Posthemorrhoidectomy Pain Research Articles

Botulinum Toxin Injection for Analgesic Effect after Hemorrhoidectomy: A Randomized Control Trial.

Objectives: Hemorrhoid is a common disease in surgical practice, but only a few numbers of patients need surgical treatment. The most common concern of patients is postoperative pain. This study aimed to evaluate the efficacy and safety of an intersphincteric injection of botulinum toxin for post-hemorrhoidectomy pain relief. Methods: Overall, 90 patients were enrolled, and 44 were randomized into a botulinum toxin injection group. Preoperative gradings were grade III 37 patients and grade II 2 patients. Patients received an intersphincteric injection of 0.5 ml of a solution containing 30 units of botulinum toxin (BTX). The postoperative data were collected pain score in a visual analog score (VAS), an analgesic used, hospital stay, and complication. Results: The VAS was lower in the BTX group at 12 hours and 24 hours postoperative phase. VAS at 12 hours 4.435 ± 2.149 vs 6.232 ± 2.307 (p < 0.001), VAS at 24 hours 2.205 ± 2.079 vs 3.744 ± 2.361(p = 0.003). The BTX group has a shorter time in defection without pain than the control group (3 vs. two days, p = 0.007). There was no difference in immediate and delay complications between the two groups. Conclusions: Postoperative hemorrhoidectomy needs multimodalities for pain reduction. Botulinum toxin has some benefit in postoperative pain reduction.

Efficacy of postoperative oral metronidazole for haemorrhoidectomy pain: a randomized double-blind, placebo-controlled trial.

The aim of this work was to examine the efficacy of oral metronidazole in reducing posthaemorrhoidectomy pain versus placebo. Forty patients were randomized to either metronidazole and standard care or placebo and standard care (21 metronidazole, 19 placebo) in a double-blinded, randomized controlled trial. The main outcome measure was posthaemorrhoidectomy pain scores over 21days, measured on a 10-point Likert scale. There were no significant differences between groups with regards to age, gender, smoking status, self-reported general health or quality of life, haemorrhoid-related pain, haemorrhoid-related impact on quality of life, reported satisfaction with surgery, experience of surgery, median overall pain score or likelihood of recommending surgery to others. For reported median worst pain scores and defaecation-related pain, a trend to significance was identified between groups on days 16 and 18-21, with the metronidazole group reporting less pain. However, these differences were not significant when prespecified Bonferroni correction criteria were used. Using multilevel mixed effects modelling, the impact of time on median worst pain score was identified to be highly significant (P<0.0001) whereas treatment allocation (placebo versus metronidazole) did not significantly affect the improvement in patients' reported pain (P=0.8837). Our data do not support the hypothesis that postoperative metronidazole has a clinically meaningful effect on posthaemorrhoidectomy pain. This study adds to the previous literature, and implies that it should not be routinely used as an adjunct to analgesia.

Effects of the pestle needle therapy, a type of acupoint stimulation, on post-hemorrhoidectomy pain: A randomized controlled trial

BackgroundHemorrhoids are one of the most common conditions that lead to surgery, and until now surgical hemorrhoidectomy has been the major effective treatment. Post-operative pain from hemorrhoidectomy has been experienced by thousands of patients and remains a major inconvenience of the operation. ObjectiveThis study evaluates the clinical efficacy of the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain. Design, setting, participants and interventionsThis was a single-center, patient-assessor-blinded and randomized controlled trial with 154 patients receiving Milligan hemorrhoidectomy surgery. Eligible patients were randomly assigned to either a treatment group or a control group at a ratio of 1:1. The treatment group received the pestle needle therapy, with manual stimulation at Yaoshu (DU2), Mingmen (DU4), Changqiang (DU1), Chengshan (BL57), Erbai (EX-UE2) and the perianal points (1, 3, 5, 7, 9, and 11o’clock around the lesion); while the control group received a sham treatment with very light pressure. Three sessions of treatment were performed at 30 min, 4 h and 12 h after the surgery, and each lasted for 15 min. Main outcome measuresThe primary outcome was post-operative pain measured with the visual analogue scale (VAS) at 12 h after surgery. The secondary outcomes included the VAS scores measured at 0.5, 2, 4, 6, 8, 24 and 48 h after surgery, the analgesic dose, the time and the VAS score of the patients’ first defecation after surgery, as well as the Hamilton Rating Scale for Anxiety (HAMA) evaluated before discharge. ResultsThe mean pain score of the treatment group was significantly lower than that of the control group (3.10 ± 1.27 vs 4.82 ± 1.29; P < 0.001) at 12 h after surgery. Compared with the control group, patients in the treatment group needed a smaller dose of analgesic within the first 24 hours after surgery (P = 0.002); and their HAMA scores before discharge were lower (4.07 ± 2.40 vs 5.10 ± 2.45, P = 0.009). Compared to the treatment group, patients in the control group had a greater time to the first defecation after surgery ([52.34 ± 15.72] h vs [27.08 ± 13.68] h; P < 0.001), but there was no difference in their VAS scores at the first defecation (P = 0.092). ConclusionThe pestle needle therapy was effective for relieving pain, reducing anxiety and improving bowel function after hemorrhoidectomy, and it is worthy of clinical application.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020.

