Association Between Hemorrhoidectomy and Sexual Dysfunction: A Prospective Case-Control Study Using the Natsal-SF Scale

Association Between Hemorrhoidectomy and Sexual Dysfunction: A Prospective Case-Control Study Using the Natsal-SF Scale | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association Between Hemorrhoidectomy and Sexual Dysfunction: A Prospective Case-Control Study Using the Natsal-SF Scale Oscar Santes, Rogelio Zayas-Borquez, Noel Salgado-Nesme, Paulina Huchim, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7781921/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Haemorrhoidectomy is a common surgical treatment for advanced haemorrhoidal disease, but its potential impact on postoperative sexual function is underexplored. This study aimed to evaluate the association between haemorrhoidectomy and short-term sexual dysfunction using the validated, gender-inclusive Natsal-SF scale. Methods: This was a prospective, case-control study conducted at a tertiary referral centre. Forty adults with symptomatic hemorrhoidal disease were included: 20 underwent haemorrhoidectomy (cases) and 20 received conservative medical management (controls). The main outcome was sexual dysfunction at 30 days post-intervention, defined as reporting problems in ≥2 items of the Natsal-SF questionnaire. Associations were analysed using univariate and multivariate methods. Results: Sexual dysfunction was significantly more frequent in the haemorrhoidectomy group compared to controls (85% vs. 25%, p<0.002). The most affected domains were physiological function—including erectile or lubrication difficulties (70%)—and overall sexual satisfaction (60%). After adjusting for age, sex, immunosuppression, psychiatric history, and haemorrhoid grade, the association remained statistically significant (p=0.023). Conclusion: Haemorrhoidectomy is associated with a high incidence of early postoperative sexual dysfunction. The Natsal-SF, a comprehensive and inclusive tool, was effective in identifying this frequently neglected outcome. Preoperative counselling for haemorrhoidectomy should address potential sexual side effects. Haemorrhoidectomy Sexual Dysfunction Natsal-SF Pelvic Floor Proctology Quality of Life Figures Figure 1 Figure 2 Figure 3 What this paper adds to the literature This study is the first to use a contemporary, gender-inclusive sexual function scale (Natsal-SF) in a prospective, controlled design to assess outcomes after haemorrhoidectomy. It quantifies a high, previously under-reported incidence of sexual dysfunction, highlighting a critical gap in patient counselling and postoperative care. Introduction Hemorrhoidal disease is one of the most prevalent conditions affecting the lower gastrointestinal tract, imposing a significant burden on patient quality of life, particularly among the working-age population [ 1 ]. For symptomatic grade III and IV haemorrhoids, or for lower grades refractory to medical management, surgical haemorrhoidectomy remains a common and effective intervention [ 2 ]. While considered safe, the procedure is not without complications. The literature has traditionally focused on postoperative outcomes such as pain, bleeding, anal stenosis, and alterations in faecal continence [ 3 ]. However, the potential impact on sexual function has been largely overlooked and remains poorly understood. The existing evidence regarding sexual function after proctological surgery is sparse and contradictory. Some studies, primarily in male populations, suggest that haemorrhoidectomy may actually improve erectile function, postulating that the resolution of chronic pelvic pain and vascular congestion alleviates a pre-existing inhibitor of sexual performance [ 4 ]. Conversely, other reports, particularly those including women, have documented a significant increase in sexual dysfunction post-surgery, with complaints of pain and decreased satisfaction being common [ 5 ]. This discrepancy highlights a critical knowledge gap and underscores the need for additional investigation. A major contributor to these conflicting findings is likely the historical reliance on limited and often inappropriate measurement tools. Many studies have employed instruments such as the International Index of Erectile Function (IIEF) for men and the Female Sexual Function Index (FSFI) for women [ 4 ]. These questionnaires, while validated for specific purposes, possess significant limitations for research in a diverse surgical population. Both the IIEF and FSFI were originally designed to assess arousal disorders in specific clinical trial settings and have demonstrated psychometric weaknesses in other domains, particularly sexual desire and orgasm. Furthermore, their focus on heterosexual, penetrative intercourse fails to capture the full spectrum of sexual experiences, practices, and orientations, potentially leading to an incomplete or biased assessment of sexual well-being [ 6 ]. To address these shortcomings, a more holistic assessment tool is required. The National Survey of Sexual Attitudes and Lifestyles Short Form (Natsal-SF) is a contemporary, 17-item questionnaire designed specifically for use in community and clinical surveys [ 7 ]. It has been psychometrically validated across genders, sexual orientations, and relationship statuses, and its multidimensional structure assesses not only physiological responses but also the crucial emotional, relational, and satisfaction components of sexuality [ 8 ]. By adopting a biopsychosocial framework, the Natsal-SF provides a more comprehensive and inclusive measure of sexual function. Therefore, the primary objective of this study was to prospectively evaluate the association between haemorrhoidectomy and short-term sexual dysfunction using the Natsal-SF scale in a controlled setting. Methods Study Design and Setting This was a prospective, non-randomized, case-control study conducted at the National Institute of Medical Sciences and Nutrition Salvador Zubiran, a tertiary referral centre in Mexico City, Mexico. Patient recruitment and follow-up occurred between July 2023 and May 2024. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. To the best of our knowledge, there is currently no published Core Outcome Set (COS) specifically addressing sexual dysfunction after proctological procedures such as haemorrhoidectomy. Nevertheless, we employed a validated and inclusive patient-reported outcome measure (Natsal-SF), aligning with the COS initiative’s goals of standardizing outcome reporting. Participants Consecutive adult patients (age > 18 years) of both sexes presenting to the coloproctology clinic with a diagnosis of symptomatic hemorrhoidal disease were assessed for eligibility. Inclusion criteria were: reported sexual activity at the time of initial assessment, absence of known pre-existing sexual dysfunction determined by a preoperative Natsal-SF questionnaire, no other concurrent anorectal pathologies (e.g., anal fissure, fistula), and no prior anorectal surgery. Patients with incomplete medical records or follow-up, those undergoing emergency haemorrhoidectomy, or those who declined to participate were excluded. Interventions and Group Allocation Patients were allocated to one of two groups based on the clinically indicated treatment plan and patient preference: Case Group (n = 20) : Patients who underwent surgical haemorrhoidectomy. The specific surgical technique (e.g., conventional excision via Milligan-Morgan or Ferguson methods, or use of an energy device) was left to the discretion