of Hemorrhoid Surgery
The following are various possible
complications from hemorrhoidectomy.
Pain is the most common reason why patients avoid hemorrhoid
surgery – therefore, although it is not technically
a complication, pain is an important factor in discussing
surgery as a treatment option.
Management of pain frequently includes the use of opiate
pain killers, such as morphine and morphine-like painkillers
(Demerol, Toradol, etc). Morphine can be delivered either
as an epidural (that is solution of morphine delivered directly
to the dura layer of the spinal cord through catheter), injection,
IV drip, and even a pump installed under the skin.
Studies have also suggested that direct injection of painkiller
to the anal sphincter muscle during surgery can reduce post-operative
pain and other side effects, such as urinary retention.
Urinary Retention or
Inability to Urinate
Inability to urinate is the most common complication from
hemorrhoid surgery. It occurs in 20% of hemorrhoid surgery.
Fortunately, for most patients, urinary retention is a temporary
condition that heals itself within a day or so.
Urinary retention is most likely caused by:
- Pain and spasm after surgery, or even fear of pain during
- Fluid overload
- The use of spinal anesthesia and/or anticholinergic medicine
to keep the airways open
- Rough handling of tissue during surgery
- Too many sutures and the use of heavy suture materials
- Tight and bulky wound dressing
- Too many hemorrhoid ligations
- Rectal blockage by feces
Pain and having too fluid are the main two causes of urinary
retention. Without adequate pain medications, it simply hurts
too much for the patient to relax the sphincter muscle to
Fluid overload can be prevented by limiting drinking until
the morning after the operation, giving minimal IV infusion
during surgery, and using an intermittent drip system for
Spinal anesthesia is also associated with higher rate of
urinary retention than local painkillers.
Interestingly, a patient’s anxiety and expectation
of pain can have direct effect on his or her inability to
urinate. Like a self-fulfilling prophecy, the incidence of
urinary retention can go up if the patient realizes that if
he or she cannot urinate, then the doctor may order the insertion
a catheter or drainage tube! Too many reminders from the nursing
staff about urinating can also hamper the patient’s
effort to do so!
Most patients will resume normal urination by the next morning
after the surgery. However, in some cases, if there is more
than 500 ml of urine in the bladder, a catheter needs to be
inserted into the bladder for 24 hours to help drain away
urine. If there is less than 500 ml of urine, then there is
no need to leave the catheter in for that long.
Urinary Tract Infection
Infection of the urinary tract is not a direct complication
of hemorrhoid surgery per se. It is actually a complication
of the insertion of a non-sterile catheter, which is used
to help with urinary retention. It’s like a complication
that generates a complication.
Most urinary tract infection can be readily treated with
antibiotics, although in rare cases, chronic infection, bladder
inflammation (cystitis), as well as kidney and pelvis inflammation
(pyelonephritis) can also occur.
Constipation after hemorrhoid surgery is very common, and
is usually a direct result of the patient’s fear of
pain during elimination. Other reasons include the use of
anesthesia and bed rest. If the patient has a history of irregular
bowel function or difficulty in elimination, then constipation
can usually be expected.
Although the patient’s fear is perfectly understandable,
avoiding bowel movement after surgery can lead to fecal impaction
or a condition where the stool becomes dry and hard in the
Fortunately, constipation resolves itself within one to two
days after the surgery. However, if 3 days after the operation
there is no bowel movement, a laxative is usually then prescribed.
In most cases, bulking agents such as fibers are also prescribed.
After the first evening of surgery, the patient is also encouraged
to drink a lot of water to help soften the stool. If laxatives
don’t work, then a tap water enema is used.
Massive Bleeding or
Massive bleeding or hemorrhage is unusual and is always the
result of bad surgical practice. Normally, this is caused
by improper suturing of the tissue after the hemorrhoidal
mass is cut away.
Bleeding is treated by use of a solution of adrenaline or
epinephrine to help blood clot, as well as direct pressure
with a gauze or finger.
In approximately 2% patients, bleeding can occur approximately
a week to 2 weeks after surgery. These patients usually experience
slight bleeding, followed by the anal passage of blood-clotted
tissue, and then massive bleeding. This is usually due to
rupture in suture or infection of the surrounding tissue.
Patients with delayed hemorrhage require immediate medical
attention, and may require hospitalization. Insertion of a
drainage line or catheter to help drain away blood, packing
with wound dressing to stop the bleeding, re-suturing of the
wound, as well as blood transfusion may be required.
Anal tags are skin growth around the anus that forms during
wound healing (similar to the way a scar forms). It interferes
with proper cleansing after bowel movement, and can become
irritated and itchy. These skin tags can be cut away by a
If not adequately removed during surgery, the mucous tissue
in the rectum can form an uncomfortable lump in the anal canal
that need to be removed. It can also itch and/or cause mucous
discharge through the anus.
