Post-Operative Advice: Hemorrhoidectomy Under Spinal Anaesthesia

Eating and Drinking

• Immediately after surgery (day of procedure): Start with clear liquids - water, clear soups, juices, jelly. This prevents nausea and vomiting that can follow any anaesthetic (even spinal).
• From the next day onwards: Advance to a regular high-fibre diet - whole grains, leafy vegetables, fruits, and legumes.
• Drink plenty of water - at least 6-8 large glasses daily. This is especially important after hemorrhoidectomy because well-hydrated, soft stools cause far less pain and reduce the risk of wound disruption.

Note on spinal anaesthesia specifically: Unlike general anaesthesia, spinal anaesthesia does NOT cause bowel paralysis. There is no pharmacological reason to delay oral intake. Oral fluids can begin as soon as the patient is alert, not nauseated, and has her gag/swallow reflex intact - typically within 1-2 hours after the block.

Going to the Toilet to Pass Stools

• First bowel movement: This is expected within 2-3 days of surgery. She must NOT delay it out of fear of pain; doing so leads to constipation and a harder, more painful stool later.
• Stool softeners and mild laxatives should be prescribed on discharge (e.g., lactulose, docusate sodium/Colace) - this is standard post-hemorrhoidectomy management. - Fischer's Mastery of Surgery, 8th ed.
• Straining is the enemy - she must avoid straining at all costs, as this can tear the wound and cause bleeding.
• Pain at first bowel movement is expected - days 2-8 are typically the most painful. Applying a topical local anaesthetic gel (e.g., lidocaine gel) to the anal area before defecation helps significantly.
• She should aim for 1-2 soft, formed stools daily - not too loose (risk of soiling/infection) and not hard (risk of pain and wound damage).

Sitz Baths - Important Addition

• Sitz baths 2-3 times a day and after every bowel movement (sit in 6-8 inches of warm water for 15-20 minutes) - this relieves pain, promotes wound healing, and keeps the area clean.
• Start sitz baths the evening of surgery or next morning.

Key Warning Signs to Report

• Temperature above 38°C (100.4°F)
• Unable to urinate within 8 hours of surgery (urinary retention is a known complication, occurring in ~15% of hemorrhoidectomies - Mulholland & Greenfield's Surgery, 7th ed.)
• No bowel movement by day 3
• Heavy rectal bleeding (not just minor spotting)
• Severe pain uncontrolled by prescribed analgesia

Pain Management Reminder

• Multimodal analgesia: paracetamol (acetaminophen) + NSAIDs + minimal opioids. Gabapentin can be added safely.
• Opioids themselves cause constipation, so minimise their use. - Mulholland & Greenfield's Surgery, 7th ed.

• "Yes, start with clear liquids like water and soup today, then normal food from tomorrow - just choose high-fibre foods and drink lots of water. You can and should go to the toilet when you feel the urge - don't hold it in. Take the stool softener we prescribe, do warm sitz baths after every bowel movement, and use the gel for pain before you go. The first bowel movement may be painful but it's safe and important."

⚠️ CLINICAL ALERT: This is a Post-Operative Emergency

Differential Diagnosis - Most Likely to Most Critical

1. HIGH / TOTAL SPINAL BLOCK - Most Likely Explanation for Head-Low Position

• Sympathetic blockade → vasodilation → severe hypotension
• The "abdominal pain" may in fact be visceral discomfort from bowel ischaemia due to hypotension, or referred discomfort from diaphragmatic irritation with high block
• If the prone jack-knife position (used for hemorrhoidectomy) was used intraoperatively with a hyperbaric local anaesthetic, repositioning the patient postoperatively can cause unexpected cranial spread of the block

• Difficulty breathing, dyspnoea, shoulder or arm tingling/weakness
• Bradycardia (the "Bezold-Jarisch reflex" - vagal surge with sympathectomy)
• Hypotension (systolic <90 mmHg)
• Pallor, diaphoresis, nausea/vomiting

