A hemorrhoidectomy is widely considered one of the most painful elective surgeries, and the data backs that reputation. In a large multicenter trial of over 700 patients, the median peak pain score during the first three days was 5 out of 10, with nearly half of patients hitting the 6-to-10 range on a standard pain scale.1PubMed Central. Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial The good news is that the worst of it is concentrated in the first few days, it drops sharply by about a week, and there are real choices in surgical technique, anesthesia, and medication that meaningfully change how much you hurt during recovery.
The Pain Timeline
The first 72 hours after surgery are the hardest stretch. That multicenter trial found an average peak pain score of about 5 on a 0-to-10 scale during those initial three days, but the spread was wide: roughly 39% of patients never reached a 5, while 46% experienced scores between 6 and 10.1PubMed Central. Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial By day 7, pain dropped substantially. The average fell to around 2.7, and only about 11% of patients were still reporting scores above 5 at that point.
What makes this timeline tricky is that pain is not steady. You can feel relatively comfortable lying on the couch and then experience a sharp spike during your first bowel movement, which many patients describe as the single worst moment of recovery. After the first few bowel movements, each one tends to hurt less, though discomfort with defecation can linger for two to three weeks as the surgical site heals. Most people are back to normal daily activities within two to four weeks, depending on the type of procedure and how many hemorrhoid columns were removed.
Why This Surgery Hurts So Much
The anal canal is one of the most nerve-rich areas of the body, packed with somatic sensory fibers that register sharp, precise pain rather than the dull ache you might feel from abdominal surgery. When tissue is excised from this area, you are left with open or sutured wounds in a spot that stretches every time you have a bowel movement. On top of that, the internal anal sphincter tends to spasm after surgery, creating a sustained, cramping pain that is distinct from the wound pain itself. This spasm is not just a minor annoyance; it is one of the main drivers of post-hemorrhoidectomy suffering and a specific target of several pain-management strategies discussed below.
Open Versus Closed Techniques
The two traditional approaches to hemorrhoidectomy are the open method (Milligan-Morgan), where the wound is left open to heal on its own, and the closed method (Ferguson), where the wound is sutured shut. Patients and surgeons often wonder whether one hurts less than the other, and the evidence is somewhat mixed. One randomized trial found that the closed group needed significantly less opioid medication afterward and reported lower pain at the first bowel movement, with only 15% requiring additional opioids compared to 45% in the open group.2PubMed. Open vs. closed hemorrhoidectomy Wound healing was also faster: about 75% of the closed group had healed at three weeks versus only 18% of the open group.
Another trial found a similar healing-time gap but reported no statistically significant difference in pain between the two methods.3PubMed. Closed vs. open hemorrhoidectomy–is there any difference? A third study reported roughly similar pain perception in both groups, though the closed wounds healed faster on average (about 15 days versus 22 days).4Pakistan Journal of Health Sciences. Comparison of Outcomes between Open and Closed Haemorrhoidectomy The overall picture is that the closed technique may give a modest early pain advantage and clearly heals faster, but the difference in pain is not dramatic enough that one method is universally recommended over the other.
Stapled Hemorrhoidopexy
Stapled hemorrhoidopexy works differently from traditional excision. Instead of cutting out the hemorrhoid tissue, a circular stapling device removes a ring of tissue higher up in the anal canal and pulls the hemorrhoids back into their normal position. Because the staple line sits above the nerve-rich zone, early pain is consistently lower. A large pragmatic trial published in The Lancet found that patients reported significantly less pain at one and three weeks compared to traditional excision, though the difference disappeared by six weeks.5The Lancet. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS) Multiple systematic reviews have confirmed reduced early pain, shorter hospital stays, and faster return to normal activities with the stapled approach.6PubMed Central. Stapled versus conventional surgery for hemorrhoids
The catch is recurrence. A study tracking patients for 12 months found that those who had stapled hemorrhoidopexy had a significantly higher recurrence rate compared to those who had conventional excision.7PubMed Central. Short term results of stapled versus conventional hemorrhoidectomy within 1 year follow-up A systematic review comparing all major operative techniques confirmed that excisional hemorrhoidectomy had the lowest recurrence rates at 12 months, in the range of 0 to 3%, while energy-based excisional tools showed similarly low rates.8East Central African Journal of Surgery. Comparative Evaluation on Operative Treatment Modalities for Hemorrhoidal Disease So the decision often comes down to a trade-off: less pain early on but a higher chance of the problem coming back, versus more pain up front but a more durable result.
