BACKGROUND: Posthemorrhoidectomy pain represents annoying problem for the surgeon & the patient; internal anal sphincterotomy with hemorrhoidectomy decreases post-operative pain and rate of recurrence. Purposes: To compare hemorrhoidectomy versus hemorrhoidectomy with internal anal sphincterotomy in management of hemorrhoids with respect to manometric and clinical measures. Patients and methods: This study included a total of 40 patients with hemorrhoids grade II, III, and IV with high resting anal pressure who randomly divided into two groups; Group A was subjected to hemorrhoidectomy plus internal sphincterotomy and group B receiving hemorrhoidectomy alone. Postoperative follow up was for 6 months. Results: In this study there was temporarily incontinence to flatus and in 4 cases in (group A) and 2 cases in (group B), both resolve spontaneously. there was no significant difference in postoperative outcomes; p-value > 0.05. Conclusion: internal sphincterotomy should not be performed as a routine procedure for any patient with hemorrhoids. In other words, patients with recurrence of hemorrhoids, severe pain, prolonged constipation, or anyone with high sphincter tonicity in the digital rectal examination would be a candidate for manometric evaluation of anal canal pressure. These patients with high anal pressure confirmed with manometry might receive internal sphincterotomy plus hemorrhoidectomy.