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

Post-Hemorrhoidectomy Pain Management: The Latest News.

Anal post-operative pain is one of the principal issues of surgical treatment of hemorrhoids and remains a distressing problem, for patients and physicians. Recent studies have concluded that appropriate postoperative pain management leads to higher patient satisfaction, earlier mobilization, fewer drug complications, eliminated adverse events, faster recovery, and decreased health care cost. However, despite advances in pain medicine, postoperative pain control remains problematic and remains an important unresolved issue that causes expense and patient dissatisfaction. Therefore, this situation calls for multi-modal pain management, choosing medication, dosing regimens and route of administration in an individualized way to optimize efficacy and minimize adverse effects. Multiple approaches, including pharmacological and surgical interventions, have been used to manage pain after hemorrhoidal surgery. Our aim was to check the latest instruments and strategies available in literature designed to find practical solutions to this challenging problem.

Impact of post-haemorrhoidectomy pain relief checklists on pain outcomes: a randomized controlled trial.

Haemorrhoidectomy is associated with significant post-operative pain which is primarily managed pharmacologically. Whether a non-pharmacological adjunct such as a checklist can improve pain outcomes after an open haemorrhoidectomy has yet to be studied. The purpose of this study was to determine if a patient-completed checklist of prescribed post-haemorrhoidectomy pain medications would improve pain management after surgery. We conducted a dual-centre randomized controlled trial of patients undergoing a Milligan-Morgan haemorrhoidectomy for symptomatic third or fourth degree haemorrhoids. Thirty-five patients were randomized into either a control group which received post-operative pain medication plus a visual analogue scale (VAS) form, or an intervention group which received a post-operative medication checklist in addition to the items the control group received. Both groups recorded their pain levels on the VAS forms at 10.00, 14.00 and 20.00 hours each day for 14 days post-operatively. Patients in the checklist group reported a significantly greater reduction in mean VAS pain score of 2.51 (95% confidence interval (CI) 1.34-3.68; P < 0.001) between day 1 post-op and day 14 post-op compared to 1.86 (95% CI 0.77-2.95; P = 0.001) for the control group. There was no significant difference between mean pain experienced by patients in either group over each of the 14 days individually or overall (P = 0.07). The pain medication checklist lead to a greater reduction in pain between day 1 and 14 after an open haemorrhoidectomy compared to standard care but did not significantly reduce mean pain across any individual days or overall.

Comparison of mean pain score using topical and oral metronidazole in post milligan morgan hemorrhoidectomy patient; A randomized controlled trial.

