Three years after hemorrhoidectomy, what normal sensation is expected and should persistent rawness be present?

Expected Sensation Three Years After Hemorrhoidectomy

Three years after hemorrhoidectomy, you should not experience persistent rawness—the surgical site should be fully healed with normal perianal skin and mucosa, though some patients report altered sensation or mild discomfort that reflects permanent nerve injury or scar tissue rather than ongoing healing. 1, 2

Normal Long-Term Expectations

Complete wound healing typically occurs within 6 weeks after open hemorrhoidectomy, with the median healing time being approximately 6 weeks. 3 By three years postoperatively, the following represents normal outcomes:

• Pain should be minimal to absent, with median pain scores dropping from 5.5/10 preoperatively to 0.1/10 at one year, and this improvement persists long-term. 3
• Anal discomfort similarly decreases from 5.5/10 to 0.1/10 by one year and should remain low thereafter. 3
• Anal sphincter function remains preserved in most patients, with mean resting pressure and squeeze pressure showing no significant changes at 6 months and beyond. 4, 5
• Continence is typically maintained, though 8.5% of patients may develop new mild incontinence (Wexner score >5), while 16.7% of those with preoperative incontinence actually improve. 3

When "Rawness" Indicates a Problem

Persistent rawness at three years is abnormal and warrants evaluation. 1, 2 This sensation most commonly reflects:

• Chronic neuropathic pain from permanent nerve injury during surgery, which affects the sensory nerves in the perianal region and does not represent ongoing tissue damage. 2
• Scar-related sensory alteration, where fibrotic tissue changes the normal sensory feedback from the anal canal. 2
• Anal stenosis, which occurs in 0-6% of patients and can cause ongoing discomfort, tightness, and a sensation of rawness. 1, 3
• Sphincter defects, documented by ultrasound in up to 12% of patients after hemorrhoidectomy, which can alter sensation and cause discomfort. 2, 3

Recommended Evaluation

You should undergo anoscopy to rule out anal fissure, recurrent hemorrhoids, or other anorectal pathology before attributing symptoms to postoperative changes. 1, 2

Anorectal manometry and endoanal ultrasound are advised to document any sphincter defects or stenosis that may be causing your symptoms. 2

Colonoscopy may be required if there is concern for inflammatory bowel disease or other pathology, as persistent symptoms must not be labeled "normal healing" without proper work-up. 2

Management Options for Persistent Symptoms

Topical Therapy

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied twice daily can reduce sphincter spasm and pain, achieving approximately 92% resolution in acute conditions, though efficacy for chronic neuropathic pain remains unproven. 1, 2
• Topical lidocaine 5% patches applied for 12-24 hours may provide gradual pain relief in chronic perianal discomfort. 1, 2
• Topical corticosteroids should be limited to ≤7 days maximum; longer use causes irreversible thinning of perianal tissue. 1, 2

Physical Therapy

• Pelvic floor physiotherapy is recommended by the American Society of Clinical Oncology for persistent postoperative pain after hemorrhoidectomy, based on expert consensus. 2, 6
• Combining cognitive-behavioral therapy with pelvic floor exercises can help reduce anxiety and discomfort. 2, 6

Biofeedback Limitations

• Biofeedback is unlikely to "re-train" deep rectal sensation or correct scar-related sensory alterations; any improvement is expected to be modest and largely non-specific. 2
• Two small randomized trials showed global symptom improvement with biofeedback programs, but a placebo-controlled trial of 60 patients found no additional benefit over attention-placebo control. 2
• Simple audio-guided relaxation may provide symptom relief comparable to formal biofeedback while requiring fewer resources. 2

Critical Pitfalls to Avoid

• Never assume persistent rawness is "normal" without proper evaluation—this symptom at three years indicates either undiagnosed pathology or permanent nerve/scar changes. 1, 2
• Avoid anal dilation, which is associated with approximately 52% long-term fecal incontinence rate and risk of sphincter injury. 1, 2
• Do not use topical corticosteroids for more than 7 days, as prolonged use causes irreversible tissue thinning. 1, 2
• Do not attribute symptoms to hemorrhoids without ruling out other causes such as inflammatory bowel disease, colorectal cancer, or anal fissure. 1

Surgical Considerations

For severe, refractory symptoms, referral to a pain management specialist for nerve blocks or other interventional techniques may be appropriate. 2

Surgical revision to address identified stenosis or scar tissue can be considered when anatomical abnormalities are confirmed on imaging, recognizing the additional operative risk. 2