Complications of Hemorrhoid Surgery

The following are various possible complications from hemorrhoidectomy.

Pain

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 urination
  • 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 urinate.

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 post-operative IV.

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

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 colon.

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 Hemorrhage

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

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 doctor.

Mucosal Prolapse

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 Deformity

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 this growth.

Anal and Rectal Stricture / Stenosis

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 stenosis.

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 / Stenosis

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.

Anal Fistula

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 Cyst

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.

Infection

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

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 itself.

Itching that is caused by unusual wound healing (such as ectropion) and mucous discharge require treatment of the underlying condition.

Soilage or Fecal incontinence

Soilage or fecal incontinence following hemorrhoid surgery affects mostly elderly patients, who often already have history of soilage.

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.


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