Background and Objectives:Milligan Morgan Hemorrhoidectomy is one of the most commonly performed surgeries. Post-operative pain is the major cause of morbidity in post hemorrhoidectomy patients. Metronidazole has an established role in relieving post hemorrhoidectomy pain. The objective was to evaluate the pain score by using topical and oral metronidazole in post Milligan Morgan hemorrhoidectomy patients.Methods:A prospective randomized controlled trail was done in surgical departments of Akbar Niazi Teaching Hospital, Islamabad. A total of 166 consecutive patients with 3rd and 4th degree hemorrhoids were presenting in surgical OPD and who underwent Milligan Morgan hemorrhoidectomy between July 2018 and December 2018 were included in the study. Patients allocated in two groups, Group-A received topical metronidazole 10% post hemorrhoidectomy for seven days and Group-B were given oral metronidazole 400mg for 07 days. Analgesics were given on patient’s requirement. Patients post hemorrhoidectomy pain was recorded by using VSA scale at baseline (1st day) and on 7th post-operative day. Data analysis was done by using SPSS 21. Pain calculated by compared in terms of mean, standard deviation between groups and independent sample T test was used. Association between demographic details like gender and ages of the patients with pain scale on 7th day was measured and chi-square distribution was used.Results:Total 166 patients were included in this study. The mean ages of the patients were 44.07±10.62 years with minimum 20 and maximum 60 years. Out of 166 patients, female were 55 (33.1%) and male were 111 (66.9%). Results showed significantly lower pain in patients using topical metronidazole as compared to oral metronidazole (p=0.001). Association of pain with respect to ages was insignificant (p=0.202) whereas between genders inside the groups showed significant difference (p=0.028).Conclusion:These results showed that topical metronidazole significantly reduces pain in post hemorrhoidectomy patients as compared to oral metronidazole overall and even when data stratified among age, gender and type of hemorrhoids.

Effect of Topical Baclofen 5% on Post-Hemorrhoidectomy Pain: Randomized Double Blind Placebo-Controlled Clinical Trial

BackgroundBaclofen is an agonist for a subtype of gamma-amino butyric acid (GABA-B) receptors and traditionally been used for the systemic treatment of spasticity. Topical application of baclofen has been shown to reduce pain in patients with localized neuropathic pain. ObjectivesIn this study, we investigate the efficacy of baclofen cream (5%) in reducing postoperative pain and analgesic requirement after open hemorrhoidectomy. DesignThe patients were randomly assigned to either baclofen (5%) cream or placebo immediately after surgery and then every 12 h for 14 days. PatientsA total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were randomly assigned to this trial. SettingThis study was conducted at a single educational hospital. Primary and Secondary Outcome MeasuresThe primary outcomes were intensity of pain, measured with a visual analog scale, and the analgesic requirement, measured by the amount of the acetaminophen consumption. ResultsNo significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the baclofen group was significantly lower on week 1 (P = 0.01) and week 2 (P = 0.02) than the placebo group. Similarly, patients in the baclofen group consumed significantly less analgesic medication on week 1 (P = 0.025) and week 2 (P = 0.024) than the control group. ConclusionTopical application of baclofen effectively relieves pain after hemorrhoidectomy with minimal side effects.

Randomized trial comparing the incidence of unintended sciatic nerve block following ultrasound-guided pudendal nerve block with two different volumes of ropivacaine for hemorrhoidectomy: A pilot study

Aim: To compare the incidence of unintended sciatic nerve block following pudendal nerve block in the interligamentous plane with two different volumes of ropivacaine for post hemorrhoidectomy pain. Materials and Methods: 30 patients undergoing hemorrhoidectomy were enrolled for the study and randomly divided into two groups. Prior to the block a scout scan was performed and the pudendal artery, nerve and the sciatic nerve were identified in the interligamentous plane. All the patients received bilateral pudendal nerve block under ultrasound guidance with 5ml of 0.25% ropivacaine in group 1 and 10 ml in group 2. The spread of local anaesthetic to the ipsilateral sciatic nerve was noted under ultrasound imaging. The time of first rescue analgesia (FRA) and total analgesic requirement(TAR) were noted in both groups. The overall patient satisfaction was assessed with a three point scale.The unintended motor and sensory block of the sciatic nerve was noted. Results: The right pudendal artery was visualized in all cases where but left pudendal artery was not visualized in 1 case. The right & left pudendal nerve was visualized in 40% & 46.7% of cases in group I and 40% in both sides of group 2. The incidence of spread of drug towards the right and left sciatic nerve was more in group II (73.3% & 66.6%) than group I (40% & 33.3%). Statistically significant difference was not noted in the time for FRA (P value 0.684) & TAR (P value 0.579). There was no clinically significant sciatic nerve block. Conclusion: We conclude that less volume of local anaesthetic can achieve effective pudendal nerve block minimizing the spread to ipsilateral sciatic nerve.

