Proctologic Surgery Post-Operative Instructions
Pain from the operation site after proctologic surgery is almost inevitable, and the most important aim of treatment for the next few days is making you feel as comfortable as possible. The surgical wounds will eventually heal, whatever you do, so focus on treating your pain and the healing will generally take care of itself.
Take the pain pills when you need them and don’t try to tough it out! It is easier to stay out of pain than to get out of pain, so try to take pills before the pain gets too bad and, looking ahead before you have a bowel movement to keep the discomfort to a minimum when you eventually have to go. If you think you are getting through the pills too quickly, try alternating doses of Percocet or Norco with something like Advil (two or three pills every four hours), which may help keep you comfortable without getting too many of the side effects of the stronger pills. Don’t take extra Tylenol as it is already in both Percocet and Norco and it can cause liver problems if you take an excessive amount. Don’t worry about getting into addiction problems with pain pills if you are using them to treat real, acute pain. This won’t happen, and in any case, although I am very generous with prescriptions while patients are recovering, once they are healed there won’t be any more pain or prescriptions either! The real dangers of narcotics come with the treatment of chronic pain. The next best thing to the pain pills is a warm bath. A “sitz” bath is OK, but a deep bath or hot tub is better because it gives you and your pelvic muscles the best chance to relax, and spasm in the muscles around the rectum is a major source of pain. The bath can be as warm as comfortable, and it will sting when you first get in, nut after a minute or so you should get some relief. You can stay in the water for as long as you want without harming the wounds at all. Washing is also the only effective way (a handheld shower is the best) to get clean after a bowel movement. Plain water is the best, but soaps, Epsom salts, bubble bath, chlorine, etc. will do no harm.
An icepack can be helpful too in the first few days after surgery. Wrap a bag of frozen vegetables or some ice cubes up in a bath towel and press it onto the area. Don’t leave it on for more than 15-20 minutes as it can increase inflammation and swelling if you overdo it. Sometimes alternating ice with warm baths is a good idea.
Topical creams, ointments, and sprays are, unfortunately, of limited help. Nevertheless, if you want to try them, they are safe and may give you some relief. Nupercainal ointment or Lidocaine cream is the strongest over-the-counter brands, and there are really no prescription medications that do any better. Almost any topical anesthetic salve is safe to use for a short while, but if they seem to make things worse then you may be extra sensitive or even allergic to them and you should stop.
Pain can be made worse by over-activity in the first few days. Try to spend as much time as you can off your feet, and if you can, get your bottom up above the level of your shoulders. This will reduce the pressure on the hemorrhoidal area and reduce the tendency to swell. After the pain begins to subside, which may be the day after surgery for a minor procedure or a week later for major Hemorrhoidectomy, you can get back to normal activity gradually.
Bowel movements after surgery are always going to be the most painful, but it is much better to have a soft, easy bowel movement soon after the operation than a hard, constipated one a few days later.
Pain pills, inactivity, and changes in eating habits can make you more constipated than you would usually be. In addition, just the pain itself can make you delay going to the bathroom out of fear for what is going to happen when you get there! Because of all of this, you must get to work right away after the surgery to make sure that the bowel movements come regularly and are soft and easy.
Don’t try starvation! It doesn’t work (you will have bowel movements anyway) and it can lead to constipation. Take regular, small meals and try to keep your fiber intake up. Fiber (either in foods or in supplements like Metamucil) will work well for most patients, but if you are one of those unfortunate people who only get gas, cramps, and great big hard stools with fiber, then this is obviously not the approach for you. Small, slippery stools are ideal.
