World J Surg (2017) 41:603–614

DOI 10.1007/s00268-016-3737-1

SCIENTIFIC REVIEW

Evidence-Based Management of Pain After Excisional

Haemorrhoidectomy Surgery: A PROSPECT Review Update
Tarik Sammour1 • Ahmed W. H. Barazanchi2 • Andrew G. Hill3,4 •

on behalf of the PROSPECT group (Collaborators)

Published online: 20 October 2016

Ó Société Internationale de Chirurgie 2016

Abstract
Background The aim of this systematic review was to update previous PROSPECT (http://www.postoppain.org)
review recommendations for the management of pain after excisional haemorrhoidectomy.
Methods Randomized studies and reviews published in the English language from July 2006 (end date of last review)
to March 2016, assessing analgesic, anaesthetic, and operative interventions pertaining to excisional haemor-
rhoidectomy in adults, and reporting pain scores, were retrieved from the EMBASE and MEDLINE databases.
Results An additional 464 studies were identified of which 74 met the inclusion criteria. There were 48 randomized
controlled trials and 26 reviews. Quantitative analyses were not performed, as there were limited numbers of trials
with a sufficiently homogeneous design.
Conclusion Pudendal nerve block, with or without general anaesthesia, is recommended for all patients undergoing
haemorrhoidal surgery. Either closed haemorrhoidectomy, or open haemorrhoidectomy with electrocoagulation of the
pedicle is recommended as the primary procedure. Combinations of analgesics (paracetamol, non-steroidal anti-inflam-
matory drugs, and opioids), topical lignocaine and glyceryl trinitrate, laxatives, and oral metronidazole are recommended
post-operatively. The recommendations are largely based on single intervention, not multimodal intervention, studies.

Introduction procedure, with patients often requiring multimodal anal-

Haemorrhoidectomy is an effective treatment for third- and
fourth-degree haemorrhoids, as well as bleeding haemor-
rhoids that do not respond to banding. It is a painful
& Ahmed W. H. Barazanchi
ahmedwhbarazanchi@gmail.com
1
Department of Surgical Oncology, MD Anderson Cancer
Center, Houston, TX, USA
2
Department of Surgery, Palmerston North Public Hospital, 50
Ruahine St, Roslyn, Palmerston North 4442, New Zealand
3
Department of Surgery, South Auckland Clinical School,
Faculty of Medical and Health Sciences, University of
Auckland, Auckland, New Zealand
4
Middlemore Hospital, Counties Manukau District Health
Board, Auckland, New Zealand
gesia to control this pain.
The PROSPECT (PROcedure-SPECific post-operative
pain managemenT) Working Group is a collaboration of
surgeons and anaesthesiologists working to formulate
evidence-based recommendations for pain management
that are specific for different surgical procedures. (http://
www.postoppain.org). For the treatment of post-operative
pain after haemorrhoidectomy, the last PROSPECT
review, published in 2010 (literature search including
data until 2006), recommended local anaesthetic infil-
tration and combinations of systemic analgesics (non-
steroidal anti-inflammatory drugs, paracetamol, and opi-
oids) [1].
Since the last PROSPECT review on the management of
pain after haemorrhoidectomy, several randomized con-
trolled trials have been published which add a considerable

