Pain after haemorrhoid surgery remains one of the most important patient complaints. Excision haemorrhoidectomy is most commonly used for 3^rdand 4^thdegree haemorrhoids. After haemorrhoid surgery, pain is reported in the early postoperative period but also after 2-3 days, around the time of first defecation. The aetiology of pain is believed to be multi-factorial, the following factors are important:

• Individual pain thresholds
• Anaesthetic and analgesic protocols
• Operative technique (stapled surgical technique recommended)
• Anal sphincter spasm
• Postoperative inflammation and secondary infections.

Evidence-based treatment recommendations specific to the condition

For overall recommendations see PROSPECT/ haemorrhoid surgery/Overall Prospect recommendations

For interventions which are NOT recommended see PROSPECT/haemorrhoid surgery/Summary Recommendations/NOT recommended

Before admission

Administration of lactulose, metronidazole and topical glyceryl-trinitrate for 4 days before surgery demonstrated a significant reduction in postoperative pain and analgesic requirements German section 4.3.7.3, p 34.

Preoperative

See PROSPECT/ see haemorrhoid surgery/ summary recommendations / pre-operative recommendations

• Parenteral glucocorticoids.
• nsNSAIDs, COX-2-selective inhibitors and paracetamol, administered in time to provide sufficient analgesia in the early recovery period.

Local analgesia

The use of perianal localanaesthetic infiltration as sole anaesthetic/analgesic technique or as an adjunct to general or spinal anaesthesia techniques, provides significant postoperative pain relief. Although peripheral nerve blocks, such as perineal, pudendal and ischiorectal fossa blocks have been shown to be beneficial as adjuncts to general or spinal anaesthesia, perianal local anaesthetic infiltration may be preferable because of the simplicity of administration.

”Four quadrant” perianal infiltration French, section 9.1, single shot infiltration, p 407 and pudendal nerve block with a long acting local anaethetic provide good postoperative analgesia. German section 4.3.7.2. p 34.

Intraoperative

nsNSAIDS or COX-2 selective inhibitors and paracetamol, administered in time to allow for an effect in the early postoperative period. PROSPECT /see haemorrhoid surgery/ summary recommendations / intra-operative recommendations

Postoperative

Systemic analgesia

• Non-opioid analgesics should be used when possible, as opioids can cause constipation, which may hinder recovery.
• Paracetamol is ineffective as a single therapy for treatment of moderate to severe pain (VAS 50 mm or above). It is, therefore, best used in combination with nsNSAID’s or COX-2 selective inhibitors and supplement with weak opioids for pain of low to moderate intensity (VAS below 50 mm), and with strong opioids for moderate to high pain intensity.
• Medications should be administered at the appropriate time (preoperative or intra-operative) to provide sufficient analgesia in the early recovery period, as well as continued in the postoperative period PROSPECT /see haemorrhoid surgery/summary recommendations / postoperative recommendations. German, section 4.3.7.3., p 34.
• The use of stool softeners instead of laxatives and additional measures should be taken to regulate bowel function to achieve a soft and pulpy stool and therefore less pain on defecation.

Summary

Pain related tohaemorrhoid surgery should be managed with a multimodal approach incorporating peripehral nerve blocks and relying mainly on oral non-opioid analgesia to prevent constipation. However, opioids can be used if the pain is severe.

Supplementary reading

1. Favreau C, Siproudhis L, Eleouet M, Bouguen G, Bretagne JF.Underlying functional bowel disorder may explain patient dissatisfaction after haemorrhoidal surgery. Colorectal Dis. 2012 Mar;14(3):356-61.
2. Panarese A, Pironi D, Vendettuoli M et al Stapled and conventional Milligan-Morgan haemorrhoidectomy: different solutions for different targets. Int J Colorectal Dis. 2012 Apr;27(4):483-7.