4 weeks if symptoms persist, as chronic pelvic floor dysfunction becomes more difficult to treat 2, 3

Limitations and Nuances

• Perioperative PFPT (before or after pelvic surgery) has conflicting evidence, with one randomized trial showing no difference in quality of life at 24 weeks compared to standard care 6
• However, this study focused on pelvic organ prolapse surgery, not hemorrhoidectomy, and may not be directly applicable 6
• Standards of PFPT treatment protocols vary widely, so outcomes depend heavily on therapist expertise and individualized assessment 2, 3
• Most PFPT studies have high risk of bias due to lack of comparison groups, small sample sizes, and non-standardized interventions 3