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amount of new data on the topic. The aim of the present
systematic review was to update the recommendations of
the previous PROSPECT review using more recent evi-
dence on management of pain after excisional haemor-
rhoidal surgery. The previous PROSPECT review explored
non-excisional and excisional haemorrhoidectomy. The
current review only examined management of pain after
excisional haemorrhoidectomy.
Methods
The literature search methods were identical as compared
to the most recent PROSPECT review, and to improve
consistency across different guideline versions, a focused
update of the existing guideline was performed rather than
a complete rewrite [1]. Previously published methods are
repeated again below for the ease of reference. For the
purposes of this updated review, we focussed on excisional
haemorrhoidectomy and did not seek to review the utility
of non-excisional procedures (such as stapled haemor-
rhoidectomy and Doppler-guided haemorrhoidal artery
ligation). Transferable evidence from procedures other than
excisional haemorrhoidectomy were not used in the current
review, but were part of earlier PROSPECT methodology
used in the last review.
Search strategy
A systematic review of the literature concerning analgesia
after excisional haemorrhoidectomy was conducted
according to the protocol recommended by the Cochrane
Collaboration. EMBASE and MEDLINE were searched for
studies published between June 2006 and March 2016.
Search terms related to pain and interventions for exci-
sional haemorrhoidectomy were as follows: pain OR
analgesi* OR anaesthe* OR anesthe* OR vas OR visual
analog* OR vrs OR mcgill OR epidural OR neuraxial OR
intrathecal OR spinal OR caudal OR perineal block OR
perianal block OR infiltration OR NSAID OR COX-2 OR
paracetamol OR acetaminophen OR gabapentin OR pre-
gabalin OR clonidine OR opioid OR ketamine OR corti-
costeroid OR glyceryl trinitrate OR GTN OR laxative OR
botulinum OR flavonoid OR EMLA OR antibiotic OR
calcium alginate OR Sorbsan OR trimebutine OR Milligan-
Morgan OR Ferguson OR diathermy OR suture fixation
OR CO2 laser OR stapled OR scalpel OR excisional OR
Longo’s procedure AND haemorrhoid* OR hemorrhoid*
OR piles. The search was not limited to randomized con-
trolled trials (RCTs), because some RCTs are not listed as
such in the databases.
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World J Surg (2017) 41:603–614
Study inclusion criteria
RCTs in the English language assessing analgesic, anaes-
thetic, or surgical interventions in adult excisional haem-
orrhoid surgery, and reporting pain on a linear visual
analogue scale (VAS), verbal or numerical rating scale,
were included.
Quality of included studies
The following criteria were used to assess the quality of
eligible studies: statistical analyses and patient follow-up
assessment—indicates whether statistical analyses were
reported and whether follow-up was greater or less than 80
per cent; allocation concealment assessment—indicates
whether there was adequate prevention of foreknowledge of
treatment assignment by those involved in recruitment (A,
adequate; B, unclear; C, inadequate; D, not used); numeri-
cal scores (total 1–5) for study quality, assigned using the
method proposed by Jadad et al. to indicate whether a study
reported appropriate randomization, double-blinding, and
statements of possible withdrawals; additional assessment
of study quality, including an assessment of how closely the
study report met the requirements of the CONSORT state-
ment. See Table 1 for an updated version of the original
table used in the previous review [1].
Analysis of outcomes and statistical analysis
Summary information for each included study was
extracted and recorded in data tables. This information
included pain scores, supplementary analgesic use, time to
first analgesic request, functional outcomes, and adverse
effects. It was assumed that the post-operative pain scores
had been assessed at rest, unless otherwise specified in the
study report.
Studies were stratified according to regimen (analgesic,
anaesthetic, and operative), mode of delivery (systemic,
neuraxial or local), and class of agent. The effectiveness of
each intervention for each outcome was evaluated quali-
tatively, by assessing the number of studies showing a
significant difference between treatment arms (p \ 0.05 as
reported in the study publication).
Quantitative meta-analyses were not performed, owing
to the limited number of included studies of homogeneous
design reporting similar outcome measures that could be
pooled for analysis.
Other sources of information to formulate
recommendations
Studies that reported data pooled from patients undergoing
mixed surgical procedures, including haemorrhoidal
World J Surg (2017) 41:603–614 605

Table 1 Relationship between quality and source of evidence, levels of evidence and grades of recommendation
Study type Study quality assessments LoE Grade of
recommendation
Statistical analyses and patient Allocation Jadad Procedure
follow-up assessment concealment (A– score specific
D)

Systematic review with homogeneous results NA NA NA 1 A

RCT Statistics reported and [80 % A or B 1–5 1 A
follow-up
RCT Statistics not reported or C or D 1–5 2 B
questionable, or \80 %
follow-up
Non-systematic review, cohort study, case study NA NA 3 C
(e.g. some adverse effect guidance)
Clinical practice information (expert opinion); NA NA 4 D
inconsistent evidence
NA not applicable, RCT randomized controlled trial
* Grades A–D, based on overall level of evidence (LoE), considering balance of clinical practice information and evidence