Sodium ducosate capsules (stool softener capsules, the 250mg dose twice a day is best) may be helpful and they don’t add bulk. These are marketed either as a generic or a Surfak, Colace, DSS, and other brand names. They are over-the-counter and not expensive. However, they are not very strong, and may not be enough if you have a tendency to hard stools and are taking a lot of pain pills. The next medication to try is Milk of Magnesia. The gel-caps may be adequate or you may need the liquid form to get a larger dose. Milk of Magnesia is not a true laxative, it is really just a strong stool softener and it, too, does not bulk up the stool as it softens it. Miralax is just as good and works the same way. However, you must be careful to start with small amounts and adjust the dose (start with a tablespoon or two at bedtime) to produce the stool softening effect without diarrhea, which is easy to get if you overdose! If the fiber and/or stool softening capsules are adequate there is no need to use Milk of Magnesia or Miralax, but if you have gone two or three days after surgery without a bowel movement, then start taking it right away and make sure you have a bowel movement within 24 hours.
Swelling is normal after any surgery, but it can be very pronounced after Hemorrhoidectomy. Until I started warning patients about this I had a number of phone calls from patients a few days after their procedure who thought that I had missed everything during the procedure and all the hemorrhoids had come back! The usual pain management advice I gave previously will also work to keep swelling to a minimum, but once the bowel movements start, a certain amount is inevitable. The good news is that most of the swelling will have disappeared by the time the healing is completed, and usually, all that is left is a few small skin tags.
The stitches I use during Hemorrhoid, Fissure, and Fistula surgeries all dissolve by themselves and do not need to be pulled out. After the bowel movements begin, sooner or later the stitches will break and often this will result in a little (or long) piece of dangling thread from the wound. If I see this during an office check-up I always cut it away, but if you notice it yourself and it is annoying you, and if you are flexible enough and have a suitable mirror, you can trim it yourself with a pair of blunt scissors.
All wounds in the anal and rectal region tend to open up in the post-operative period when the stitches dissolve and the wounds are stretched during bowel movements. This is quite normal and eventually, the skin edges grow in as healing progresses. However, while the wounds are open there is usually some drainage, which can be watery or bloody, and it can be quite heavy when there is any problem with infection. Keep the area washed regularly while drainage is occurring and wear a clean, dry pad to protect your clothes.
Itching in the post-operative period is partly from the healing process, but probably mainly from the moisture caused by the drainage. Keep the area as clean as possible and use some baby powder or cornstarch to stay as dry as possible, and this should get the itching cleared up quickly. If that is not enough, a barrier ointment like Desitin or Calmoseptine will be a big help.
Slight bleeding from the wounds, while you are healing, is normal, and it stops after ten to fourteen days with major surgery and sooner with a minor one. Heavier bleeding can occasionally happen, and the most common time for it is either the night of the operation or about a week later. If it is only a show of blood along with bowel movement it is usually not a problem and will clear up soon. Occasionally, the bleeding can get even heavier, and the time to call me is if the bleeding becomes continuous and you have to go to the bathroom just to pass blood on its own.
After hemorrhoid surgery, it is quite common for patients, especially men, to have some difficulty emptying their bladders. When people used to get General Anesthetics and stay in the hospital after surgery, it used to be common to use a catheter for the first night before they could urinate on their own, but this is rare now that people have lighter Anesthesia and go home right away. If you are having difficulty, the first thing to try is a good hot shower and, failing that, a good hot bath. The heat relaxes the pelvic muscles, which cause the problem by going into spasm and blocking off the outlet of the bladder. When you are trying to get the stream going, think “…relax…”, not “PUUUSH!”. If you are getting desperate and have tried everything, just go straight to the emergency room. They can use a quick in and out catheter to empty the bladder and make you feel a lot better. It is almost never necessary to do this more than once and it gets easier to pass urine every time after that.
In summary, pain after hemorrhoid surgery is a sad, but inevitable experience and there really will come a day when it has gone completely, and usually for good! My surgery colleagues or I will always be on call and available for special needs or problems, but we will not have any more advice to give about pain control other than what I have outlined above. If the pain level is intolerable using all these techniques, our next move is to admit a patient back to the hospital and use injectable medications, and you should call us if you think this may be necessary. Also, call if there is any other worrisome symptom that I have not covered above, and we will do our best to solve the problem. Otherwise, keep this information handy and use it!