Assessment of Oral Metronidazole in Pain Management Post Haemorrhoidectomy

Background: Haemorrhoids are a very popular disease. Approximately 50% to 66% of people have problems with haemorrhoids at some point in their lives. The pathophysiology of haemorrhoids is not exactly well known. Theories were developed trying to understand the pathophysiology of haemorrhoids e.g., varicose vein theory, anal lining sliding theory, hyperactivity of internal sphincter theory and vascular hyperplasia theory. Diagnosis is made by integration of available clinical data (symptoms), clinical examination and investigations. Although, we are using the term to refer to the disease resulting from their congestion and swelling, it is hard to evaluate the exact prevalence of haemorrhoids in a certain community as a lot of people suffering from the condition don’t seek for medical advice Objectives: This thesis study was done to assess the efficacy of oral metronidazole administration in management of post haemorrhoidectomy pain. Patients and Method: This study was conducted at El Demerdash Hospital and Damanhour National Institute in 1/1/2018 to 30/6/2018. 80 patients presented to the General Surgery Clinic and met the inclusion criteria in six month duration. The participants were divided into two groups 40 in each group. Results: When the results of both groups were put in a comparison, it showed that group A had a significant lower pain values in day 1 and 3 than group B but both groups(p=0.043*,p= 0.004)results were equivocal in day seven with no significant difference(p=0.268). Also results showed that group B needed more analgesics than group A and that confirms that metronidazole do decrease pain experienced by the patients after the operation and decreased their need for analgesics(p=0.043). Otherwise, both groups show no significant differences according to the time of first bowel movement(p=0.967). Conclusion: Oral Metronidazole administration post haemorrhoidectomy significantly decrease the post-operative pain and decrease the need for more analgesics with no significant effect on the time of the first bowel movement.

Effect of acupuncture on post-hemorrhoidectomy pain: a randomized controlled trial.

ObjectivesTo observe the clinical efficacy and safety of electroacupuncture (EA) in relieving pain after hemorrhoidectomy treatment for mixed hemorrhoids.DesignThis was a randomized controlled trial.MethodsWe conducted a single-center, single-blind, and randomized controlled clinical trial. Seventy-two patients with mixed hemorrhoids who had undergone hemorrhoidectomy were randomly assigned to the following 2 groups: the EA treatment group (EA) received surround needling with EA (n=36), and the control group received sham acupuncture (SA) treatment (n=36). The treatment was conducted within 15 min after the completion of the surgery and lasted for 30 min. The pain intensity was recorded by using the visual analog scale as the primary outcome. Secondary outcomes were verbal rating scale and Wong–Baker Faces Pain Rating. These measurements were evaluated at 11 time points: once every hour in the first 8 h after the treatment, 24 and 48 h after the treatment, and at the first defecation. Besides, quality of life was measured by Symptom Checklist-90 Scale at 24 and 48 h follow-ups.ResultsThe EA group had significantly lower visual analog scale scores at the 3 time points of 6, 24 h, and during the defecation (p<0.05). Verbal rating scale showed a significantly lower score in the treatment group compared to the SA group at 4 h after the treatment as well as during defecation (p<0.05). The Wong–Baker Faces Pain Rating scores of EA group were significantly lower at 5, 7, and 8 h after treatment and during defecation (p<0.05) compared with those of SA group.ConclusionAcupuncture is effective in alleviating postoperative pain in patients who have undergone hemorrhoidectomy.

A prospective randomized double-blind study of pain control by topical calcium channel blockers versus placebo after Milligan-Morgan hemorrhoidectomy.

Post-hemorrhoidectomy pain is significantly associated with a hypertonicity of the internal anal sphincter. We evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. Purpose of our study was to determine difference in extent of pain control by application of topical calcium channel blocker (diltiazem 2%) versus placebo ointment. This was a prospective randomized double-blind clinical study conducted at Sawai Man Singh Hospital, Jaipur, from May 2016 to May 2017. Sixty patients, who had undergone hemorrhoid, were randomly assigned to receive 2% diltiazem ointment (n = 30) or a placebo ointment (n = 30) postoperatively. Ointments were applied to the perianal region three times daily for 7days. Pain scores were recorded using visual analog scale at 6, 24, and 48h and seventh day postoperatively and number of analgesic doses consumed by patients in the first 3days. Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week (p < 0.001) except for reading at 6h. Also, there was significantly less number of analgesic doses consumed in the diltiazem group compared to the placebo group. Perianal application of 2% diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial.