surgery, were excluded from the procedure-specific sys-
tematic review.
Information on clinical practice was taken into
account to ensure that the recommendations had clinical
validity. The recommendations were formulated by the
PROSPECT Working Group, using the Delphi method to
collate rounds of individual comments on the evidence
and draft recommendations, followed by round-table dis-
cussion, and then further Delphi rounds, to achieve final
consensus.
Recommendations for optimal pain relief are graded A–
D according to the overall level of evidence (LoE), as
determined by the quality of studies included, consistency
of evidence, and source of evidence (Table 1). Transfer-
able evidence from procedures other than excisional
haemorrhoidectomy was not used in the current review, but
was part of earlier PROSPECT methodology used in the
last review.
The methodological quality scores for each included
study (allocation concealment score, Jadad quality score,
and LoE) are summarized in Table 2. For qualitative
analysis, the trials were allocated to three broad groups:
pharmacological interventions, anaesthetic techniques, and
surgical techniques.
The changes in recommendations have been highlighted
in Table 3. Some recommendations have remained
unchanged with some new recommendations based on
emerging evidence over the last 10 years.
Pharmacological interventions
The trials in this section were grouped as follows: con-
ventional analgesics (conventional non-steroidal anti-in-
flammatory drugs (NSAIDs), cyclo-oxygenase (COX) 2
selective inhibitors, paracetamol, opioids, topical agents,
analgesic adjuncts, and regional anaesthesia.

Results
The Quality of Reporting of Meta-analyses (QUOROM)
guidelines were followed for this study (Fig. 1). The first
PROSPECT study identified a total of 207 studies of
analgesic interventions in adult haemorrhoidal surgery, of
which 65 were included in the systematic review [1]. After
repeating the search, an additional 464 studies were iden-
tified of which 66 were reviewed in more detail. Of these,
48 were RCT and 8 were reviews. The most common
reasons for study exclusion were as follows: Study not a
RCT (2 studies), duplicate study (6 studies), pain scores not
reported (1 study).
Conventional analgesics
Non-steroidal anti-inflammatory drugs
Diclofenac suppositories administered immediately post-
operatively reduced pain scores on the evening of surgery
and the morning after (p \ 0.05 in a study of 60 patients)
[2]. There were no procedure-specific studies evaluating
COX2 selective inhibitors in this review or the last review.
Paracetamol
There were no procedure-specific studies with paracetamol
in this review or the last review.

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Fig. 1 QUORUM diagram
Opioids
There were no additional studies on opioids since the last
review, which recommended that, because opioids can
cause constipation which may hinder recovery, non-opioid
analgesics should be used when possible (Grade B) [1].
Topical agents
Previous review did not recommend the use of topical
antispasmotic agents due to paucity of evidence. Khan
et al. investigated topical application with 210 patients of
2 % lidocaine or 0.2 % glyceryl trinitrate (GTN)
(p = 0.016) or the combination of both (p \ 0.05). The
combination reduced pain scores on days 1–4 post-
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operatively, and analgesic requirements on days 1–3 [3].
GTN ointment (0.4 %) on its own applied for 6 weeks also
reduced post-operative pain, reduced time to return to
work, significantly improved time to complete wound
healing (p \ 0.0001 with 203 patients) [4]. Diltiazem gel
did not reduce pain or analgesic requirement compared to
placebo in a small study of 62 patients [5].
Previous review did not recommend the use of topical
cholestyramine, EMLA of nifidipine due to paucity of evi-
dence. Cholestyramine ointment reduced pain in one study
on days 1 and 2, and pain with bowel motions up to 4 weeks
after surgery (p \ 0.0001 with 91 patients) [6], and a similar
study by the same authors demonstrated a reduction in pain
for 2 weeks using topical sucralfate ointment (p \ 0.0001
with 48 patients) [7], a finding supported by an older study
World J Surg (2017) 41:603–614 607

