Three years after hemorrhoidectomy, the patient has persistent anal guarding, altered urinary pattern, and abnormal rectal sensations; is this due to chronic pelvic‑floor hypertonicity or partial pudendal nerve injury that could improve with sphincter release, or is it permanent nerve damage?

Post-Hemorrhoidectomy Chronic Pelvic Floor Hypertonicity

This is almost certainly chronic pelvic-floor muscle guarding and hypertonicity rather than permanent nerve damage, and specialized pelvic-floor physical therapy with internal myofascial release should be initiated immediately as the primary treatment. 1

Why This Is Muscle Dysfunction, Not Nerve Injury

• Hemorrhoidectomy is a superficial procedure that involves only the anal canal and does not approach the deep pelvic autonomic nerves (hypogastric plexus, pelvic splanchnic nerves) responsible for bladder and sexual function. 2
• The deep autonomic pathways controlling urination lie several centimeters away from the hemorrhoidectomy surgical field and are anatomically protected. 2
• Permanent autonomic nerve injury from hemorrhoidectomy would cause complete loss of bladder sensation or erectile/ejaculatory dysfunction, not the altered sensations and guarding pattern this patient describes. 2
• The majority of individuals with pelvic-floor muscle dysfunction achieve clinically meaningful improvement when therapy targets muscle tension and guarding rather than structural damage. 1

The Pathophysiology of Chronic Guarding

• Pelvic-floor muscle tension and protective guarding patterns commonly develop during the painful post-hemorrhoidectomy period and persist long after tissue healing is complete. 2
• Neuropathic pain and dysesthesia—rather than structural sphincter or nerve damage—frequently occur after hemorrhoidectomy and anal surgery. 2
• Elevated anal resting pressure is documented in hemorrhoid patients, but resting tone normalizes after hemorrhoidectomy in most cases, indicating that sphincter hypertonicity is secondary, not permanent. 3, 4
• In one prospective study of 385 patients, sphincter overactivity resolved in 98.3% of patients by 12 months post-hemorrhoidectomy, confirming that chronic hypertonicity is reversible. 4

Primary Treatment: Pelvic-Floor Physical Therapy

Initiate specialized pelvic-floor physical therapy 2–3 times per week, incorporating internal myofascial release, external perineal work, gradual desensitization, and coordinated muscle-retraining. 1

Core Therapeutic Components

• Internal myofascial release is employed to deactivate trigger points and reduce hypertonicity within the deep pelvic floor musculature. 1
• External myofascial techniques focus on the perineum and surrounding soft tissues to alleviate peripheral tension. 1
• Gradual desensitization exercises are used to diminish hypersensitivity and burning sensations in the anoderm. 1
• Muscle-coordination retraining restores normal timing and synergy of pelvic-floor contraction and relaxation during voiding and sexual activity. 1
• Structured pelvic-floor exercise programs reliably increase muscle strength and endurance, which is associated with reductions in lower urinary-tract symptoms and better quality-of-life scores. 1

Expected Outcomes

• Patients who complete a targeted pelvic-floor program typically experience resolution of muscle hypertonicity, leading to improved bladder sensation and sexual function. 1
• Myofascial release and desensitization techniques markedly reduce burning and tightness sensations in the anoderm. 1

Adjunctive Pharmacologic Measures

• Apply topical lidocaine 5% ointment to the affected anoderm to manage neuropathic burning pain. 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours can relax residual internal anal sphincter hypertonicity and reduce pain, with a 92% resolution rate in post-hemorrhoidectomy patients. 5, 6
• Nifedipine works by inhibiting calcium channels in vascular smooth muscle, lowering internal anal sphincter tone without systemic side effects. 6, 5

Lifestyle and Bowel Management

• Avoid straining during defecation, as excessive intra-abdominal pressure can perpetuate pelvic-floor dysfunction. 1
• Consume 25–30 g of dietary fiber daily together with adequate hydration to prevent constipation that may exacerbate symptoms. 1
• Limit topical corticosteroid use to ≤7 days; longer courses risk mucosal thinning and symptom worsening. 1

When to Consider Advanced Evaluation

• Refer promptly to a pelvic-floor physical therapist experienced in post-surgical pelvic pain; delayed therapy makes chronic muscle guarding harder to reverse. 1
• If symptoms persist after 8–12 weeks of dedicated therapy, consider dynamic pelvic MRI to rule out structural complications such as anal stenosis (0–6% incidence post-hemorrhoidectomy) or sphincter defects (up to 12% incidence with excessive retraction). 1, 2
• Urodynamic testing may be indicated for ongoing bladder complaints despite optimal pelvic-floor rehabilitation. 1
• Referral to a pelvic-pain specialist or urogynecology/urology service is advised when comprehensive evaluation is needed to exclude other etiologies such as overactive bladder or unrelated sexual dysfunction. 1

Critical Pitfalls to Avoid

• Do not assume persistent symptoms represent permanent autonomic nerve injury, because hemorrhoidectomy spares deep pelvic autonomic pathways. 1, 2
• Never proceed with repeat anal surgery (sphincterotomy, revision hemorrhoidectomy) without first completing a full course of pelvic-floor physical therapy, as additional sphincter manipulation will worsen incontinence risk (2–12% baseline incidence) and may exacerbate guarding. 2, 3
• Avoid attributing all symptoms to "nerve damage" when the clinical picture—chronic guarding, altered but not absent sensation, and pain—is classic for reversible pelvic-floor hypertonicity. 1, 2

Rare True Nerve Injury

• In the exceptional case of true pudendal nerve injury from excessive intraoperative traction, patients present with complete sensory loss, not altered sensation, and electrophysiologic studies (pudendal nerve motor latency) would demonstrate denervation. 7
• One small case series identified seven patients with isolated rectal pain after colorectal surgery who required surgical resection of rectal sensory branches of the pudendal nerve, but this represents a rare subset with complete diagnostic nerve blocks confirming the diagnosis. 8
• This patient's presentation—guarding, altered (not absent) sensation, and urinary changes—does not fit the profile of structural nerve transection and should be managed as muscle dysfunction first. 1, 2