What is a hemorrhoidectomy

Hemorrhoidectomy is a hemorrhoid surgery where the enlarged hemorrhoids are removed (“ectomy” means “removal”) using instruments like scissors, a scalpel or a laser. Hemorrhoidectomy can be done in your health care provider’s office or in the hospital operating room. In most cases, you can go home the same day. In some approaches the wound is left open afterwards, in others it is partially or completely closed with stitches. These types of surgical techniques are referred to as “open,” “partially open,” or “closed.” Leaving the wound partially or completely open has the advantages of fewer stitch-related complications and fewer hematoma (bruising) problems. One disadvantage is that it takes longer for open wounds to heal.

The type of hemorrhoidectomy surgery you have depends on your symptoms and the location and size of the hemorrhoid.

Before the hemorrhoidectomy surgery, your doctor will numb the area so you can stay awake, but not feel anything. For some types of surgery, you may be given general anesthesia. This means you will be given medicine in your vein that puts you to sleep and keeps you pain-free during surgery.

Regardless of which operation they have, most patients experience pain in their anal region afterwards. Bowel movements and sitting may hurt as a result. These problems can usually be treated with painkillers. Other problems that may arise include bleeding after the operation, wound infections, abscesses, narrowing of the anus (anal stenosis), and – rarely – fecal incontinence. Fecal incontinence is the inability to control bowel movements.

The cause of post-operative excisional hemorrhoidectomy pain is multi-factorial with secondary bacterial colonization, inflammation and anal sphincter spasm/hypertonicity all purposed to play a role ¹. Several pharmacological agents have been introduced in the last two decades targeting specific parts of the hypothesized pathway of pain pathogenesis showing promising improvements.

Metronidazole is part of the nitroimidazole class of antibiotics and primarily affects anaerobic bacteria and protozoa and traditionally has been used in surgical prophylaxis and treating anaerobic infections. It has been postulated to decrease pain following excisional hemorrhoidectomy via two mechanisms; first by decreasing secondary bacterial colonization and hence reducing post-operative inflammation; and second via a hitherto poorly understood direct anti-inflammatory response. The oral route has been initially investigated but topical administration has more recently been mooted for analgesia and theoretically reduces the unpleasant systemic side effects of oral administration. A research group ¹ has recently completed a systematic review of both oral and topical administration of metronidazole. This review showed benefit in reducing postoperative hemorrhoidectomy pain from both routes of administration but this far there has been no comparison of the two routes.

Metronidazole has been proposed to have both anti-bacterial and pleiotropic anti-inflammatory properties but its precise mechanism of action is unknown. The investigators hope research into this drug will enable its use beyond that of hemorrhoidectomies, with possible multiple applications into other similar operations.

Hemorrhoidectomy may involve:

• Putting a small rubber band around a hemorrhoid to shrink it by blocking blood flow.
• Stapling a hemorrhoid to block blood flow, causing it to shrink.
• Using a knife (scalpel) to remove hemorrhoids. You may or may not have stitches.
• Injecting a chemical into the blood vessel of the hemorrhoid to shrink it.
• Using a laser to burn the hemorrhoid.

Often you can manage small hemorrhoids by:

• Eating a high fiber diet
• Drinking more water
• Avoiding constipation (taking a fiber supplement if needed)
• Not straining when you have a bowel movement

When these measures do not work and you are having bleeding and pain, your doctor may recommend hemorrhoid surgery.

Before the hemorrhoidectomy surgery

Be sure to tell your doctor:

• If you are or could be pregnant
• What medicines you are taking, including drugs, supplements, or herbs you bought without a prescription
• If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day

During the days before the surgery:

• You may be asked to temporarily stop taking blood thinners such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), clopidogrel (Plavix), warfarin (Coumadin).
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, try to stop. Smoking can slow healing. Ask your provider for help quitting.
• Let your provider know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery. If you do get sick, your surgery may need to be postponed.

On the day of your hemorrhoidectomy surgery:

• Follow your provider’s instructions about when to stop eating and drinking.
• Take any medicines you are asked to take with a small sip of water.
• Follow instructions on when to arrive at your provider’s office or at the hospital. Be sure to arrive on time.

Hemorrhoidectomy recovery

You will usually go home the same day after your hemorrhoidectomy surgery. Be sure you arrange to have someone drive you home. You may have a lot of pain after hemorrhoidectomy surgery as the area tightens and relaxes. You may be given medicines to relieve pain.

Regardless of which operation they have, most patients experience pain in their anal region afterwards. Your anal area will be painful or ache for 2 to 4 weeks. Bowel movements and sitting may hurt as a result. These problems can usually be treated with painkillers. It is common to have some light bleeding and clear or yellow fluids from your anus. This is most likely when you have a bowel movement. These symptoms may last for 1 to 2 months after surgery.