In rare cases, the entire tissue can prolapse or jut out
of the anal canal.
Minor mucosal prolapse is treated in similar fashion as rubber
band ligation of hemorrhoids – a small rubber ring is
put on the lump to cut off its blood circulation. Within a
few weeks, the withered mass of tissue would be sloughed off
along with the rubber band during regular bowel movement.
Ectropion or Whitehead
If after incision, too much of the rectal mucous tissue is
cut away or if it is not properly anchored, it can heal outside
of the anus in a condition called anal ectropion or Whitehead
deformity. Ectropion can also lead to mucous discharge, itchiness,
and skin irritation. A simple excision can be done to eliminate
Anal and Rectal Stricture
If too much rectal mucosal tissue and skin are removed during
surgery of a particularly large hemorrhoid, a large scar tissue
may develop. Over time, this scar tissue would cause the narrowing
of the anal canal in a condition called anal stricture or
As with ectropion, anal stricture can be avoided by preserving
as much mucous tissue or skin bridges as possible. However,
in rare instances of large or infected hemorrhoids and fissure,
there may not be any viable option other than to remove all
skin bridges and face the potential development of anal stricture
as a complication.
If this is the case, then daily digital examination of the
anal canal (i.e. using a finger to check for wound healing)
or the use of an anal dilator (a tool to enlarge the anal
canal) is necessary. If the wound heals without stricture,
then digital examination and the use of dilator is stopped,
usually within 6 to 8 weeks.
Treatment for anal stricture is anoplasty or plastic surgery
of the anus.
Rectal Stricture /
A similar condition to anal stricture, rectal stricture is
the narrowing of the rectum due to too many or too vigorous
ligation of hemorrhoids in one area of the rectum. Because
the symptoms can be similar to anal stricture, rectal stricture
is often misdiagnosed.
Treatments for rectal structure include the use of dilators
and proctoplasty (surgery).
Anal Fissure and Ulcer
A tear in the anal canal, called an anal fissure, may result
as a complication of hemorrhoidectomy. If left untreated,
the fissure may become infected and develop into a chronic
and painful ulcer.
Treatments for anal ulcer include using laxatives, enemas,
suppositories and local painkillers to aid bowel movement,
as well as using a dilator. In extreme cases, surgery –
in the forms of internal anal sphincterotomy (where the ulcer
is excised followed by anoplasty where the anal opening is
enlarged) – may be required.
A fistula is a tunnel-like tract that extends from an infected
gland in the anal canal to an external opening in the skin
near the anus. It is rare complication and occurs in less
than 1% of hemorrhoid surgeries.
A fistulotomy or surgical removal of an anal fistula can
be often performed in the doctor’s office, without the
need of hospitalization.
Pseudopolyps and Epidermal
When the hemorrhoid is cut away, there is a “stem”
or stump of tissue left behind. These stump tissues are usually
ligated or sutured. In some cases, tissue death can occur
at the location of these stumps, thus resulting in wounds
that subsequently heal in a “lumpy” fashion called
pseudopolyps. The presence of suture material is also though
to promote pseudopolyp formation.
Pseudopolyps can be removed by excision by a doctor.
In rare cases, months after the hemorrhoid surgery, an epidermal
cyst or sac-like lump appears in the anal canal and/or around
the anus. These cysts usually do not have any symptoms, although
they can cause general discomfort. If so, they can be simply
removed by excision.
Given the fact that feces carry many bacteria, it is actually
surprising that hemorrhoid surgery is not followed more often
by infection or sepsis.
Some doctors thought that this is because the major veins
draining away from the rectum passes through the liver, which
actively filters away bacteria and other microorganisms.
Pruritus Ani or Anal
Itching is usually the result of over-cleaning of the anus,
which irritates the skin. It can also be due to allergic reaction
to certain food.
Anal itching after surgery is not unusual, and may be caused
by skin irritation after surgery. Although uncomfortable,
itching is usually a temporary condition that goes away by
Itching that is caused by unusual wound healing (such as
ectropion) and mucous discharge require treatment of the underlying
Soilage or Fecal incontinence
Soilage or fecal incontinence following hemorrhoid surgery
affects mostly elderly patients, who often already have history
It used to be thought that accidental removal of nerves in
the anal canal lead to the loss of anal canal sensation and
control of sphincter muscle – however, there are no
solid data to support this hypothesis.
In cases of profound soilage, especially in patients with
mucous prolapse, a sphincterotomy or cutting of the anal sphincter
muscle can be performed.