2. RECTAL/BOWEL PERFORATION - Must Exclude Urgently

• Forceful or aggressive dilatation was performed
• Pre-existing bowel wall weakness
• Patient was in prone jack-knife with poor visualisation

• Severe generalised abdominal pain (peritoneal contamination)
• Abdominal rigidity and guarding
• Septic shock - fever, tachycardia, hypotension (explaining the head-low position)
• Can present within hours of surgery

Published cases of rectal perforation post-hemorrhoidectomy causing peritonitis have been reported (PMC8272392), most after stapled procedures but also after conventional surgery. This is a surgical emergency.

• Urgent surgical review
• Erect CXR or CT abdomen (free gas under diaphragm = perforation)
• Blood cultures, IV antibiotics immediately (piperacillin-tazobactam + metronidazole)
• Emergency exploratory laparotomy if confirmed

3. INTRA-ABDOMINAL / PELVIC HAEMORRHAGE

• Bleeding from the dissection site can track intraperitoneally
• Presents as severe abdominal pain + haemodynamic instability (hypotension → head-low given)
• Tachycardia, dropping haematocrit
• Abdominal distension

4. VASOVAGAL SYNCOPE / REFLEX HYPOTENSION

• Very common after anorectal surgery
• Triggered by pain, anxiety, blood loss
• Presents: pallor, sweating, bradycardia, hypotension, feeling of faintness, sometimes epigastric discomfort misinterpreted as "abdominal pain"
• Head-low position is first-line correct treatment
• Usually self-limiting with positioning, fluids, and atropine if bradycardic

5. URINARY RETENTION WITH BLADDER DISTENSION

• Urinary retention occurs in up to 20% of hemorrhoidectomies (commonest complication)
• A massively distended bladder causes severe lower abdominal pain and discomfort
• Ask: has the patient urinated since surgery?
• Management: Urethral catheterisation - provides immediate relief

6. FECAL IMPACTION / GASEOUS DISTENSION

• Bowel handling during surgery + spinal anaesthesia can cause paralytic ileus or gaseous distension
• Distension causes crampy abdominal pain

Immediate Clinical Assessment Required - ABCDE Approach

• Vital signs monitoring (continuous)
• ECG (bradycardia from vagal/high spinal)
• SpO₂ continuous
• Erect CXR (free gas = perforation)
• FBC, urea/electrolytes, coagulation
• CT abdomen/pelvis with contrast (if haemodynamically stable)
• Bladder scan / catheterisation

Bottom Line Summary

1. High/total spinal block with sympathetic hypotension and visceral pain - treat with fluids, vasopressors, O₂
2. Rectal/bowel perforation with peritonitis - requires emergency surgery
3. Intraperitoneal haemorrhage - requires emergency surgery
4. Urinary retention - simplest and most common cause to rule out first with a bladder scan

Severe Abdominal Pain - 3 Hours Post-Hemorrhoidectomy + Anal Dilatation Under Spinal Anaesthesia

The Most Likely Diagnosis: URINARY RETENTION

• Spinal anaesthesia blocks S2-S4 sacral nerves - the same nerves that control bladder sensation and detrusor contraction
• The patient cannot feel the urge to void, so the bladder fills silently and massively
• At 3 hours post-op, the spinal block may still be partially active, or just wearing off - the patient now starts to feel the distended, overstretched bladder as severe lower/suprapubic abdominal pain
• A massively distended bladder (>500 mL) triggers reflex pain and can even cause a vasovagal response (bradycardia, hypotension) - which may itself be why the head-low protocol was initiated

"Patients usually complain of lower abdominal fullness, suprapubic pain, or discomfort. Although uncommon, the massively distended bladder can stimulate the vasovagal reflex causing cardiovascular symptoms, including bradycardia, arrhythmia, hypotension, or asystole." - Sabiston Textbook of Surgery

Assessment

• Have you passed urine since surgery? (Almost certainly: NO)
• Where exactly is the pain? (Lower abdomen / suprapubic)
• Does it feel like pressure or fullness in the lower tummy?