of the attending surgeon. Control Group (n = 20) : Patients who received conservative medical management. This consisted of dietary advice to increase fiber intake, prescription of oral flavonoids, and recommendations for local hygiene measures. Variables and Data Collection Data were collected prospectively. Sociodemographic variables included age and sex. Clinical variables included comorbidities and presenting symptoms. Hemorrhoidal disease severity was graded according to the Goligher classification [ 9 ]. The primary outcome variable was the presence of sexual dysfunction at 30 days following the intervention (either surgery or initiation of medical therapy). This was operationally defined a priori as the patient reporting problems in two or more items on the Natsal-SF questionnaire. The primary independent variable was the treatment group (Haemorrhoidectomy vs. Medical Management). Measurement Instrument: Natsal-SF Sexual function was assessed using the 17-item Natsal-SF, a validated, self-administered questionnaire. This instrument evaluates three key components of sexual function: (1) problems with sexual response (e.g., desire, arousal, orgasm); (2) sexual function within a relational context; and (3) the individual's personal appraisal of their sex life (e.g., satisfaction, distress). It is designed for use in diverse populations and is not limited by gender, sexual orientation, or specific sexual practices, making it highly suitable for this study. Sample Size The sample size was calculated to ensure sufficient statistical power to detect a clinically significant difference in the incidence of postoperative sexual dysfunction, the study's primary binary outcome. As this study is among the first to use the Natsal-SF scale in this surgical context, the power analysis was informed by the most relevant prior evidence on the magnitude of the effect. The calculation was based on the difference in the prevalence of sexual dysfunction post-haemorrhoidectomy reported by Lin et al [ 5 ]. That study found a sexual dysfunction prevalence of 48.7% in the surgical group compared to 7.7% in a control group, indicating a large expected effect size. Using these proportions to power a test for the difference between two independent proportions (two-tailed z-test or equivalent Chi-squared test), a calculation performed with G*Power 3.1 software, setting a statistical power (1-β) of 0.95 and an alpha level of 0.05, indicated that a minimum of 10 subjects per group was required to detect such a difference. To enhance the statistical robustness of the findings and to account for potential patient dropouts, the sample size was conservatively increased to 20 patients in each group, for a total of 40 participants. Bias Minimization Several measures were implemented to minimize potential bias, in line with STROBE recommendations. Selection Bias : Minimized by applying uniform and strict inclusion/exclusion criteria to a consecutive series of patients presenting to a single specialized clinic, ensuring a well-defined study population. Information Bias : Addressed by using a standardized, validated, and self-administered questionnaire (Natsal-SF) for all participants. The assessment was performed at a fixed time point (30 days post-intervention) for both groups to ensure uniformity and prevent recall bias. Confounding Bias : Managed through statistical analysis. A multivariate logistic regression model was used to adjust for key baseline variables known to be potential confounders for sexual function, including age, sex, specific comorbidities, and disease severity. Statistical Analysis Data analysis was performed using SPSS version 28 (IBM Corp., Armonk, NY, USA). Normality of quantitative data was assessed using the Lilliefors test. As data were not normally distributed, continuous variables were described using medians and interquartile ranges (IQR), while categorical variables were presented as frequencies and percentages. Univariate comparisons between the case and control groups were made using the Mann-Whitney U test for continuous variables and the Chi-squared or Fisher's exact test for categorical variables. A binary logistic regression model was constructed to assess the independent association between haemorrhoidectomy and the primary outcome of sexual dysfunction. Covariates included in the model were selected a priori based on their clinical relevance as potential confounders: age, sex, immunosuppression status, presence of a diagnosed psychiatric disorder, and haemorrhoid grade. A two-tailed p-value of < 0.05 was considered statistically significant. Ethical Considerations This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study protocol was reviewed and approved by the Institutional Review Board of the National Institute of Medical Sciences and Nutrition Salvador Zubirán. All participants provided written informed consent prior to enrolment in the study. All patient data were anonymized to ensure confidentiality and protect patient privacy. Results Participant Flow and Baseline Characteristics From March 2023 to January 2024, a total of 50 patients with symptomatic hemorrhoidal disease were assessed for eligibility. Ten patients were excluded: eight declined to participate in the study, and two had incomplete clinical records. The remaining 40 patients were enrolled and allocated to either the surgical group (n = 20) or the medical management group (n = 20). The flow of participants through the study is detailed in Fig. 1 . The baseline demographic and clinical characteristics of the study population are presented in Table 1 . The two groups were largely comparable in terms of sex distribution (65% male in surgical vs. 60% in medical, p = 0.513) and the prevalence of most comorbidities. However, patients in the surgical group were slightly older (median age 56.7 years vs. 55.0 years, p = 0.016) and presented with clinically more severe disease. This was evidenced by a higher prevalence of grade III haemorrhoids and a significantly greater frequency of rectal bleeding (90% vs. 35%, p < 0.001), which is consistent with the standard indications for surgical intervention. Table 1 Baseline Demographic and Clinical Characteristics of Study Participants Variable Haemorrhoidectomy Group (n = 20) Medical Management Group (n = 20) p-value Age, years (median, range) 56.7 (38–69) 55 (25–66) 0.016 Male sex, n (%) 13 (65) 12 (60) 0.513 Comorbidities, n (%) Diabetes Mellitus Type 2 6 (30) 2 (10) 0.231 Systemic Hypertension 1 (5) 6 (30) 0.083 Liver Cirrhosis 0 (0) 3 (15) 0.229 Immunosuppression † 7 (35) 5 (25) 0.729 Psychiatric Disorder 3 (15) 2 (10) 1.000 Presenting Symptoms, n (%) Rectorrhagia 18 (90) 7 (35) < 0.001 Pruritus 6 (30) 8 (40) 0.729 Pain 10 (50) 4 (20) 0.118 Haemoglobin, g/dL (median, range) 13.3 (7.0–17.1) 14.5 (9.4–17.3) 0.245 Haemorrhoid Grade, n (%) Grade II 5 (25) 14 (70) < 0.001 Grade III 8 (40) 4 (20) Grade IV 7 (35) 2 (10) † Immunosuppression includes HIV, primary immunodeficiency, solid organ transplant, or use of immunosuppressive medication for solid tumors or connective tissue disease. p-values calculated using Mann-Whitney U test for continuous variables and Chi-squared or Fisher's exact test for categorical variables. Primary Outcome: Post-intervention Sexual Dysfunction The primary outcome of sexual dysfunction at 30 days was observed in 17 of 20 patients (85%) in the haemorrhoidectomy group. In contrast, only 5 of 20 patients (25%) in the medical management group reported sexual dysfunction. This marked difference