A randomized controlled trial to evaluate the efficacy of Karpura Ghrita as a topical analgesic with lignocaine jelly 2% in posthemorrhoidectomy pain

INTRODUCTION: Effective postoperative pain control is an essential component of the care of the surgical patient. Uncontrolled pain may cause restlessness and thereby delay in wound healing. Haemorrhoids are certainly one of the commonest ailments that afflict mankind. NSAID's have been traditionally been used to relieve pain after minor or major surgery. There are many modes of treating the local pain like by lignocaine Jelly2%, glycerine packing, diclofenac suppository which reduces the pain but they may bring delayed wound healing. The use of Karpura-Ghrita is mentioned in classics after shastrakriya for Pain (Vedana) management. Hence, this study is planned to evaluate the effect of Karpura-Ghritaan topical analgesic in post haemorrhoidectomy pain. AIM: To evaluate the analgesic effect of KarpuraGhrita OBJECTIVES: To evaluate the analgesic effect of KarpuraGhrita with Lignocaine jelly 2% gauze packing in post-operative Haemorrhoidectomy. MATERIALS AND METHODS: 30 patients who undergone haemorrhoidectomy under local anaesthesia, fulfilling the inclusion criteria were randomly selected from I.P.D of Shalyatantra of KLEU's Shri BMK Ayurveda Mahavidyalaya, Belgavi and divided into Group 1 and Group 2 comprising of 15 patients each. Group 1 (study group) was treated with KarpuraGhrita gauze packing and Group 2 (control group) was treated with lignocaine jelly 2% gauze packing after Haemorrhoidectomy. Patients were assessed for requirement of 1st dose of analgesic and Pain assessed by Verbal Descriptive Scale. OBSERVATIONS AND RESULTS: Pain score by Kruskalwallis multiple comparison test showed significant result in both the groups. Pain score between the two groups was evaluated by Mann-Whitney U test which showed non-significant result. CONCLUSION: KarpuraGhrita has shown analgesic effect. Both the drugs have shown significant effect in post haemorrhoidectomy pain management.

Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief.

Conventional haemorrhoidectomy is still considered the reference standard for the management of severe or recurrent haemorrhoids. Pain is reported by patients to be the most common postoperative complication. Although the literature lacks a consensus on its effectiveness, metronidazole is often used to reduce postoperative pain. We have performed a meta-analysis of all randomized controlled trials (RCTs) that investigated the use of metronidazole for pain relief after haemorrhoidectomy. A systematic review was undertaken in accordance with the PRISMA protocol using the MESH headings 'haemorrhoidectomy', 'hemorhoidectomy', 'hemorrhoidectomy', 'haemorrhoid', 'metronidazole', 'Flagyl® ' 'antibiotic' and 'pain'. The search returned 421 articles of which eight were RCTs suitable for inclusion in the review with a total population of 437 patients. The outcomes of interest were postoperative pain intensity on days 1, 2 and 7 and on first defaecation as measured using a visual analogue scale. The meta-analysis demonstrated a significant reduction in postoperative pain for patients treated with metronidazole with a reduced mean difference for the metronidazole group on day 1 of -1.42 (95% CI: -2.14 to -0.69, P=0.0001), on day 2 of -1.43 (95% CI: -2.45 to -0.40, P=0.006) and on day 7 of -2.40 (95% CI: -3.10 to -1.71, P<0.00001). Pain on first defaecation was likewise reduced with a mean difference of -1.38 (95% CI: -2.15 to -0.60, P=0.0005). Limitations of this study include variation in the grade of haemorrhoids treated and variability in the quality of included studies. Metronidazole is a cheap, safe and effective intervention for reducing postoperative pain following conventional haemorrhoidectomy.

Topical diltiazem ointment in post-hemorrhoidectomy pain relief: A meta-analysis of randomized controlled trials

