Painful Bowel Movements: When Surgery is Necessary for Hemorrhoids

Painful bowel movements with bleeding?

Hello, doctor.
I have third-degree internal and external hemorrhoids, as well as anal fissures.
I experience sharp pain every time I have a bowel movement, and this has been ongoing for nearly ten years.
I have had internal hemorrhoids banded twice and have undergone two colonoscopies (both showing no polyps).
The most recent colonoscopy was five years ago.
For the past month and a half, every time I have a bowel movement, regardless of whether the stool is soft or hard, I notice blood dripping beforehand, and it is very painful when the stool is passing.
After the stool comes out, there is again blood dripping.

I would like to ask if, in the later stages of hemorrhoids, bleeding occurs with both soft and hard stools, does this mean that conservative treatment is no longer effective? Is surgery the only option? I feel anxious every time I have a bowel movement due to the pain.
If surgery is necessary, could you please advise which surgical method is most suitable for third-degree internal and external hemorrhoids? Thank you!

A-Ming, 40~49 year old female. Ask Date: 2024/03/05

Dr. Zhang Shuhao reply Surgery

Based on the description, the persistent pain and bleeding issues caused by internal and external hemorrhoids as well as anal fissures have affected your quality of life, and surgical treatment should be considered.
Hemorrhoid ligation is only applicable to internal hemorrhoids and cannot alleviate the pain associated with anal fissures and external hemorrhoids.
Given your condition, hemorrhoidectomy may be a more suitable option, especially considering that you have undergone multiple ligation treatments.
The surgical approach can involve traditional hemorrhoidectomy or energy-assisted excision.
Additionally, laser ablation can be considered, but its drawback is that it cannot simultaneously address the issue of anal fissures.
Ultimately, the choice of surgery should be determined by the physician based on your specific situation and diagnostic results.

Reply Date: 2024/03/05

More Info

When it comes to managing painful bowel movements, particularly in the context of advanced hemorrhoids and anal fissures, it is crucial to understand the underlying conditions and the potential need for surgical intervention. Based on your description, you are experiencing significant discomfort due to third-degree internal and external hemorrhoids, along with anal fissures, which have persisted for nearly a decade. The presence of bleeding during bowel movements, regardless of stool consistency, indicates that your condition may have progressed to a point where conservative treatments are no longer effective.

Understanding Hemorrhoids and Anal Fissures
Hemorrhoids are swollen veins in the lower rectum and anus that can cause pain, discomfort, and bleeding. They are classified into internal and external types, with third-degree hemorrhoids being those that protrude outside the anal canal and can be manually pushed back in. Anal fissures, on the other hand, are small tears in the lining of the anus, often caused by passing hard stools, which can lead to severe pain and bleeding during bowel movements.

When is Surgery Necessary?
Surgery is typically considered when conservative treatments—such as dietary changes, increased fiber intake, topical treatments, and sitz baths—fail to alleviate symptoms. Given that you have been dealing with this issue for a long time and are experiencing significant pain and bleeding, it may be time to discuss surgical options with your healthcare provider.
The decision to proceed with surgery often depends on several factors, including:
1. Severity of Symptoms: If you are experiencing severe pain and bleeding that affects your quality of life, surgery may be warranted.

2. Response to Conservative Treatments: If you have tried various non-surgical treatments without success, this may indicate that surgery is necessary.

3. Frequency of Fissures: Recurrent anal fissures can complicate hemorrhoid treatment and may necessitate surgical intervention.

Surgical Options for Hemorrhoids
There are several surgical procedures available for treating third-degree hemorrhoids, and the choice of procedure often depends on the specific characteristics of your hemorrhoids and your overall health. Some common surgical options include:
1. Hemorrhoidectomy: This is a surgical procedure that involves the complete removal of hemorrhoids. It is typically recommended for severe cases and can provide long-term relief, but it may involve a longer recovery period and postoperative pain.

2. Stapled Hemorrhoidopexy: This technique involves using a stapling device to reposition and secure the hemorrhoids back into their normal position within the rectum. It is less painful than traditional hemorrhoidectomy and has a quicker recovery time.

3. Rubber Band Ligation: This is a less invasive procedure where a rubber band is placed around the base of the hemorrhoid to cut off its blood supply, causing it to shrink and fall off. This method is generally used for smaller hemorrhoids.

4. Sclerotherapy: This involves injecting a solution into the hemorrhoid to shrink it. It is typically used for smaller hemorrhoids and may not be suitable for larger, third-degree hemorrhoids.

Conclusion
Given your symptoms and the duration of your condition, it is advisable to consult with a colorectal surgeon who can evaluate your specific situation and recommend the most appropriate surgical option. Surgery can significantly improve your quality of life by alleviating pain and preventing further complications. Additionally, addressing any underlying issues, such as dietary habits and bowel habits, will be essential in your recovery process. Remember, it is important to have an open discussion with your healthcare provider about your fears and concerns regarding surgery, as they can provide you with the necessary information and support to make an informed decision.

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