• Palpate suprapubically - a tense, dull, rounded mass in the suprapubic region = full bladder
• Percuss the lower abdomen - dullness up to the umbilicus in severe cases

• Bedside bladder ultrasound scan - the gold standard, quick, non-invasive
• Bladder volume ≥500 mL = intervention required

Treatment

• Insert a Foley catheter (12-14 Fr)
• Drain the bladder - patient will get immediate relief of the abdominal pain
• Record urine output (expect 500-800 mL or more)
• Leave catheter in situ for 12-24 hours, then trial of void

• Warm compress / hot pack to lower abdomen and perineum before attempting catheter
• Ambulate if safe (walking stimulates voiding)
• Minimise further IV fluids
• Alpha-blocker (tamsulosin 0.4 mg OD) can reduce recatheterisation rate in males

Other Causes to Keep in Mind (Less Likely at 3 Hours)

Bottom Line

Removing the Catheter at 12 Hours - Yes, with a Structured "Trial Without Catheter" (TWOC)

• Spinal block is fully resolved (typically resolves in 4-6 hours)
• Patient is stable and comfortable
• Bladder has had adequate rest and decompression
• 12 hours is a perfectly appropriate and standard time for TWOC in post-hemorrhoidectomy urinary retention

Before Removing - Check These Conditions Are Met

How to Do the TWOC

• Encourage him to drink 2-3 glasses of water before removal
• Give adequate analgesia first - pain causes urethral sphincter spasm and failed voiding
• Ask him to sit up or stand to void (not lying flat)

• Deflate the balloon fully (deflate before pulling)
• Withdraw gently - men may feel brief discomfort

• Patient should void within 2-4 hours of catheter removal
• Ask him to call when he first passes urine
• Note the time, volume, and ease of voiding

• After first void, do a bladder ultrasound scan
• PVR < 200 mL = successful TWOC ✅
• PVR ≥ 200 mL = recatheterise (bladder not emptying properly)

What to Tell the Patient

If He Fails the TWOC (Cannot Void or PVR ≥ 200 mL)

• Recatheterise for another 24-48 hours
• Start tamsulosin 0.4 mg once daily - alpha-blocker relaxes the bladder neck and urethral sphincter; takes 3-5 days for full effect
• Reassess daily
• If repeated failure → refer to urology

Key Point

Tamsulosin - NOT Required if TWOC is Successful

This Patient's Specific Context

When Tamsulosin IS Indicated

• TWOC fails - patient cannot void or PVR remains ≥ 200 mL after catheter removal
• The patient is older with likely subclinical BPH (benign prostatic hyperplasia)
• Recurrent retention episodes
• Retention was caused by opioid use, anticholinergics, or other ongoing reversible factors

Bottom Line

For a 26-year-old male, with no pre-existing urological disease, whose retention was caused entirely by spinal anaesthesia that has now fully worn off, and who passes urine successfully after TWOC - tamsulosin is not needed.

• Good pain control (pain-driven sphincter spasm is the main remaining risk)
• Adequate oral hydration
• Early ambulation
• Warm sitz baths (relax the perineal muscles)

Fever Within 4 Hours of Surgery - "IMMEDIATE" Post-Operative Fever

The 5 W's Framework - Timing of Post-Op Fever

Causes of Fever at 4 Hours Post-Op - This Patient

1. Surgical/Tissue Inflammatory Response - Most Common, Most Likely

• Surgery itself causes tissue trauma → release of IL-1, IL-6, TNF-α → hypothalamic fever response
• This is a normal physiological response to any surgical procedure
• Typically low-grade: 38.0 - 38.5°C
• Requires no treatment other than paracetamol/antipyretics
• Resolves on its own within 12-24 hours