Hemorrhoidectomy is commonly associated with postoperative pain. Calcium channel blockers are known to cause relaxation of gastrointestinal smooth muscle and oral diltiazem has also been shown to reduce the resting anal pressure. We attempted to analyze efficacy and side effects of topical diltiazem oint. in post-operative pain control. This is a meta-analysis of patients who underwent hemorrhoidectomy using topical diltiazem oint. versus placebo (Vaseline) for pain control. Patients with third or fourth degree hemorrhoids undergoing traditional hemorrhoidectomy were included. Procedures took place in the colorectal division of a hospital in 5 countries. Five randomized control trials (RCTs) published between 2005 and 2016 including 227 patients were included our meta-analysis (Diltiazem (calcium channel block) group=137; Placebo (Vaseline) group=90). Pain assessment was performed using a standardized Visual Analogue Scale. Any side effects of surgery or medication use, which were noted by the patient or the surgeon, also were recorded. A total of 227 patients were included in the meta-analysis. The results revealed that Diltiazem ointment was statistically significant in reducing pain within 48h, at 72h, and more than 96h after operation compared to the placebo group. Regarding overall complications (including headache), there was no statistical significance between diltiazem and placebo group. Topical application of diltiazem effectively relieves pain after hemorrhoidectomy with minimal side effects. Further large studies are needed to substantiate its value in clinical practice.

Systemic Metronidazole May Not Reduce Posthemorrhoidectomy Pain: A Meta-Analysis of Randomized Controlled Trials.

Hemorrhoidectomy is associated with significant postoperative pain. Oral metronidazole has been recommended as an adjunct to improve posthemorrhoidectomy analgesia. This study aimed to evaluate the impact of oral metronidazole on patient-reported pain following hemorrhoidectomy. We conducted a systematic search in the MEDLINE, EMBASE, ISI Web of Science, and Cochrane Central Register of Controlled Trials databases. Randomized controlled trials examining adults who underwent surgical hemorrhoidectomy were included. Participants in an active intervention group received oral metronidazole postoperatively, and those in a control group received placebo or usual care. Postoperative pain was assessed for at least 3 days postoperatively. A random-effects model was used. The primary outcome was pain during the first 2 postoperative weeks, measured on a visual analogue scale. The secondary outcome was time to return to normal activities. Patients who received oral metronidazole had significantly lower reported pain scores on postoperative day 1 (standardized mean difference, -0.87 ± 0.44; 95% CI, -1.73 to -0.015; p = 0.046; n = 4) and day 4 (standardized mean difference, -1.43 ± 0.71; 95% CI, -2.83 to -0.037; p = 0.044; n = 3). Metronidazole use was associated with a significantly shorter time to return to normal activities (standardized mean difference, -0.76 ± 0.34; 95% CI, -1.43 to -0.088, p = 0.027). The improvements disappeared in a sensitivity analysis excluding the largest trial with a high risk of bias, and no significance was observed during the remaining postoperative days. The meta-analysis was limited by lack of double blinding, absence of a placebo, and unclear or high risk of bias in a proportion of the included trials. Although a favorable adverse effect profile supports consideration of oral metronidazole to reduce posthemorrhoidectomy pain, pooled analysis reveals inconsistent results with no pain reduction on most postoperative days. The current recommendation for routine prescription of oral metronidazole should be reevaluated in the absence of additional well-designed trials.

Xiaozhi decoction reduced posthemorrhoidectomy pain and analgesic medication consumption: a prospective study.

ObjectiveThe aim of this study was to investigate the effect of Xiaozhi decoction (XZD) on posthemorrhoidectomy pain and analgesic medication consumption.MethodsFrom May 2013 to March 2015, 315 patients who underwent open hemorrhoidectomy in our hospital were enrolled in this study, of whom, 160 patients were randomly assigned to accept sitz bath with warm water after hemorrhoidectomy (control group) and 155 patients were randomly assigned to accept sitz bath with XZD (XZD group) after hemorrhoidectomy. Postoperative pain at 12 hours after surgery and on postoperative days (PODs) 1, 2, 7, 14 and 28 was evaluated by Visual Analog Scale (VAS). Pain on defecation on PODs 1, 2, 7, 14 and 28 was also recorded using the VAS. The consumption of analgesics was also analyzed.ResultsNo significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the XZD group was significantly lower on POD 2 (6.04±1.11 vs 6.33±1.14, P=0.0229), POD 7 (3.35±0.75 vs 4.22±0.87, P=0.0000) and POD 14 (2.87±0.64 vs 3.64±0.77, P=0.0000) than that of the control group. Similarly, patients in the XZD group experienced significantly less pain on defecation on POD 2 (5.02±1.34 vs 5.43±1.56, P=0.0130), POD 7 (3.08±1.17 vs 3.52±1.29, P=0.0017) and POD 14 (2.31±0.85 vs 2.68±0.99, P=0.0004). Patients in the XZD group consumed significantly less analgesic medication on POD 2 (P=0.0136), POD 7 (P=0.0074) and POD 14 (P=0.0046) than the control group.ConclusionXZD could effectively relieve postoperative pain and reduce analgesic medication consumption after hemorrhoidectomy.