Table 2 Quality assessment and level of evidence assigned to ran- Other N-methyl-D-aspartic acid antagonists
domized haemorrhoidectomy trials included in the review (dextromethorphan)
Quality Level of References
score* evidence There were no additional studies on dextromethorphan since the
A5 1 [3, 5–7, 9, 11, 14, 15, 21, 34, 37]
last review, which did not recommend that dextromethorphan be
A4 1 [22, 46]
used (Grade D, LoE 4) based on inconclusive procedure-specific
A3 1 [2, 18, 23, 25, 26, 41, 45]
evidence (with low-quality scores) and transferable evidence [1].
A2 1 [44]
Glucocorticoids
A1 1 [28, 42]
B5 1 [8, 35]
There were no additional studies on glucocorticoids since
B4 1 [31]
the last review, which recommended that parenteral glu-
B3 1 [20, 24]
cocorticoids should be used (Grade B), based on limited
B2 2 [48]
procedure-specific (LoE 1 and LoE 2) and transferable
B1 1 [4]
evidence (LoE 1) for analgesic efficacy [1].
C3 2 [19, 30]
C1 2 [13, 17, 43]
Flavonoids
D4 2 [40]
D3 2 [10, 39]
Low-quality evidence in the last review prevented the recom-
D2 2 [12, 27, 29, 32, 49] mendation of flavonoids in the last review. In a study of 86
D1 2 [16, 33, 36, 38, 47] patients 1 week of post-operative, diosmin 500 mg reduced
* Allocation concealment (A–D), randomization, blinding and pain at rest and on passing bowel motion for up to 2 weeks
withdrawal score. (p B 0.04) [15]. Another study comparing diosmin to parac-
etamol alone showed reduction in pain at day 3 (p = 0.0166)
post-operatively but not at day 1 or 9 [16]. There has been one
(p \ 0.001 for 14 days after surgery or less with 116
small study of 26 patients looking at quercetin 200 mg and
patients) [8]. Topical EMLA applied at the end of surgery
hesperidin 50 mg in combination with resveratrol, bromelain,
reduced pain in the very short term after surgery in three
folic acid, vitamins C and E, and this did not reduce pain [17].
studies (p \ 0.05; with 60, 30, and 60 patients, respectively)
[2, 9, 10]. Topical nifedipine decreased pain at 6 h
Antibiotics
(p \ 0.011) and 7 (p \ 0.054) days after surgery, with no
effect on analgesic use in a study of 270 patients [11].
Prophylactic intravenous antibiotics on anaesthetic induction
Topical metronidazole ointment reduced pain up to day 14
made no difference to post-operative pain in 100 patients
(p B 0.04), and analgesic requirements up to day 7 post-
between post-operative days 1 and 7 [18]. Oral metronidazole
operatively (p \ 0.05) in a study of 47 patients [12].
for 7 days after surgery reduced pain, analgesia requirement,
No study reported significant perianal side effects from
and time to resumption of daily activities (p \ 0.05) in one
any ointment such as anal pruritis. Some studies using GTN
RCT on 44 patients [19]. While post-operative metronidazole is
ointment have reported headache as a side effect but nearly
recommended from the last review, the new review brings
all have failed to reach significance. Khan et al. [3] showed
evidence against the use of preoperative intravenous
the highest rate or side effect with GTN; the study reported a
antibiotics.
discontinuation rate of 4 % due to symptomatic headaches.
Balta et al. [13] used non-surgical gloves filled with Bowel preparation
warm water and applied locally for 15 min sessions, and
this reduced pain at 24 h (p = 0.013) and 72 h (p = 0.039) Mechanical bowel preparation prior to haemorrhoidectomy did
in a study of 40 patients. not improve pain scores at 3 days or with first bowel movement
in a RCT of 44 patients [20]. This is new evidence as the last
Analgesic adjuncts review did not examine mechanical bowel preparation.
Regional anaesthesia
Ketamine
Perianal local anaesthetic infiltration
A bolus of ketamine (5 mg/kg) continuing as an infusion until
2 min after end of surgery (5 mg/kg/min) did not have any Liposomal bupivacaine infiltration reduced pain scores up to
effect on pain or analgesic use in a trial of 78 patients [14]. 96hh after surgery and analgesic requirement (p \ 0.05)

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Table 3 Current recommendations compared to recommendations from previous review