Energy-Based Devices
Another way surgeons have tried to reduce pain is by replacing the traditional scalpel and diathermy with devices like LigaSure, which seals blood vessels using controlled energy with minimal heat spreading to surrounding tissue. A randomized trial found that patients in the LigaSure group reported significantly less pain at first defecation and on postoperative days 1 and 14 compared to conventional diathermy.9PubMed. Randomized, clinical trial of Ligasure vs conventional diathermy in hemorrhoidectomy A comparison with Ferguson’s method showed less blood loss, shorter operating time, and fewer complications alongside the pain benefit.10PubMed Central. Comparison of Ligasure Hemorrhoidectomy with Conventional Ferguson’s Hemorrhoidectomy The mechanism makes intuitive sense: less collateral tissue damage from heat means less inflammation and less pain. Because these devices still perform a full excision, they maintain the low recurrence rates of traditional surgery while shaving off some of the pain penalty.
How Anesthesia Choices Affect Recovery Pain
What happens in the operating room does not stay in the operating room when it comes to hemorrhoidectomy pain. The type of anesthesia your surgeon and anesthesiologist choose can shape your pain experience for the first day or two.
Pudendal nerve blocks, where local anesthetic is injected around the nerve that supplies sensation to the anal area, have shown a consistent advantage over spinal anesthesia in multiple studies. One trial found that patients who received a pudendal block went about 9 hours before feeling pain compared to just 3 hours for spinal anesthesia, and their pain scores were roughly half as high (2.7 versus 5.2 on a 10-point scale).11Diseases of the Colon & Rectum. The Effect of Pudendal Block on Voiding After Hemorrhoidectomy A more recent prospective study confirmed significantly lower pain scores at rest through 48 hours in the pudendal block group, along with much lower rates of urinary retention.12PubMed Central. Ultrasound-Guided Pudendal Nerve Block Combined with Propofol Deep Sedation versus Spinal Anesthesia for Hemorrhoidectomy That urinary retention point matters because it is the most common complication after hemorrhoidectomy, affecting roughly 14% of patients in a large retrospective study of over 2,000 cases.13PubMed Central. Predictors of postoperative urinary retention after semiclosed hemorrhoidectomy
Long-acting local anesthetics injected directly at the surgical site are another tool. Liposomal bupivacaine, a slow-release formulation, delayed the need for a first opioid dose to about 14 hours versus just over an hour with placebo, and pain scores through 72 hours were significantly lower.14Diseases of the Colon & Rectum. Bupivacaine Extended-Release Liposome Injection for Prolonged Postsurgical Analgesia in Patients Undergoing Hemorrhoidectomy When compared to standard bupivacaine rather than placebo, the liposomal version still reduced pain through 72 hours and cut opioid-related side effects from 35% down to 4%.15PubMed. A double-blind, randomized, active-controlled study for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation
Medications That Target Sphincter Spasm
Because so much of the pain comes from sphincter spasm rather than from the wound alone, relaxing that muscle is a direct route to relief. Several topical medications have been studied for this purpose. A meta-analysis found that topical diltiazem (a calcium channel blocker applied as an ointment) reduced pain scores significantly within 48 hours and continued to do so past 96 hours compared to placebo.16PubMed. Topical diltiazem ointment in post-hemorrhoidectomy pain relief A separate meta-analysis confirmed these findings and also looked at glyceryl trinitrate (GTN) and botulinum toxin, both of which reduced pain at day 7.17PubMed Central. Can Targeting Sphincter Spasm Reduce Post-Haemorrhoidectomy Pain?
One trial using a combination of GTN and lignocaine ointment found better pain relief and less oral analgesic use than either medication alone.18PubMed. Efficacy of combination of 0.2% GTN and lignocaine ointments in wound healing and pain relief after Milligan Morgan hemorrhoidectomy That said, not every trial has been uniformly positive. A randomized double-blind study of diltiazem gel found trends toward lower pain during defecation and fewer analgesic tablets used, but the differences did not quite reach statistical significance.19PubMed. A randomized, prospective, double-blind, placebo-controlled trial of the effect of diltiazem gel on pain after hemorrhoidectomy Still, the weight of the pooled evidence favors these topical agents as helpful add-ons, and they have few side effects.
