Post-Operative Care After Hemorrhoidectomy

Pain Management

The World Journal of Emergency Surgery recommends administering paracetamol and NSAIDs on a fixed schedule, combined with short-acting opioids only as rescue medication 1
Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours reduces anal sphincter spasm and associated pain 2

The World Journal of Emergency Surgery and Praxis Medical Insights recommend prescribing bulk-forming laxatives starting immediately postoperatively and adding osmotic laxatives if bulk-forming agents alone are insufficient 1, 2
Patients should increase dietary fiber to 25-30 grams daily and maintain adequate hydration 1, 2

Praxis Medical Insights recommends warm sitz baths 3-4 times daily and after each bowel movement to reduce inflammation and promote healing 2
Remove urinary catheter within 24 hours after surgery in most cases to reduce urinary retention risk 1, 2

Praxis Medical Insights states that minimal spotting on toilet paper or small amounts in the toilet bowl is normal and typically resolves within 7-14 days 2
Bright red blood filling the toilet bowl, passage of clots, or bleeding requiring pad changes constitutes excessive bleeding requiring immediate evaluation 2
Urinary retention occurs in 2-36% of patients, and catheter reinsertion should be considered if unable to void within 6-8 hours 2

Praxis Medical Insights recommends assessing pain control, bowel function, and wound healing at the first post-operative visit 2
Evaluate for complete wound healing and resolution of symptoms at the second follow-up 2
Conventional excisional hemorrhoidectomy has a recurrence rate of only 2-10%, making it the most definitive treatment 2

Praxis Medical Insights warns against attributing significant bleeding or anemia to "normal postoperative bleeding" without proper evaluation 2
Never continue topical corticosteroids beyond 7 days, as prolonged use causes irreversible thinning of perianal tissue 2

Urinary retention occurs in approximately 2 % to 36 % of patients after hemorrhoidectomy, making it one of the most common postoperative complications; the wide range reflects differences in surgical technique, anesthesia type, and patient characteristics. (Evidence from observational studies) 3, 4
Adding a lateral internal sphincterotomy (LIS) to hemorrhoidectomy reduces the overall incidence of urinary retention compared with hemorrhoidectomy alone. (Evidence from comparative studies) 3, 4

Post‑operative urinary retention is primarily driven by reflex inhibition of detrusor muscle contraction caused by anal‑region pain and internal sphincter spasm. (Mechanistic insight) 3
Excessive retraction or dilation of the anal canal during surgery can injure the internal sphincter, further contributing to urinary retention. (Surgical‑technique related mechanism) 3
Narcotic analgesics administered for postoperative pain impair bladder sensation and detrusor contractility, increasing the risk of retention. (Pharmacologic effect) 4

Parasympathomimetic agents have been investigated as a strategy to prevent postoperative urinary retention, but study results have been mixed, indicating uncertain benefit. (Therapeutic trial) 4

Clinicians should avoid attributing all postoperative voiding difficulty solely to the anorectal procedure; a systematic assessment for other contributors such as medications, fluid status, or pre‑existing bladder dysfunction is essential. (Clinical guidance) 3

Avoid excessive anal dilation during hemorrhoidectomy, as it is associated with a ≈ 52 % long‑term fecal incontinence rate and an increased risk of urinary retention. (Outcome data) 3, 4

The ASCO recommends that pelvic floor physiotherapy be considered for patients who develop symptoms suggestive of pelvic floor dysfunction—such as persistent postoperative pain and urinary leakage—following hemorrhoidectomy. This recommendation is based on expert consensus rather than graded evidence. 5

The AUA/SUFU guideline designates pelvic floor muscle training as the first‑line therapeutic option for overactive bladder and other urinary symptoms that may arise after hemorrhoidectomy, emphasizing functional retraining over isolated strengthening. The guideline does not assign a specific strength grade but reflects a strong clinical preference. 6

According to ASCO, integrating cognitive‑behavioral therapy with pelvic floor (Kegel) exercises can help reduce anxiety, discomfort, and lower urinary tract symptoms in patients experiencing postoperative pelvic floor issues after hemorrhoidectomy. This recommendation is based on expert opinion without a formal evidence grading. 5