Intervention Old review New review

Preoperative
Parenteral glucocorticoids Recommended No new evidence
Laxative Recommended No new evidence
Mechanical bowl prep No recommendation Not recommended (Grade A). No difference in pain shown
Oral metronidazole Recommended No new evidence
IV antibiotic No recommendation Not recommended (Grade A)
LA/GA ± nerve block Recommended no Pudendal nerve block over perianal LA (Grade B, LoE 2) recommended under
preference one over GA or LA [3]. Pudendal nerve block recommended over spinal
another (Grade A, LoE 1)
Liposomal bupivocaine No recommendation Liposomal bupivacaine cannot yet be recommended due to a lack of inclusion of
other recommended analgesic techniques despite extended analgesia seen in
two studies (Grade D)
Gabapentinoids Not recommended No new evidence
Ketamine Not recommended No new evidence
Dextromethophan Not recommended No new evidence
Strong opioids Not recommended No new evidence
Adjuncts to spinal Not recommended Would not recommend despite latest evidence of slight reduction in pain due to
potential side effects (Grade D)
Intra-operative
Conventional analgesia, Recommended No new evidence to change practice
COX-2 inhibitor,
paracetamol
Botulinum toxin Not recommended No new evidence to change practice
Lateral sphincterotomy Not recommended New evidence to suggest reduction in pain (LoE 1) but safety and potential
complication are a concern (Grade D)
Anal dilator No recommended No new evidence
Stapled haemorrhoidectomy Recommended Excluded non-excisional haemorrhoidectomy from this review
Closed versus open No recommendation Lower level evidence that closed haemorrhoidectomy is less painful than open
haemorrhoidectomy (Grade B)
Cautery of pedicle with energy Not recommended Recommended as latest evidence suggests a reduction in pain following Cautery
device of pedicle with energy devices with some studies showing no benefit (Grade A)
Post-operative
Laxatives Recommended No new evidence
Metronidazole Recommended No change with 1 paper reinforcing use of metronidazole
Topical GTN/lignocaine Not recommended The combination of topical 2 % lignocaine and 0.2 % GTN, or 0.4 % GTN on its
own, is recommended post-operatively (Grade A)
Topical cholestyramine No recommendation Use of topical cholestyramine is recommended (Grade A, LoE 1)
EMLA/nifidipine Not recommended Topical EMLA and nifedipine only reduce pain in the very short term and is
recommended (Grade A)
Topical metronidazole No recommendation There is lower quality evidence for topical metronidazole (Grade D, LoE 2)
Topical diltiazem Not recommended Topical diltiazem is not recommended as it does not reduce pain (Grade A)
Flavinoids Not recommended Diosmin can be used as an adjunct to non-opioid analgesia (Grade A, LoE 1)

compared to plain with 75 patients [21, 22]. In another study
of 187 patients, liposomal bupivacaine infiltration reduced
cumulative pain scores for up to 72 h [22]. Neither of these
studies utilized other recommended analgesic techniques in
addition to the liposomal bupivacaine. Furthermore, cost-
benefits were not discussed. The previous review did not
present evidence for liposomal bupivacaine.
Posterior perineal injection versus no injection
There were no additional studies on posterior perineal
injection since the last review, which did not make any
specific recommendations on posterior perineal injection
(one study only) [1].

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Ischiorectal fossa block Local anaesthetic infiltration versus spinal anaesthesia

Rajabi et al. [23] found reduced pain scores and analgesia There were no additional studies on this comparison since
requirement at 12 h after ischiorectal block with 0.25 % the last review which identified one study showing that the
bupivacaine versus saline and no block at all (p = 0.0001 two techniques were comparable, but recommended that
in 90 patients). perianal local anaesthetic infiltration is preferable because
of the simplicity of administration (Grade D, LoE 4) [1].
Pudendal nerve block versus general anaesthesia alone
Pudendal nerve block versus spinal anaesthesia
There were no additional studies on this comparison since
the last review, which recommended that peripheral nerve The previous review recommended preoperative local
blocks, such as perineal, pudendal, and ischiorectal fossa anaesthetic with no preference of one block over another.
blocks, are beneficial as adjuncts to general or spinal From the current review, pudendal combined with local
anaesthesia (LoE 1), but that perianal local anaesthetic block resulted in reduced analgesia requirement
infiltration may be preferable because of the simplicity of (p = 0.030 but not pain scores compared to spinal anaes-
administration (Grade D, LoE 4). thesia in one study of 67 patients [27], but reduced both
pain scores and analgesia requirement up to 24 h in another
study (p \ 0.001 with 74 patients). The second study was
Caudal epidural
of higher quality (A1 vs. D2), with less chance of type II
error [28].
Caudal block with a local anaesthetic solution combining
ropivacaine plus lidocaine was more effective up to 6 h
Pudendal nerve block versus local anaesthetic infiltration
post-operatively (p B 0.002) than with lidocaine alone in a
large study with 287 patients [24].
Tepetes et al. [29] demonstrated reduced pain scores at 8 h
and reduced analgesia requirement for pudendal nerve
Methylene blue
block versus perianal local anaesthetic infiltration
(p \ 0.001) in a study of 120 patients (40 ml of 1 %
Sim et al. [25] injected 4 ml of 1 % methylene blue with
lidocaine solution used in both arms).
bupivacaine (37 patients) compared with bupivacaine plain
solution (30 patients) and demonstrated reduced pain
Spinal/Epidural local anaesthetic with or without adjuncts
scores on days 1–3, with decreased used of paracetamol on
those days with the combined solution.
Moreira et al. [30] compared intrathecal block with 7 mg
bupivacaine and 80 mcg morphine (20 patients), versus
Anaesthetic interventions
bupivacaine alone (20 patients) and found a significant
reduction in pain scores at 6 h (p = 0.010), 12 h
Intra-anal injection (Nivatvongs’ technique)
(p = 0.043), and 24 h (p = 0.014). The addition of cloni-
versus conventional local anaesthetic infiltration
dine (4 mcg/kg) to ropivacaine epidural only reduced pain
at 4 h (p \ 0.05) post-operatively in one study of 80
There were no additional studies on this comparison since
patients [31], but another study demonstrated reduction in
the last review, which identified only one study showing
pain up to 24 h (p \ 0.05 with 80 patients) after surgery
that both techniques provided comparable analgesia and
[32].
patient satisfaction. No specific recommendation were
made regarding this technique [1].
Operative interventions
Local anaesthesia versus general anaesthesia
This review has only included studies relating to excisional
haemorrhoidectomy (we did not evaluate studies on stapled
In open haemorrhoidectomy, local block only without
haemorrhoidectomy or Doppler-guided haemorrhoidal
general anaesthesia was associated with more pain imme-
artery ligation for instance). The aim of this paper was to
diately post-operatively but less pain on day 8 (p \ 0.05
discuss different methods of pain relief with excisional
with 41 patients) and no difference in mean pain score
haemorrhoidectomy rather than the indications of various
overall compared to general anaesthesia with preoperative
surgical techniques.
perianal block [26].

