Anal Stenosis After Hemorrhoid Surgery: Key Insights

Postoperative anal stenosis following hemorrhoid surgery?

Hello Dr.
Ke,
I have read through your responses multiple times, but I still feel anxious.
On January 7th of this year, I underwent a minimally invasive complete excision of hemorrhoids at Far Eastern Memorial Hospital.
However, at that time, I was unaware that minimally invasive procedures could vary, such as PPH and other techniques; I only knew that I had to pay nearly NT$30,000 out of pocket.
My recovery period was normal, with daily bowel movements of 2 to 3 well-formed stools that were not overly dry.
I paid close attention to my diet, ensuring I consumed 20 to 30 grams of fiber daily, and I also drank 2,000 to 2,500 cc of water, as I work from home.
However, without any changes to my diet or routine, I began experiencing issues around February 10th.
When having a bowel movement, I had to exert significant effort to pass the stool, and the process was accompanied by intense tearing pain due to the stool stretching the anal opening; the stool also had blood in it.
Most importantly, I noticed that the stool was noticeably thinner than before, with a diameter ranging between 1 to 5 cents.
On February 17th, I returned for a follow-up appointment, and the surgeon performed a digital rectal examination.
During the exam, I experienced severe tearing pain at the 6 o'clock position of the anus (facing the groin).
After the examination, I started to bleed, but I was unsure of the bleeding source.
The surgeon stated that there was no anal or rectal stricture.
When I asked why I felt like my stool was stretching the anal opening, he explained that the scar tissue from the surgery lacked elasticity, causing the anal opening to narrow.
I inquired about how to resolve this and whether I needed anal dilation; he suggested that continuing regular bowel movements would help restore normal function.
I also asked why I bled during the exam, and he said it was due to the relaxation of the scar tissue.
Finally, he prescribed me medication for two weeks, assuring me that there would be no further issues.
The medications prescribed were:
- Tranexamic acid: for hemostasis
- Magnesium oxide: for stool softening
- Polyethylene Glycol 4000: for mild laxation
I would like to ask Dr.
Ke:
1.
If the digital rectal examination showed no anal stricture, can I be assured that there is truly none?
2.
Will the scar tissue from the hemorrhoid surgery really return to normal with continued bowel movements?
3.
I am unclear about the logic behind the surgeon's medication prescriptions.
If I take stool softeners and laxatives, which may lead to looser stools, does that negate the effect of relaxing the scar tissue through bowel movements? If my bowel movements are normal, do I still need to take these medications? Did the surgeon mistakenly think I was constipated?
4.
If my condition does not improve after two weeks, will I need to undergo another surgery? Just thinking about it makes me feel helpless...

Wang Rongrong, 30~39 year old female. Ask Date: 2024/02/17

Dr. Ke Fangxu reply Surgery

1.
Anal stenosis is not always a complete or absolute condition; it can vary in severity.
While a digital rectal examination can help determine the presence of stenosis, there are different degrees of narrowing.
It is generally accepted that if the examination causes pain, it indicates some level of stenosis.

2.
Mild stenosis may gradually improve over time, while more severe cases may require surgical intervention or anal dilation for correction.
3.
The use of stool softeners helps to soften the stool, thereby reducing pain during bowel movements.
The expectation is that scar tissue will soften over time, leading to gradual improvement of the stenosis.
4.
Unless the case is very severe, anal stenosis is typically monitored for six months before deciding on surgery.
This period allows for the absorption of scar tissue.
If symptoms do not improve or worsen after six months, surgical treatment may then be considered.

Reply Date: 2024/02/17

More Info

After undergoing hemorrhoid surgery, it is not uncommon for patients to experience complications such as anal stenosis, which can lead to difficulties in bowel movements. Anal stenosis refers to the narrowing of the anal canal, which can cause pain, straining, and bleeding during defecation. Your experience of needing to exert significant effort to pass stool, along with the presence of blood and the sensation of tearing pain, suggests that you may be dealing with this condition.

1. Is there really no anal stenosis if the doctor did not find it during the examination?
While your doctor did not identify any anal stenosis during the digital examination, it is important to note that the absence of visible narrowing does not completely rule out the possibility of functional stenosis. The scar tissue from the surgery can create a less elastic area that may not be easily detected during a physical exam. The sensation of needing to push harder and the presence of thinner stools can indicate that the anal canal is not functioning optimally, even if it appears normal structurally.

2. Will the scar tissue really return to normal with continued bowel movements?
Scar tissue can indeed change over time, but it may not always return to its original state. The elasticity of the scar tissue can improve with regular bowel movements, as the act of passing stool can help to stretch the area. However, this process can take time, and in some cases, additional interventions may be necessary if symptoms persist. It is crucial to maintain a high-fiber diet and adequate hydration to facilitate smoother bowel movements, which can help in reducing the strain on the anal area.

3. What is the rationale behind the prescribed medications?
The medications prescribed by your doctor serve specific purposes. Tranexamic acid is used to help control bleeding, while magnesium oxide and polyethylene glycol 4000 are intended to soften the stool and promote regular bowel movements. While it may seem counterintuitive to take laxatives if you are not constipated, these medications can help ensure that your stools remain soft and manageable, reducing the risk of further tearing or irritation of the scar tissue. If you are already having regular bowel movements without straining, you might not need to continue these medications indefinitely, but it is essential to follow your doctor's advice regarding their use.

4. What if the situation does not improve in two weeks?
If your symptoms do not improve after two weeks, it is advisable to follow up with your healthcare provider. They may consider further evaluation, which could include imaging studies or a more detailed examination to assess the anal canal's function. In some cases, if significant stenosis is confirmed or if conservative measures fail, surgical intervention may be necessary to relieve the narrowing. However, it is essential to discuss all options with your doctor, who can provide guidance based on your specific situation.

In summary, while your current symptoms are concerning, they are not uncommon after hemorrhoid surgery. It is crucial to maintain open communication with your healthcare provider and to adhere to their recommendations regarding medication and dietary adjustments. If symptoms persist or worsen, do not hesitate to seek further evaluation to ensure that you receive the appropriate care.

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