Separately, applying a topical anesthetic cream (EMLA, a lidocaine-prilocaine mix) directly to the wound area significantly lowered pain scores, reduced opioid injections, and improved patient satisfaction in a controlled trial.20PubMed. Use of a topical anesthetic cream (EMLA) to reduce pain after hemorrhoidectomy Gabapentin, a nerve-pain medication taken by mouth starting before surgery, also showed strong results: pain scores on postoperative day 1 were roughly half those of the control group, and the benefit persisted through day 14.21PubMed. Gabapentin significantly decreases posthemorrhoidectomy pain
A systematic review looking across all these strategies concluded that a multimodal approach combining several interventions is likely the most effective path, though the ideal combination has not been nailed down yet.22PubMed Central. Strategies to Reduce Post-Hemorrhoidectomy Pain In practice, many colorectal surgeons already prescribe some combination of stool softeners, topical sphincter relaxants, oral pain medications, and sometimes gabapentin, tailoring the mix to each patient.
What Actually Helps at Home
Sitz baths, the warm shallow soaks that are almost universally recommended after anorectal surgery, have surprisingly weak evidence behind them. One randomized controlled trial found no significant difference in pain scores, analgesic use, or wound healing between patients who used sitz baths and those who did not.23PubMed. Warm sitz bath does not reduce symptoms in posthaemorrhoidectomy period A more recent trial told a somewhat different story, finding that early warm-water sitz baths did produce a statistically significant, though modest, reduction in wound pain.24PubMed. Effects of early warm water sitz bath on urinary retention and pain after haemorrhoidectomy At worst, sitz baths are harmless and may offer a small comfort benefit; at best, they provide real if moderate pain reduction.
Ice packing may actually be the stronger home remedy. A randomized trial directly comparing ice packs to warm sitz baths found lower pain scores within 16 hours, less swelling at 24 hours, better wound healing at one week, and significantly lower morphine use in the ice-packing group.25Diseases of the Colon & Rectum. Ice Packing Versus Warm Sitz Baths for Post-hemorrhoidectomy Pain Management If your surgeon does not mention ice, it is worth asking about.
Keeping your stool soft is one of the simplest and most controllable things you can do for yourself. A study examining stool form and post-hemorrhoidectomy pain found a clear relationship: the harder the stool, the more clinically significant the defecation pain.26PubMed Central. Pain at the First Post-hemorrhoidectomy Defecation Is Associated with Stool Form Drinking plenty of water and taking an oral laxative or stool softener as prescribed are not optional extras. They are core pain management.
Who Tends to Hurt More
Not everyone experiences the same level of pain after the same procedure, and several patient-specific factors play a role. A study developing a predictive score for post-excisional hemorrhoidectomy pain identified younger age, male sex, higher education level, constipation, the presence of an external hemorrhoid component, anxiety, and high resting anal sphincter tone as independent predictors of worse pain.27PubMed. Development and validation of a practical score to predict pain after excisional hemorrhoidectomy A retrospective analysis confirmed that age, sex, and the number of hemorrhoid columns removed were significant factors influencing pain at both three and seven days after surgery.28PubMed Central. Analysis of factors impacting postoperative pain and quality of life in patients with mixed hemorrhoids
The mental health angle is real too. A prospective cohort study found that patients with pre-surgical depression reported significantly higher pain scores afterward, and those with anxiety used substantially more painkillers on days two and three. Depression remained an independent predictor of pain even after adjusting for age, sex, and education.29PubMed Central. Psychological states could affect postsurgical pain after hemorrhoidectomy If you are dealing with anxiety or depression heading into surgery, flagging that for your care team is not an afterthought. It can change what pain-management plan they set up for you.
Urinary Retention After Surgery
Pain is the headline concern, but urinary retention is the complication you should know about going in. In a study of over 2,100 patients, roughly 14% developed difficulty urinating after surgery, sometimes requiring a catheter.13PubMed Central. Predictors of postoperative urinary retention after semiclosed hemorrhoidectomy Men, older patients, those with higher body weight, those who had more hemorrhoid columns removed, and those who needed additional pain medication all had higher odds. The choice of anesthesia matters here as well: pudendal nerve blocks were associated with considerably lower retention rates than spinal anesthesia.12PubMed Central. Ultrasound-Guided Pudendal Nerve Block Combined with Propofol Deep Sedation versus Spinal Anesthesia for Hemorrhoidectomy Limiting intravenous fluids during surgery and avoiding excessive opioids in the immediate postoperative period are practical steps your surgical team can take to reduce this risk.