Does removal of a single hemorrhoidal cushion during hemorrhoidectomy cause a noticeable decrease in rectal fullness?

Removal of a Single Hemorrhoidal Column and Rectal Fullness Sensation

Removing a single hemorrhoidal column during hemorrhoidectomy will not cause a noticeable decrease in rectal fullness sensation in most patients, because the hemorrhoidal cushions themselves do not contribute meaningfully to normal rectal distension awareness—that function depends on intact rectal wall compliance and sensory thresholds, which remain unchanged after limited excision. 1

Physiological Basis of Rectal Sensation

The sensation of rectal fullness arises from mechanoreceptors in the rectal wall that respond to distension, not from the hemorrhoidal cushions themselves. 2 The hemorrhoidal cushions (corpus cavernosum) contribute to anal continence by providing fine-tuning of the anal seal, but they do not serve as primary sensory organs for detecting rectal contents. 3

Evidence from Limited Hemorrhoidectomy Studies

• A retrospective study of 115 patients who underwent one-quadrant or two-quadrant hemorrhoidectomy showed that 96% experienced initial relief of symptoms, with no significant difference in recurrent anorectal symptoms compared to three-quadrant excision (34% vs. 29%, respectively). 1
• The study demonstrated that focused treatment of problematic columns is effective, with fewer than 2% requiring further procedural intervention over a mean 8.1-year follow-up. 1
• Importantly, no patients reported altered rectal sensation or awareness of fullness as a complication after limited hemorrhoidectomy. 1

Changes in Rectal Physiology After Hemorrhoidectomy

Rectal Compliance and Sensory Thresholds

• After closed hemorrhoidectomy, rectal compliance actually increases significantly (P < 0.001), meaning the rectum becomes more distensible, not less. 4
• Volume thresholds for first sensation remain stable or increase after traditional hemorrhoidectomy, indicating that patients do not develop heightened awareness of rectal contents. 4
• The physiological differences observed between patients with different hemorrhoid grades are abolished after treatment, suggesting these changes are consequences rather than causes of hemorrhoidal disease. 4

Contrast with Stapled Hemorrhoidopexy

It is critical to distinguish limited hemorrhoidectomy from stapled hemorrhoidopexy, which does alter rectal sensation:

• After stapled hemorrhoidopexy, rectal distensibility and volume thresholds for sensations decrease significantly (P < 0.02), meaning patients become more aware of smaller rectal volumes. 2
• This altered distensibility is associated with fecal urgency and increased stool frequency in 41% of patients after stapled procedures. 2
• The mechanism involves removal of a circumferential ring of rectal mucosa above the anal canal, which fundamentally changes rectal wall mechanics—a completely different operation than excising a single hemorrhoidal column. 5

Clinical Implications and Patient Counseling

What Patients Should Expect

• Removal of a single hemorrhoidal column addresses the symptomatic tissue (bleeding, prolapse, thrombosis) without altering the patient's baseline awareness of rectal fullness. 1
• The hemorrhoidal cushions contribute to continence through vascular engorgement that fine-tunes the anal seal, but this function is preserved when only one column is removed. 3
• Postoperative pain, urinary retention (2-36%), and bleeding (0.03-6%) are the primary concerns after hemorrhoidectomy, not altered rectal sensation. 6

Common Pitfalls to Avoid

• Do not confuse the role of hemorrhoidal cushions in continence with their role in rectal sensation—these are distinct functions. 3
• Avoid attributing any postoperative changes in bowel habits to "loss of rectal fullness sensation" when the more likely causes are postoperative pain, dietary changes, or stool softener use. 7
• Recognize that if a patient reports altered rectal sensation after limited hemorrhoidectomy, this suggests other pathology (such as sphincter injury from excessive retraction) rather than the expected outcome of single-column excision. 6

Supporting Evidence from Anal Physiology Studies

• A prospective study comparing rubber band ligation (which preserves tissue) to closed hemorrhoidectomy showed that basal and squeeze pressures dropped after hemorrhoidectomy (P < 0.001), but rectal compliance increased in both groups. 4
• Critically, no patients in either group reported altered awareness of rectal fullness despite these measurable physiological changes. 4
• The presence of muscle fibers in hemorrhoidectomy specimens is a normal feature and does not correlate with functional deficits when proper surgical technique is used. 3

Definitive Recommendation

Patients should be counseled that removing a single hemorrhoidal column will not diminish their ability to sense rectal fullness. 1 The hemorrhoidal cushions do not function as sensory organs for detecting stool in the rectum—that role belongs to stretch receptors in the rectal wall, which remain intact after limited excision. 2, 4 Any postoperative changes in bowel habits are far more likely to result from pain, dietary modifications, or stool softeners than from altered rectal sensation. 7