between the groups was statistically significant (p < 0.002), as shown in Table 2 . Table 2 Association Between Treatment Modality and Sexual Dysfunction at 30 Days Sexual Dysfunction No Sexual Dysfunction Total Haemorrhoidectomy Group 17 (85%) 3 (15%) 20 (100%) Medical Management Group 5 (25%) 15 (75%) 20 (100%) p-value < 0.002 Data are n (%). Sexual dysfunction was defined as ≥ 2 altered items on the Natsal-SF scale. p-value calculated using Fisher's exact test. An item-by-item analysis of the Natsal-SF scale demonstrated that patients in the surgical group reported a higher frequency of problems across all domains of sexual function (Fig. 2 ). The most pronounced differences were seen in items related to physiological response and overall satisfaction. Specifically, 70% of patients in the surgical group reported problems getting or keeping an erection or becoming sufficiently lubricated, compared to just 15% in the control group. Similarly, 60% of the surgical group reported not feeling satisfied with their sex life, versus 10% of controls. A comparison of the total Natsal-SF scores also showed significantly worse overall sexual function in the haemorrhoidectomy group (Fig. 3 ). Multivariate Analysis To determine if the association between surgery and sexual dysfunction was independent of other factors, a multivariate logistic regression analysis was performed. After adjusting for age, sex, immunosuppression status, presence of a psychiatric disorder, and haemorrhoid grade, haemorrhoidectomy remained a significant independent predictor of sexual dysfunction at 30 days (p = 0.023). Discussion This prospective, controlled study provides compelling evidence of a strong association between surgical haemorrhoidectomy and the development of sexual dysfunction in the immediate postoperative period. To our knowledge, it is the first to employ the Natsal-SF scale, a comprehensive and gender-inclusive instrument, to investigate this outcome in a proctological surgery cohort. The principal finding was that 85% of patients who underwent haemorrhoidectomy reported sexual dysfunction at 30 days, a rate significantly higher than the 25% observed in the medically managed control group. This association remained robust after adjusting for potential confounding variables, suggesting that the surgical intervention itself is an independent risk factor. The high incidence of sexual dysfunction observed in our surgical cohort is likely multifactorial, best understood through a biopsychosocial lens that modern instruments like the Natsal-SF are designed to capture [ 10 ]. Biologically, the surgical dissection in the perianal region occurs in close proximity to a dense network of somatic and autonomic nerves critical for sexual function, including the pudendal nerve and the pelvic plexus. Direct injury, traction, or postoperative inflammation and oedema in this area can lead to neuropraxia, resulting in the physiological impairments—such as erectile difficulties in men and lubrication issues in women [ 11 ]—that were the most frequently reported problems in our study. Psychologically, significant postoperative pain is a well-established complication of haemorrhoidectomy and a potent inhibitor of sexual desire and activity. Qualitative studies have documented that the experience of severe postoperative pain contributes to a "lack of desire to engage in sexual relations" [ 12 ]. This pain, coupled with the anxiety, fear of injury, and potential alterations in body image following surgery in a highly sensitive area, can create a powerful fear-avoidance cycle that disrupts sexual intimacy. The Natsal-SF effectively captured these interconnected domains, identifying not only the physical issues but also the high rates of dissatisfaction and distress about sexual life reported by patients. Our findings align with some previous reports, particularly a study by Lin et al. that used the FSFI and found a 48.7% prevalence of sexual dysfunction in women after hemorrhoidectomy [ 5 ]. However, our results appear to conflict with studies in male patients that have reported an improvement in erectile function following surgery [ 4 ]. This discrepancy may be explained by several factors. First, those studies often involved patients with pre-existing erectile dysfunction potentially caused by the chronic pain of hemorrhoidal disease itself; resolving the pain could thus improve function over a longer term. By contrast, our study included only patients without pre-existing sexual dysfunction and focused on the acute, 30-day postoperative period, where pain and inflammation are maximal. The short-term detriment we observed may not preclude long-term improvement, a question that warrants further investigation with longitudinal follow-up. The primary strength of this study is its methodological innovation in using the Natsal-SF. This choice allowed for a more nuanced and inclusive assessment of sexual function than would have been possible with traditional instruments like the IIEF and FSFI. These older scales have well-documented psychometric limitations, particularly in their desire and orgasm domains, and their heteronormative, penetration-centric focus is poorly suited to capturing the diverse experiences of a general clinical population [ 6 ]. By moving beyond a purely physiological model, we were able to detect the broader impact of surgery on patients' sexual well-being. Additional strengths include the prospective design, the inclusion of a medically-managed control group, and the use of multivariate analysis to isolate the effect of the surgical intervention. Nevertheless, this study has limitations that must be acknowledged. The sample size of 40 patients is small, which, although formally powered, restricts the ability to perform detailed subgroup analyses, such as comparing outcomes between different surgical techniques. Furthermore, while our multivariate analysis provides evidence for an independent association, the small sample size results in a low events-per-variable ratio, which may limit the stability of the regression model and suggests that the results should be interpreted with caution until confirmed in larger cohorts. The single-centre design may limit the generalizability of our findings to other settings, and the non-randomized nature of group allocation introduces a potential for selection bias; however, we attempted to mitigate this by controlling for baseline differences in disease severity and other clinical factors in our statistical model. Finally, the 30-day follow-up period is short. The observed dysfunction may be a transient phenomenon related to acute postoperative pain and tissue healing, and it is unknown whether this high rate of dysfunction persists, resolves, or even improves over a longer period. The clinical implications of our findings are direct and significant. The high incidence of postoperative sexual dysfunction suggests that this is a common, important, but under-recognized complication of haemorrhoidectomy. Surgeons have a responsibility to include this potential outcome in their preoperative counselling to allow for fully informed patient consent, particularly for individuals who are sexually active. Future research is essential to build upon these findings. Large-scale, multi-centre studies with longitudinal follow-up of at least one year are needed to map the trajectory of sexual function recovery. Moreover, prospective randomized trials comparing different haemorrhoidectomy techniques (e.g., LigaSure vs. conventional, stapled vs. conventional) should incorporate a comprehensive patient-reported outcome measure like the Natsal-SF to determine if certain techniques can mitigate this adverse effect. Conclusions In this prospective controlled study, surgical haemorrhoidectomy was associated with a significantly higher rate of short-term sexual dysfunction compared to medical management. This finding, captured by the inclusive Natsal-SF scale, underscores the importance of adopting a biopsychosocial approach to patient outcomes. It highlights a critical need to incorporate comprehensive counselling on sexual function into the routine care of patients undergoing proctological surgery. Declarations Conflict of Interest Statement: The authors declare no conflicts of interest. Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethics Approval Statement The study protocol was reviewed and approved by the Institutional Review Board of the National Institute of Medical Sciences and Nutrition Salvador Zubirán. The study was conducted in accordance with the Declaration of Helsinki. Patient Consent Statement All participants provided written informed consent prior to enrolment. Permission to Reproduce Material from Other Sources No material from other sources requiring copyright permission was used in this manuscript. Clinical Trial Registration This study was not registered as a clinical trial, as it was an observational case-control study. Authorship Contribution Statement: Oscar Santes: Conceptualization, Methodology, Data Curation, Formal Analysis, Project Administration, Investigation, Writing - Original Draft. Rogelio Zayas-Borquez: Investigation, Resources, Writing - Review & Editing. Francisco E. Alvarez-Bautista: Methodology, Visualization, Writing - Review & Editing. Noel Salgado-Nesme: Supervision, Resources, Writing - Review & Editing. Paulina Huchim: Investigation, Data Curation, Writing - Review & Editing. Jorge Canto-Losa: Methodology, Visualization, Writing - Review & Editing. Oscar Emmanuel Posadas-Trujillo: Conceptualization, Methodology, Data Curation, Project Administration, Supervision, Writing - Review & Editing. All authors have read and approved the final version of the manuscript for publication. References Liu Y, Wang L, Liu J, Geng F, Li Y, Zheng L (2022) The relationship between anal disease and quality of life: a bibliometric study. Ann Transl Med 10(8):484 Sandler RS, Peery AF (2019) Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol 17(1):8–15 Jóhannsson HO, Graf W, Påhlman L (2002) Long-term results of haemorrhoidectomy. Eur J Surg 168(8–9):485–489 Abdelaziz AS, Ghoneem AM, Elewesy EA (2019) The impact of surgical hemorrhoidectomy on male sexual function: A preliminary study. Urol Ann 11(3):235–240 Lin YH, Stocker J, Liu KW, Chen HP (2009) The impact of hemorrhoidectomy on sexual function in women: a preliminary study. 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J Sex Med 4(1):4–13 Tavani ME, Partovi Y, Poursaki T, Gharibi F (2025) The Complications of Hemorrhoidectomy From Patients' Perspective: A Qualitative Study. Health Sci Rep 8(5):e70724 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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15:44:37","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68598,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7781921/v1/27ce03338514833a8d2d6d28.html"},{"id":94473852,"identity":"2e84ff9d-4ad2-4d93-b05c-feb4968ed808","added_by":"auto","created_at":"2025-10-27 15:45:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74536,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSTROBE Flow Diagram of Patient Enrolment.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiagram illustrating the flow of participants through the study, from initial assessment for eligibility to allocation into the haemorrhoidectomy and medical management groups, including reasons for exclusion.\u003c/p\u003e","description":"","filename":"Figure1Flowchartpatientinclusionprocess.png","url":"https://assets-eu.researchsquare.com/files/rs-7781921/v1/aee0eb5190a5a7a502adc352.png"},{"id":94473527,"identity":"8a9e9ff7-632c-4fd2-8501-4c46a50fc2af","added_by":"auto","created_at":"2025-10-27 15:44:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":733712,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of Patients with Dysfunction by Natsal-SF Item.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBar chart comparing the percentage of patients in the haemorrhoidectomy group (n=20) versus the medical management group (n=20) who reported dysfunction on key items of the Natsal-SF scale at 30 days post-intervention. Error bars represent 95% confidence intervals.\u003c/p\u003e","description":"","filename":"Figure2.ComparisonofsexualdysfunctionitemsNatsalSFbygroup.png","url":"https://assets-eu.researchsquare.com/files/rs-7781921/v1/44aff6cb1ab91762b902512c.png"},{"id":94473747,"identity":"17752aab-ac79-424e-b167-a04db307a3d6","added_by":"auto","created_at":"2025-10-27 15:45:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":312709,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Total Natsal-SF Scores.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBox-and-whisker plot showing the distribution of total scores on the Natsal-SF scale for the haemorrhoidectomy group (n=20) and the medical management group (n=20). Higher scores indicate worse sexual function. The boxes represent the interquartile range (IQR), the horizontal line represents the median, and the whiskers represent the range. The p-value is from the Mann-Whitney U test.\u003c/p\u003e","description":"","filename":"Figure3.TotalNatsalSFscorebytreatmentgroup.png","url":"https://assets-eu.researchsquare.com/files/rs-7781921/v1/1d983e1241f3e35998ca1f97.png"},{"id":94489819,"identity":"791de72b-55b6-4c39-97ac-40f8c4f49eb1","added_by":"auto","created_at":"2025-10-27 17:06:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2087648,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7781921/v1/a4fc429f-def2-4f78-a322-ac57f925d901.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association Between Hemorrhoidectomy and Sexual Dysfunction: A Prospective Case-Control Study Using the Natsal-SF Scale","fulltext":[{"header":"What this paper adds to the literature","content":"\u003cp\u003eThis study is the first to use a contemporary, gender-inclusive sexual function scale (Natsal-SF) in a prospective, controlled design to assess outcomes after haemorrhoidectomy. It quantifies a high, previously under-reported incidence of sexual dysfunction, highlighting a critical gap in patient counselling and postoperative care.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eHemorrhoidal disease is one of the most prevalent conditions affecting the lower gastrointestinal tract, imposing a significant burden on patient quality of life, particularly among the working-age population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For symptomatic grade III and IV haemorrhoids, or for lower grades refractory to medical management, surgical haemorrhoidectomy remains a common and effective intervention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While considered safe, the procedure is not without complications. The literature has traditionally focused on postoperative outcomes such as pain, bleeding, anal stenosis, and alterations in faecal continence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the potential impact on sexual function has been largely overlooked and remains poorly understood.