2. Atelectasis

• Micro-collapse of lung segments from shallow breathing under/after anaesthesia
• Even under spinal anaesthesia, immobility and pain cause reduced tidal volume and shallow breathing
• Presents: low-grade fever, reduced breath sounds at bases, mild tachycardia
• Treatment: Deep breathing exercises, incentive spirometry, early ambulation, adequate analgesia so he can breathe deeply

3. Drug/Medication Reaction

• Anaesthetic agents, antibiotics given intraoperatively, latex allergy, IV fluids with additives
• Check what was given in theatre - antibiotics (e.g. cefazolin), local anaesthetic agents, sedation
• Usually self-limiting

4. Transfusion Reaction

• If any blood products were given intraoperatively - unlikely in hemorrhoidectomy but worth checking
• Presents within minutes to hours

5. Pre-existing Infection (Brought Into Theatre)

• Was there any pre-existing anorectal abscess, perianal sepsis, or systemic infection?
• Surgical manipulation can "stir up" a pre-existing infection → fever shortly after surgery

6. Malignant Hyperthermia - RARE but Life-Threatening - Must Exclude

• Triggered by volatile anaesthetic agents (halothane, sevoflurane, desflurane) or suxamethonium
• However: this patient was under spinal anaesthesia - if no volatile agents were used, malignant hyperthermia is effectively excluded
• If MH is suspected: very high fever (>39°C), muscle rigidity, tachycardia, rising CO₂ - emergency treatment with dantrolene

7. Bacteraemia from Bowel Manipulation

• Hemorrhoidectomy + anal dilatation involves the heavily colonised anal canal
• Transient bacteraemia from instrumentation can occur
• Usually self-limiting in a healthy 26-year-old with intact immunity

Assessment - What to Do Now

• Respiratory: breath sounds, SpO₂ (atelectasis)
• Skin: rash, flushing (drug reaction)
• Abdomen: any new rigidity, guarding (surgical complication)
• Wound/perineum: unusual swelling, discharge, crepitus (necrotising infection - rare but fatal)
• Calves: DVT unlikely at 4 hrs but check

• Full vital signs (HR, BP, RR, SpO₂, temperature)
• FBC (white cell count - though may not be elevated this early from infection)
• CRP (non-specific at this stage)
• CXR if SpO₂ dropping or respiratory symptoms
• Blood cultures only if temp ≥ 38.9°C or patient looks unwell

One Critical Warning - Necrotising Soft Tissue Infection (NSTI)

• Fever disproportionate to clinical appearance
• Severe pain, swelling, crepitus (gas) in perineal/scrotal region
• Rapidly deteriorating patient

Bottom Line for This Patient

1. Measure temperature precisely
2. Check SpO₂ and respiratory status
3. Give paracetamol 1g IV/oral as antipyretic + analgesic
4. Encourage deep breathing exercises
5. Check the wound/perineal area
6. Monitor - if fever resolves within a few hours with paracetamol → reassure and observe
7. If fever persists beyond 24-48 hours or is >38.9°C → investigate seriously for infection

Paracetamol (PCM) 1g - Correct Dose for This Patient

Standard Adult Paracetamol Dosing

Why 1g and Not 500 mg?

• 500 mg is a sub-therapeutic dose for an adult - it is typically used for mild pain in patients with risk factors (low body weight <50 kg, elderly, hepatic impairment)
• 1g achieves better antipyretic and analgesic effect in a healthy adult
• Post-hemorrhoidectomy pain is significant - 1g is appropriate for both fever AND analgesia simultaneously
• Multimodal analgesia guidelines after hemorrhoidectomy specifically recommend paracetamol 1g + NSAIDs as the backbone - Mulholland & Greenfield's Surgery, 7th ed.

When to Reduce to 500 mg

• Weight < 50 kg
• Hepatic impairment (chronic liver disease, alcoholism)
• Severe renal impairment (eGFR < 30)
• Elderly / frail patients