Effects of Topical Atorvastatin (2%) on Posthemorrhoidectomy Pain and Wound Healing: A Randomized Double-Blind Placebo-Controlled Clinical Trial.

Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor widely used in treatment of hypercholesterolemia and prevention of coronary heart disease and has various pleiotropic effects. In this study, the efficacy of atorvastatin emulgel (2%) in reducing postoperative pain at rest, pain during defecation and analgesic requirement after open hemorrhoidectomy was investigated. A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12h for 14days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of pethidine and acetaminophen consumption, and percent of wound healing. There was no significant difference in the average postoperative pain scores in the first 48h (P 12h=1, P 24h=0.128 and P 48h=0.079) after the surgery between the two groups, but at the week 1 the pain scores during defecation were considerably lower in the atorvastatin group than in placebo group (P=0.004), which also was the same at the week 2 (P=0.03). There was no significant difference in the average pethidine and acetaminophen (mg) administration at 12h and 24h between the two groups after surgery. Regarding the data about wound healing, at the week two the healing was much better in the treatment group than it was in control group and the difference was statistically significant (P=0.04). Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy. IRCT201404013014N8.

Literature review of the role of lateral internal sphincterotomy (LIS) when combined with excisional hemorrhoidectomy.

Pain following hemorrhoidectomy is a distressing sequel to the procedure. Various methods have been used to alleviate post-hemorrhoidectomy pain; among these methods is the lateral internal sphincterotomy (LIS). This review aimed to analyze all studies that evaluated the impact of LIS on the outcome of excisional hemorrhoidectomy. Seventeen studies were included after organized search of the literature using electronic databases including PubMed/Medline and EMBASE. The studies included comprised 2180 patients with median age of 44years. Variables selected for the review comprised patients' characteristics, postoperative pain assessment, analgesic consumption, and complications as fecal incontinence (FI), urinary retention, and anal stenosis. Overall, 933 (42.7%) patients underwent LIS. Almost all studies assessing postoperative pain reported lower pain scores and less need for postoperative analgesia among patients who underwent LIS in comparison with patients who did not have LIS. Eleven of 13 studies that assessed continence state postoperatively reported higher rates of FI among patients who had LIS with a median rate of 7.7% versus 1.25% for patients who did not have LIS. Incidence of urinary retention after LIS ranged from 0 to 60%. Anal stenosis occurred in 0-14.5% of patients who had LIS versus 0-36.4% in patients without LIS. LIS effectively reduced postoperative pain and need for analgesics following excisional hemorrhoidectomy. LIS also managed to decrease incidence of postoperative urinary retention and anal stenosis significantly. The negative aspect of adding LIS to excisional hemorrhoidectomy was developing minor FI after surgery which was temporary in duration.

Topical diltiazem for pain after closed hemorrhoidectomy.

Anal sphincter spasm contributes to the appearance of postoperative pain following hemorrhoidectomy. To determine the efficacy of topical diltiazem in the control of post-hemorrhoidectomy pain. A randomized, prospective, experimental, double-blind study was conducted on 2 groups of patients in the postoperative period of closed hemorrhoidectomy. Each group consisted of 17 patients. Group A received topical diltiazem in the anal region 3 times a day and group B received a placebo. Ketorolac was administered to both groups as rescue therapy. In group A, the mean score on the visual analog scale was 2.97±1.18cm at 24h, 1.51±1.18cm at 48h, and 0.84±0.92cm at 72h. In group B, it was 6.82±1.9cm at 24h, 5.3±1.66cm at 48h, and 4.32±2.13cm at 72h (P<.001, 95% CI). The mean number of analgesic doses in group A was 2.41±0.87 at 24h, 1.11±0.85 at 48h, and 0.94±0.96 at 72h. In group B, it was 3.82±0.52 at 24h, 3.64±0.70 at 48h, and 2.88±1.26 at 72h (P<.001, 95% CI). In this study, topical administration of diltiazem resulted in a statistically significant reduction of postoperative pain in patients that underwent closed hemorrhoidectomy.