\u003c/p\u003e\u003cp\u003eThe existing evidence regarding sexual function after proctological surgery is sparse and contradictory. Some studies, primarily in male populations, suggest that haemorrhoidectomy may actually improve erectile function, postulating that the resolution of chronic pelvic pain and vascular congestion alleviates a pre-existing inhibitor of sexual performance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Conversely, other reports, particularly those including women, have documented a significant increase in sexual dysfunction post-surgery, with complaints of pain and decreased satisfaction being common [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This discrepancy highlights a critical knowledge gap and underscores the need for additional investigation.\u003c/p\u003e\u003cp\u003eA major contributor to these conflicting findings is likely the historical reliance on limited and often inappropriate measurement tools. Many studies have employed instruments such as the International Index of Erectile Function (IIEF) for men and the Female Sexual Function Index (FSFI) for women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These questionnaires, while validated for specific purposes, possess significant limitations for research in a diverse surgical population. Both the IIEF and FSFI were originally designed to assess arousal disorders in specific clinical trial settings and have demonstrated psychometric weaknesses in other domains, particularly sexual desire and orgasm. Furthermore, their focus on heterosexual, penetrative intercourse fails to capture the full spectrum of sexual experiences, practices, and orientations, potentially leading to an incomplete or biased assessment of sexual well-being [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address these shortcomings, a more holistic assessment tool is required. The National Survey of Sexual Attitudes and Lifestyles Short Form (Natsal-SF) is a contemporary, 17-item questionnaire designed specifically for use in community and clinical surveys [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It has been psychometrically validated across genders, sexual orientations, and relationship statuses, and its multidimensional structure assesses not only physiological responses but also the crucial emotional, relational, and satisfaction components of sexuality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. By adopting a biopsychosocial framework, the Natsal-SF provides a more comprehensive and inclusive measure of sexual function. Therefore, the primary objective of this study was to prospectively evaluate the association between haemorrhoidectomy and short-term sexual dysfunction using the Natsal-SF scale in a controlled setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis was a prospective, non-randomized, case-control study conducted at the National Institute of Medical Sciences and Nutrition Salvador Zubiran, a tertiary referral centre in Mexico City, Mexico. Patient recruitment and follow-up occurred between July 2023 and May 2024. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, there is currently no published Core Outcome Set (COS) specifically addressing sexual dysfunction after proctological procedures such as haemorrhoidectomy. Nevertheless, we employed a validated and inclusive patient-reported outcome measure (Natsal-SF), aligning with the COS initiative\u0026rsquo;s goals of standardizing outcome reporting.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eConsecutive adult patients (age\u0026thinsp;\u0026gt;\u0026thinsp;18 years) of both sexes presenting to the coloproctology clinic with a diagnosis of symptomatic hemorrhoidal disease were assessed for eligibility. Inclusion criteria were: reported sexual activity at the time of initial assessment, absence of known pre-existing sexual dysfunction determined by a preoperative Natsal-SF questionnaire, no other concurrent anorectal pathologies (e.g., anal fissure, fistula), and no prior anorectal surgery. Patients with incomplete medical records or follow-up, those undergoing emergency haemorrhoidectomy, or those who declined to participate were excluded.\u003c/p\u003e\n\u003ch3\u003eInterventions and Group Allocation\u003c/h3\u003e\n\u003cp\u003ePatients were allocated to one of two groups based on the clinically indicated treatment plan and patient preference:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCase Group (n\u0026thinsp;=\u0026thinsp;20)\u003c/b\u003e: Patients who underwent surgical haemorrhoidectomy. The specific surgical technique (e.g., conventional excision via Milligan-Morgan or Ferguson methods, or use of an energy device) was left to the discretion of the attending surgeon.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eControl Group (n\u0026thinsp;=\u0026thinsp;20)\u003c/b\u003e: Patients who received conservative medical management. This consisted of dietary advice to increase fiber intake, prescription of oral flavonoids, and recommendations for local hygiene measures.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eVariables and Data Collection\u003c/h3\u003e\n\u003cp\u003eData were collected prospectively. Sociodemographic variables included age and sex. Clinical variables included comorbidities and presenting symptoms. Hemorrhoidal disease severity was graded according to the Goligher classification [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary outcome variable was the presence of sexual dysfunction at 30 days following the intervention (either surgery or initiation of medical therapy). This was operationally defined a priori as the patient reporting problems in two or more items on the Natsal-SF questionnaire. The primary independent variable was the treatment group (Haemorrhoidectomy vs. Medical Management).\u003c/p\u003e\n\u003ch3\u003eMeasurement Instrument: Natsal-SF\u003c/h3\u003e\n\u003cp\u003eSexual function was assessed using the 17-item Natsal-SF, a validated, self-administered questionnaire. This instrument evaluates three key components of sexual function: (1) problems with sexual response (e.g., desire, arousal, orgasm); (2) sexual function within a relational context; and (3) the individual's personal appraisal of their sex life (e.g., satisfaction, distress). It is designed for use in diverse populations and is not limited by gender, sexual orientation, or specific sexual practices, making it highly suitable for this study.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSample Size\u003c/h2\u003e\u003cp\u003eThe sample size was calculated to ensure sufficient statistical power to detect a clinically significant difference in the incidence of postoperative sexual dysfunction, the study's primary binary outcome. As this study is among the first to use the Natsal-SF scale in this surgical context, the power analysis was informed by the most relevant prior evidence on the magnitude of the effect. The calculation was based on the difference in the prevalence of sexual dysfunction post-haemorrhoidectomy reported by Lin et al [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. That study found a sexual dysfunction prevalence of 48.7% in the surgical group compared to 7.7% in a control group, indicating a large expected effect size. Using these proportions to power a test for the difference between two independent proportions (two-tailed z-test or equivalent Chi-squared test), a calculation performed with G*Power 3.1 software, setting a statistical power (1-β) of 0.95 and an alpha level of 0.05, indicated that a minimum of 10 subjects per group was required to detect such a difference. To enhance the statistical robustness of the findings and to account for potential patient dropouts, the sample size was conservatively increased to 20 patients in each group, for a total of 40 participants.