Rectal Prolapse and Hemorrhoid Ligation: Key Insights

Hemorrhoid ligation / Rectal prolapse

Hello Dr.
Chang,
1.
I have been experiencing a protrusion of a mass during bowel movements for at least four to five years, which is a fleshy lump at least four to five centimeters in size that I have to push back in manually.
It is not painful and does not bleed.
Sometimes, when my stool is softer, or when I have diarrhea, or even when I overeat (with hard stool), I experience fecal incontinence where the stool uncontrollably comes out.
I have been taking large amounts of laxatives daily for over ten years during my university years due to severe constipation, but I have stopped taking laxatives for at least eight years now.
Could this be due to long-term laxative use leading to relaxation of the anal sphincter? Is the protruding mass during bowel movements a sign of rectal prolapse or prolapsed internal hemorrhoids?
2.
Due to the above issues, I visited a colorectal department at a large hospital yesterday.
The director was so busy that I didn't have the opportunity to ask my questions.
After a direct examination, I immediately underwent a rubber band ligation for internal hemorrhoids, with a total of four ligation procedures planned to see if that would help; if not, surgery would be necessary.
The ligation was done at 3 PM, and by 8 PM, one black rubber band had fallen off, but I am unsure if the other one has also fallen into the toilet.
Additionally, I still experience the same protrusion during bowel movements, which I have to push back in!
(1) Will the rubber band falling off after five hours affect the effectiveness of the ligation?
(2) Should I immediately return to see the director for further management? He scheduled me for a second ligation in two weeks.

(3) After the ligation that afternoon, I started feeling a soreness near the urethra late at night; is this normal?
I apologize for the lengthy questions, and I appreciate your help.
Thank you!

Ms. H, 40~49 year old female. Ask Date: 2023/08/23

Dr. Zhang Shuhao reply Surgery

1.
Based on your description, it seems more like rectal prolapse, and the severity has affected your quality of life.
Surgical intervention is recommended.
If there is a full-thickness bowel wall prolapse, it is not merely a hemorrhoid surgery; rather, it requires suspension or partial resection specifically for the rectal prolapse.

2.
During a digital examination, if the prolapse is not present, it is easy to overlook the severity of the rectal prolapse.
If it is indeed rectal prolapse, banding of internal hemorrhoids will not be effective; no matter how many times it is done, it will not work.
The rubber band will fall off immediately, usually because there is no suitable internal hemorrhoid to band.
If there is no discomfort, there is no need for an immediate follow-up.
The soreness near the urethra may be related to the banding, but since the rubber band falls off quickly, it is best to allow time for gradual recovery.

Reply Date: 2023/08/23

More Info

Dear Patient,
Thank you for your detailed questions regarding your symptoms and the recent procedures you've undergone. Let's break down your concerns regarding rectal prolapse and hemorrhoid ligation.

1. Understanding Your Symptoms: Based on your description, it sounds like you are experiencing rectal prolapse. This condition occurs when the rectum protrudes through the anus, which can happen during bowel movements, especially if there is straining involved. The fact that you have a "ball" of tissue that you can push back in, along with the history of constipation and laxative use, suggests that the pelvic floor and anal sphincter muscles may have been weakened over time. Chronic laxative use can indeed lead to decreased muscle tone in the anal sphincter, contributing to issues like fecal incontinence and rectal prolapse.

On the other hand, internal hemorrhoids can also cause similar symptoms, particularly if they become prolapsed. However, the significant size of the tissue you describe (4-5 cm) and the need to manually reduce it are more indicative of rectal prolapse rather than just hemorrhoids. It is essential to have a thorough examination by a colorectal specialist to confirm the diagnosis and determine the best course of action.

2. Regarding the Rubber Band Ligation: Rubber band ligation is a common procedure for treating internal hemorrhoids. The ligation works by cutting off the blood supply to the hemorrhoid, causing it to shrink and eventually fall off. If a rubber band falls off shortly after the procedure, it may not necessarily indicate failure, but it could affect the effectiveness of the treatment. The ligation typically requires some time to take effect, and it is not uncommon for some bands to fall off early. However, if you are still experiencing significant prolapse or if the tissue is still protruding after the procedure, it is crucial to follow up with your doctor.

3. Follow-Up with Your Doctor: Given that you are still experiencing the same symptoms after the ligation, it would be wise to contact your healthcare provider sooner rather than later. They may want to reassess your condition and determine whether additional treatment is necessary. It is essential to communicate any ongoing symptoms, especially if they are causing discomfort or concern.

4. Post-Procedure Symptoms: Feeling discomfort or a sensation of pressure near the urethra after the procedure can occur, especially if there was manipulation in the area during the ligation. However, if the discomfort persists or worsens, it is advisable to seek medical advice to rule out any complications.

In summary, your symptoms suggest rectal prolapse, which may be exacerbated by previous laxative use. The rubber band ligation is a standard treatment for hemorrhoids, but if you are still experiencing significant issues, a follow-up with your doctor is essential. They can provide a more tailored approach to your treatment and ensure that any complications are addressed promptly.

Please take care, and do not hesitate to reach out to your healthcare provider for further assistance. Your health and comfort are paramount.

Best regards.

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