What are the recommended postoperative follow‑up schedule and care instructions after hemorrhoidectomy?

Postoperative Follow-Up After Hemorrhoidectomy

Patients should be seen at 1–2 weeks and again at 3–4 weeks postoperatively to assess pain control, bowel function, wound healing, and complications. 1

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First Postoperative Visit (1–2 Weeks)

Primary objectives: Assess pain control, bowel function, and early complications. 1

Pain Assessment and Management

• Verify that patients are taking paracetamol and NSAIDs on a fixed schedule (not as-needed), with short-acting opioids reserved only for breakthrough pain. 1
• If anal sphincter spasm persists, prescribe topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours to reduce spasm-related pain. 1
• Most patients require narcotic analgesics during the first 2–4 weeks and cannot return to work during this period. 2, 3

Bowel Function Evaluation

• Confirm that patients are taking bulk-forming laxatives (started immediately postoperatively) and add osmotic laxatives if constipation persists. 1
• Reinforce dietary fiber intake of 25–30 grams daily with adequate hydration to prevent straining. 1
• Patients should continue warm sitz baths 3–4 times daily and after each bowel movement to reduce inflammation and promote healing. 1

Bleeding Assessment

• Minimal spotting on toilet paper or small amounts in the toilet bowl is normal and typically resolves within 7–14 days. 1
• Bright red blood filling the toilet bowl, passage of clots, or bleeding requiring pad changes constitutes excessive bleeding and requires immediate evaluation—do not attribute this to "normal postoperative bleeding." 1
• Severe bleeding typically occurs 1–2 weeks after surgery when the eschar sloughs, affecting 0.03–6% of patients. 2

Urinary Function Monitoring

• Urinary retention occurs in 2–36% of patients after hemorrhoidectomy. 1
• If the patient was catheterized postoperatively, verify that the catheter was removed within 24 hours (standard practice). 1
• If urinary retention develops, consider catheter reinsertion if the patient cannot void within 6–8 hours. 1

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Second Postoperative Visit (3–4 Weeks)

Primary objectives: Evaluate complete wound healing, resolution of symptoms, and identify late complications. 1

Wound Healing Assessment

• In closed (Ferguson) hemorrhoidectomy, wounds heal primarily over 4–8 weeks; 75% of patients have healed by 3 weeks. 3, 4
• In open (Milligan-Morgan) hemorrhoidectomy, wounds heal by secondary intention over 4–8 weeks; only 18% have healed by 3 weeks. 3, 4
• Perform anoscopy to directly visualize healing and rule out early anal stenosis (occurs in 0–6% of patients). 2

Symptom Resolution

• Verify resolution of bleeding, pain, and prolapse—conventional excisional hemorrhoidectomy has a recurrence rate of only 2–10%, making it the most definitive treatment. 2, 1
• If symptoms persist or worsen, reassess for complications such as abscess formation (0.5–5.5% incidence), incomplete excision, or alternative diagnoses. 2

Late Complication Screening

• Anal stenosis develops in 0–6% of patients and may present as difficulty with bowel movements or thin stools. 2
• Sphincter defects occur in up to 12% of patients and may manifest as fecal leakage or incontinence; if present, consider anorectal manometry and referral for pelvic floor physical therapy. 2, 1

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Critical Pitfalls to Avoid

• Never attribute significant bleeding or anemia to "normal postoperative bleeding" without proper evaluation—colonoscopy may be required to exclude proximal colonic pathology. 1
• Never continue topical corticosteroids beyond 7 days, as prolonged use causes irreversible thinning of perianal tissue. 1
• Do not delay evaluation of urinary retention—catheterization should be considered if the patient cannot void within 6–8 hours postoperatively. 1
• Avoid assuming all postoperative pain is normal—severe pain with fever and urinary retention suggests necrotizing pelvic sepsis, a rare but life-threatening complication requiring emergency evaluation. 2

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Long-Term Follow-Up Considerations

• Most patients return to work within 2–4 weeks after conventional hemorrhoidectomy. 2, 3
• Long-term recurrence rates are 2–10% for conventional excisional techniques, making additional follow-up beyond 3–4 weeks unnecessary unless symptoms recur. 2, 1
• If fecal incontinence develops, pelvic floor physical therapy should be considered as first-line treatment. 1