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eBias Minimization\u003c/h3\u003e\n\u003cp\u003eSeveral measures were implemented to minimize potential bias, in line with STROBE recommendations.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSelection Bias\u003c/b\u003e: Minimized by applying uniform and strict inclusion/exclusion criteria to a consecutive series of patients presenting to a single specialized clinic, ensuring a well-defined study population.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInformation Bias\u003c/b\u003e: Addressed by using a standardized, validated, and self-administered questionnaire (Natsal-SF) for all participants. The assessment was performed at a fixed time point (30 days post-intervention) for both groups to ensure uniformity and prevent recall bias.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eConfounding Bias\u003c/b\u003e: Managed through statistical analysis. A multivariate logistic regression model was used to adjust for key baseline variables known to be potential confounders for sexual function, including age, sex, specific comorbidities, and disease severity.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData analysis was performed using SPSS version 28 (IBM Corp., Armonk, NY, USA). Normality of quantitative data was assessed using the Lilliefors test. As data were not normally distributed, continuous variables were described using medians and interquartile ranges (IQR), while categorical variables were presented as frequencies and percentages. Univariate comparisons between the case and control groups were made using the Mann-Whitney U test for continuous variables and the Chi-squared or Fisher's exact test for categorical variables.\u003c/p\u003e\u003cp\u003eA binary logistic regression model was constructed to assess the independent association between haemorrhoidectomy and the primary outcome of sexual dysfunction. Covariates included in the model were selected a priori based on their clinical relevance as potential confounders: age, sex, immunosuppression status, presence of a diagnosed psychiatric disorder, and haemorrhoid grade. A two-tailed p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study protocol was reviewed and approved by the Institutional Review Board of the National Institute of Medical Sciences and Nutrition Salvador Zubir\u0026aacute;n. All participants provided written informed consent prior to enrolment in the study. All patient data were anonymized to ensure confidentiality and protect patient privacy.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eParticipant Flow and Baseline Characteristics\u003c/h2\u003e\u003cp\u003eFrom March 2023 to January 2024, a total of 50 patients with symptomatic hemorrhoidal disease were assessed for eligibility. Ten patients were excluded: eight declined to participate in the study, and two had incomplete clinical records. The remaining 40 patients were enrolled and allocated to either the surgical group (n\u0026thinsp;=\u0026thinsp;20) or the medical management group (n\u0026thinsp;=\u0026thinsp;20). The flow of participants through the study is detailed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe baseline demographic and clinical characteristics of the study population are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The two groups were largely comparable in terms of sex distribution (65% male in surgical vs. 60% in medical, p\u0026thinsp;=\u0026thinsp;0.513) and the prevalence of most comorbidities. However, patients in the surgical group were slightly older (median age 56.7 years vs. 55.0 years, p\u0026thinsp;=\u0026thinsp;0.016) and presented with clinically more severe disease. This was evidenced by a higher prevalence of grade III haemorrhoids and a significantly greater frequency of rectal bleeding (90% vs. 35%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which is consistent with the standard indications for surgical intervention.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Demographic and Clinical Characteristics of Study Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHaemorrhoidectomy Group (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical Management Group (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years (median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.7 (38\u0026ndash;69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (25\u0026ndash;66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComorbidities, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes Mellitus Type 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.231\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystemic Hypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiver Cirrhosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.229\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmunosuppression\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.729\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatric Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePresenting Symptoms, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectorrhagia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePruritus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.729\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.118\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaemoglobin, g/dL (median, range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.3 (7.0\u0026ndash;17.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.5 (9.4\u0026ndash;17.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.245\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHaemorrhoid Grade, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e Immunosuppression includes HIV, primary immunodeficiency, solid organ transplant, or use of immunosuppressive medication for solid tumors or connective tissue disease.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003ep-values calculated using Mann-Whitney U test for continuous variables and Chi-squared or Fisher's exact test for categorical variables.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePrimary Outcome: Post-intervention Sexual Dysfunction\u003c/h2\u003e\u003cp\u003eThe primary outcome of sexual dysfunction at 30 days was observed in 17 of 20 patients (85%) in the haemorrhoidectomy group. In contrast, only 5 of 20 patients (25%) in the medical management group reported sexual dysfunction. This marked difference between the groups was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.002), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation Between Treatment Modality and Sexual Dysfunction at 30 Days\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSexual Dysfunction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo Sexual Dysfunction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHaemorrhoidectomy Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (85%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedical Management Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eData are n (%). Sexual dysfunction was defined as \u0026ge;\u0026thinsp;2 altered items on the Natsal-SF scale. p-value calculated using Fisher's exact test.