A 68-year-old man presented to our outpatient clinic with a history of faecal incontinence.

The patient had had a typical three-piles Milligan–Morgan haemorrhoidectomy 25 years earlier for grade III haemorrhoids. Furthermore, a posterior sphincterotomy, resulting in a key-hole deformity, had been performed (Fig. 1). His medical history was unremarkable. Anorectal manometry showed a reduction in both rest and squeeze sphincter pressures associated with impaired rectoanal coordination. Endoanal ultrasound showed an internal sphincter injury.

Fig. 1
figure 1

Sequelae of a three-piles Milligan–Morgan haemorrhoidectomy with posterior sphincterotomy

Full size image

The patient underwent sacral neurostimulation, through the S3 sacral foramen, with a 65% improvement of the faecal incontinence.

Open excisional haemorrhoidectomy marked the twentieth century and is still the gold standard for grade III and grade IV haemorrhoids [1]. However, a step-up-approach avoiding an unnecessary removal of the piles as well as the potential side effects, such as a poor sphincter function or anal stenosis, should be considered especially considering the current technological evolution and the less invasive options [1]. Posterior sphincterotomy should be discouraged.