Most people do very well after hemorrhoid surgery. You should recover fully in a few weeks, depending on how involved the surgery was.

After 1 to 2 weeks, you should be able to do most of your normal activities. But don’t do things that require a lot of effort. It is important to avoid heavy lifting and straining with bowel movements while you recover.

You will need to continue with diet and lifestyle changes to help prevent the hemorrhoids from coming back.

Follow instructions on how to care for yourself at home.

Pain Management

Your doctor will give you a prescription for pain medicines. Get it filled right away so you have it available when you go home. Remember to take your pain medicine before your pain gets severe.

• You may apply an ice pack to your bottom to help reduce swelling and pain. Wrap the ice pack in a clean towel before applying it. This prevents cold injury to your skin. Do not use the ice pack for more than 15 minutes at a time.
• Your doctor may recommend that you do a sitz bath. Soaking in a warm bath can also help relieve pain. Sit in 3 to 4 inches (7.5 to 10 centimeters) of warm water a few times a day.

Medications

• Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructions about taking any new medicines.
• If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. He or she will tell you if and when to start taking those medicines again. Make sure that you understand exactly what your doctor wants you to do.
• Be safe with medicines. Read and follow all instructions on the label.
• If the doctor gave you a prescription medicine for pain, take it as prescribed.
• If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
• If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.
• You may apply numbing medicines before and after bowel movements to relieve pain.

Wound Care

Follow instructions on how to care for your wound.

• You may want to use a gauze pad or sanitary pad to absorb any drainage from the wound. Be sure to change it often.
• Ask your doctor when you can start taking a shower. Usually, you can do so the day after surgery.

Diet

• Follow your doctor’s instructions about eating after surgery.
• Start adding high-fiber foods to your diet 2 or 3 days after your surgery. This will make bowel movements easier. And it lowers the chance that you will get hemorrhoids again.
• If your bowel movements are not regular right after surgery, try to avoid constipation and straining. Drink plenty of water. Your doctor may suggest fibre, a stool softener, or a mild laxative.

Activity

Gradually return to your normal activities.

• Rest when you feel tired.
• Be active. Walking is a good choice.
• Avoid lifting, pulling, or strenuous activity until your bottom has healed. This includes straining during bowel movements or urination.
• Depending on how you feel and the type of work you do, you may need to take time off work.
• As you start feeling better, increase your physical activity. For example, do more walking.
• You should have a complete recovery in a few weeks.

Hemorrhoidectomy recovery time

Recovery time depends on the type of procedure you had. In general:

• You may have a lot of pain after surgery as the area tightens and relaxes. Take the pain medicines on time as instructed. DO NOT wait until the pain gets bad to take them.
• You may notice some bleeding, especially after your first bowel movement. This is to be expected.
• Your doctor may recommend eating a softer diet than usual for the first few days. Ask your doctor about what you should eat.
• Be sure to drink plenty of fluids, such as broth, juice, and water.
• Your doctor may suggest using a stool softener so that it is easier to have bowel movements.

Hemorrhoidectomy recovery tips

• Sitz bath: Sit in 8 to 10 centimeters of warm water for 15 to 20 minutes 3 times a day and after bowel movements. Then pat the area dry. Do this as long as you have pain in your anal area.
• Avoid sitting on the toilet for long periods of time or straining during bowel movements.
• Keep your anal area clean.
• Support your feet with a small step stool when you sit on the toilet. This helps flex your hips and places your pelvis in a squatting position. This can make bowel movements easier after surgery.
• Use baby wipes or medicated pads, such as Tucks, instead of toilet paper after a bowel movement. These products do not irritate the anus.
• If your doctor recommends it, use an over-the-counter hydrocortisone cream on the skin in your anal area. This can reduce pain and itching after surgery.
• Apply ice several times a day for 10 minutes at a time.
• Try lying on your stomach with a pillow under your hips to decrease swelling.
• You may take showers and baths as usual. Pat your anal area dry when you are done.
• You will probably need to take 1 to 2 weeks off work. It depends on the type of work you do and how you feel.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines you take.

Hemorrhoidectomy complications

Hemorrhoidectomy surgery complications include:

• Leaking a small amount of stool (long-term problems are rare)
• Narrowing of the anus (anal stenosis)
• Problems passing urine because of the pain

Risks for anesthesia and surgery in general are:

• Reactions to medicines, breathing problems
• Bleeding, blood clots and infection

1. Topical Versus Oral Metronidazole Following Excisional Haemorrhoidectomy. https://clinicaltrials.gov/ct2/show/NCT03343509[↩][↩]