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAn item-by-item analysis of the Natsal-SF scale demonstrated that patients in the surgical group reported a higher frequency of problems across all domains of sexual function (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The most pronounced differences were seen in items related to physiological response and overall satisfaction. Specifically, 70% of patients in the surgical group reported problems getting or keeping an erection or becoming sufficiently lubricated, compared to just 15% in the control group. Similarly, 60% of the surgical group reported not feeling satisfied with their sex life, versus 10% of controls. A comparison of the total Natsal-SF scores also showed significantly worse overall sexual function in the haemorrhoidectomy group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eMultivariate Analysis\u003c/h2\u003e\u003cp\u003eTo determine if the association between surgery and sexual dysfunction was independent of other factors, a multivariate logistic regression analysis was performed. After adjusting for age, sex, immunosuppression status, presence of a psychiatric disorder, and haemorrhoid grade, haemorrhoidectomy remained a significant independent predictor of sexual dysfunction at 30 days (p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective, controlled study provides compelling evidence of a strong association between surgical haemorrhoidectomy and the development of sexual dysfunction in the immediate postoperative period. To our knowledge, it is the first to employ the Natsal-SF scale, a comprehensive and gender-inclusive instrument, to investigate this outcome in a proctological surgery cohort. The principal finding was that 85% of patients who underwent haemorrhoidectomy reported sexual dysfunction at 30 days, a rate significantly higher than the 25% observed in the medically managed control group. This association remained robust after adjusting for potential confounding variables, suggesting that the surgical intervention itself is an independent risk factor.\u003c/p\u003e\u003cp\u003eThe high incidence of sexual dysfunction observed in our surgical cohort is likely multifactorial, best understood through a biopsychosocial lens that modern instruments like the Natsal-SF are designed to capture [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Biologically, the surgical dissection in the perianal region occurs in close proximity to a dense network of somatic and autonomic nerves critical for sexual function, including the pudendal nerve and the pelvic plexus. Direct injury, traction, or postoperative inflammation and oedema in this area can lead to neuropraxia, resulting in the physiological impairments\u0026mdash;such as erectile difficulties in men and lubrication issues in women [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026mdash;that were the most frequently reported problems in our study. Psychologically, significant postoperative pain is a well-established complication of haemorrhoidectomy and a potent inhibitor of sexual desire and activity. Qualitative studies have documented that the experience of severe postoperative pain contributes to a \"lack of desire to engage in sexual relations\" [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This pain, coupled with the anxiety, fear of injury, and potential alterations in body image following surgery in a highly sensitive area, can create a powerful fear-avoidance cycle that disrupts sexual intimacy. The Natsal-SF effectively captured these interconnected domains, identifying not only the physical issues but also the high rates of dissatisfaction and distress about sexual life reported by patients.\u003c/p\u003e\u003cp\u003eOur findings align with some previous reports, particularly a study by Lin et al. that used the FSFI and found a 48.7% prevalence of sexual dysfunction in women after hemorrhoidectomy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, our results appear to conflict with studies in male patients that have reported an improvement in erectile function following surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This discrepancy may be explained by several factors. First, those studies often involved patients with pre-existing erectile dysfunction potentially caused by the chronic pain of hemorrhoidal disease itself; resolving the pain could thus improve function over a longer term. By contrast, our study included only patients without pre-existing sexual dysfunction and focused on the acute, 30-day postoperative period, where pain and inflammation are maximal. The short-term detriment we observed may not preclude long-term improvement, a question that warrants further investigation with longitudinal follow-up.\u003c/p\u003e\u003cp\u003eThe primary strength of this study is its methodological innovation in using the Natsal-SF. This choice allowed for a more nuanced and inclusive assessment of sexual function than would have been possible with traditional instruments like the IIEF and FSFI. These older scales have well-documented psychometric limitations, particularly in their desire and orgasm domains, and their heteronormative, penetration-centric focus is poorly suited to capturing the diverse experiences of a general clinical population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. By moving beyond a purely physiological model, we were able to detect the broader impact of surgery on patients' sexual well-being. Additional strengths include the prospective design, the inclusion of a medically-managed control group, and the use of multivariate analysis to isolate the effect of the surgical intervention.\u003c/p\u003e\u003cp\u003eNevertheless, this study has limitations that must be acknowledged. The sample size of 40 patients is small, which, although formally powered, restricts the ability to perform detailed subgroup analyses, such as comparing outcomes between different surgical techniques. Furthermore, while our multivariate analysis provides evidence for an independent association, the small sample size results in a low events-per-variable ratio, which may limit the stability of the regression model and suggests that the results should be interpreted with caution until confirmed in larger cohorts. The single-centre design may limit the generalizability of our findings to other settings, and the non-randomized nature of group allocation introduces a potential for selection bias; however, we attempted to mitigate this by controlling for baseline differences in disease severity and other clinical factors in our statistical model. Finally, the 30-day follow-up period is short. The observed dysfunction may be a transient phenomenon related to acute postoperative pain and tissue healing, and it is unknown whether this high rate of dysfunction persists, resolves, or even improves over a longer period.\u003c/p\u003e\u003cp\u003eThe clinical implications of our findings are direct and significant. The high incidence of postoperative sexual dysfunction suggests that this is a common, important, but under-recognized complication of haemorrhoidectomy. Surgeons have a responsibility to include this potential outcome in their preoperative counselling to allow for fully informed patient consent, particularly for individuals who are sexually active. Future research is essential to build upon these findings. Large-scale, multi-centre studies with longitudinal follow-up of at least one year are needed to map the trajectory of sexual function recovery. Moreover, prospective randomized trials comparing different haemorrhoidectomy techniques (e.g., LigaSure vs. conventional, stapled vs. conventional) should incorporate a comprehensive patient-reported outcome measure like the Natsal-SF to determine if certain techniques can mitigate this adverse effect.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this prospective controlled study, surgical haemorrhoidectomy was associated with a significantly higher rate of short-term sexual dysfunction compared to medical management. This finding, captured by the inclusive Natsal-SF scale, underscores the importance of adopting a biopsychosocial approach to patient outcomes. It highlights a critical need to incorporate comprehensive counselling on sexual function into the routine care of patients undergoing proctological surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Institutional Review Board of the National Institute of Medical Sciences and Nutrition Salvador Zubirán. The study was conducted in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent prior to enrolment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to Reproduce Material from Other Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo material from other sources requiring copyright permission was used in this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not registered as a clinical trial, as it was an observational case-control study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship Contribution Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eOscar Santes: Conceptualization, Methodology, Data Curation, Formal Analysis, Project Administration, Investigation, Writing - Original Draft.\u003c/li\u003e\n \u003cli\u003eRogelio Zayas-Borquez: Investigation, Resources, Writing - Review \u0026amp; Editing.\u003c/li\u003e\n \u003cli\u003eFrancisco E. Alvarez-Bautista:\u0026nbsp;Methodology, Visualization, Writing - Review \u0026amp; Editing.\u003c/li\u003e\n \u003cli\u003eNoel Salgado-Nesme: Supervision, Resources, Writing - Review \u0026amp; Editing.\u003c/li\u003e\n \u003cli\u003ePaulina Huchim: Investigation, Data Curation, Writing - Review \u0026amp; Editing.\u003c/li\u003e\n \u003cli\u003eJorge Canto-Losa: Methodology, Visualization, Writing - Review \u0026amp; Editing.\u003c/li\u003e\n \u003cli\u003eOscar Emmanuel Posadas-Trujillo: Conceptualization, Methodology, Data Curation, Project Administration, Supervision, Writing - Review \u0026amp; Editing.\u003c/li\u003e\n \u003cli\u003eAll authors have read and approved the final version of the manuscript for publication.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiu Y, Wang L, Liu J, Geng F, Li Y, Zheng L (2022) The relationship between anal disease and quality of life: a bibliometric study. Ann Transl Med 10(8):484\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSandler RS, Peery AF (2019) Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol 17(1):8\u0026ndash;15\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJ\u0026oacute;hannsson HO, Graf W, P\u0026aring;hlman L (2002) Long-term results of haemorrhoidectomy. Eur J Surg 168(8\u0026ndash;9):485\u0026ndash;489\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdelaziz AS, Ghoneem AM, Elewesy EA (2019) The impact of surgical hemorrhoidectomy on male sexual function: A preliminary study. Urol Ann 11(3):235\u0026ndash;240\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin YH, Stocker J, Liu KW, Chen HP (2009) The impact of hemorrhoidectomy on sexual function in women: a preliminary study. Int J Impot Res 21(6):343\u0026ndash;347\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eForbes MK, Baillie AJ, Schniering CA (2014) Critical flaws in the Female Sexual Function Index and the international index of Erectile Function. J Sex Res 51(5):485\u0026ndash;491\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones KG, Mitchell KR, Ploubidis GB et al (2015) The Natsal-SF Measure of Sexual Function: Comparison of Three Scoring Methods. J Sex Res 52(6):640\u0026ndash;646\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMitchell KR, Ploubidis GB, Datta J, Wellings K (2012) The Natsal-SF: a validated measure of sexual function for use in community surveys. Eur J Epidemiol 27(6):409\u0026ndash;418\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoligher J (1980) Surgery of the anus, rectum and colon, 4th edn. Bailierre Tindall, London, p 96\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerelman M (2024) Reframing the bio-psychosocial model. J Sex Med 21(Suppl 1):qdae001341\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosenbaum TY (2007) Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. J Sex Med 4(1):4\u0026ndash;13\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTavani ME, Partovi Y, Poursaki T, Gharibi F (2025) The Complications of Hemorrhoidectomy From Patients' Perspective: A Qualitative Study. Health Sci Rep 8(5):e70724\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Haemorrhoidectomy, Sexual Dysfunction, Natsal-SF, Pelvic Floor, Proctology, Quality of Life","lastPublishedDoi":"10.21203/rs.3.rs-7781921/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7781921/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eHaemorrhoidectomy is a common surgical treatment for advanced haemorrhoidal disease, but its potential impact on postoperative sexual function is underexplored. This study aimed to evaluate the association between haemorrhoidectomy and short-term sexual dysfunction using the validated, gender-inclusive Natsal-SF scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was a prospective, case-control study conducted at a tertiary referral centre. Forty adults with symptomatic hemorrhoidal disease were included: 20 underwent haemorrhoidectomy (cases) and 20 received conservative medical management (controls). The main outcome was sexual dysfunction at 30 days post-intervention, defined as reporting problems in ≥2 items of the Natsal-SF questionnaire. Associations were analysed using univariate and multivariate methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Sexual dysfunction was significantly more frequent in the haemorrhoidectomy group compared to controls (85% vs. 25%, p\u0026lt;0.002). The most affected domains were physiological function—including erectile or lubrication difficulties (70%)—and overall sexual satisfaction (60%). After adjusting for age, sex, immunosuppression, psychiatric history, and haemorrhoid grade, the association remained statistically significant (p=0.023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Haemorrhoidectomy is associated with a high incidence of early postoperative sexual dysfunction. The Natsal-SF, a comprehensive and inclusive tool, was effective in identifying this frequently neglected outcome. Preoperative counselling for haemorrhoidectomy should address potential sexual side effects.\u003c/p\u003e","manuscriptTitle":"Association Between Hemorrhoidectomy and Sexual Dysfunction: A Prospective Case-Control Study Using the Natsal-SF Scale","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 14:28:55","doi":"10.21203/rs.3.rs-7781921/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2e35832d-1f1c-4fcb-b1b8-8dcfbc2f29ba","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T15:16:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-27 14:28:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7781921","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7781921","identity":"rs-7781921","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}