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Closed versus open haemorrhoidectomy
The previous review reported 3 papers indicated reduced
pain using closed haemorrhoidectomy with 3 papers
showing no difference with pain between the two methods.
Closed haemorrhoidectomy reduced pain at 24 h compared
to open haemorrhoidectomy (p \ 0.0001 with 213
patients) [33].
Electrocoagulation versus ligation of the pedicle
Electrocoagulation reduced pain scores for the first 6 days
after surgery compared to ligation, with decreased anal-
gesia use in the first 24 h after open haemorrhoidectomy
(p = 0.001 with 120 patients) [34].
Submucosal closed haemorrhoidectomy
with radiofrequency bistoury versus open
haemorrhoidectomy with diathermy
There were no additional studies on this comparison since
the last review.
Semi-closed versus open haemorrhoidectomy
There were no additional studies on this comparison since
the last review that identified one study that showed that
pain scores were significantly lower with submucosal
closed haemorrhoidectomy with radiofrequency bistoury at
post-operative day 1, but not at post-operative day 7. In
addition, use of rescue analgesia was lower, and patient
satisfaction was higher with haemorrhoidectomy with
radiofrequency bistoury. No specific recommendations
were made regarding this technique [1].
Sphincterotomy
Previous review did not recommend sphincterotomy due
to limited and inconsistent procedure-specific evidence.
Lateral internal sphincterotomy reduced pain up to day 9
after open haemorrhoidectomy (p \ 0.05 with 60
patients) [16]. When the addition of internal sphinctero-
tomy was compared with topical diltiazem, patients had
significantly less pain on days 4 and 7 post-operatively
(p \ 0.05 with a 102 patients) [35]. Partial internal
sphincter resection (with anal cushion suspension) also
reduced pain after haemorrhoidectomy (p \ 0.014 with
192 patients) [36]. Inducing a ‘‘chemical sphincterotomy’’
using botulinum toxin injection was not beneficial in a
study of 32 patients [37].
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Energy devices
The last review did not recommend the use of energy
devices due to paucity of consistent evidence. Harmonic
scalpel haemorrhoidectomy reduced pain compared with
electrocautery at 24 h and at 7 days post-operatively in one
study of 151 patients (p \ 0.05) [38], as well as overall
pain for 28 days and analgesic requirement in another
study of 64 patients (p = 0.01) [39]. LigaSure haemor-
rhoidectomy reduced pain compared to open haemor-
rhoidectomy in 6 studies [40–45], and in four of these,
there was an associated reduction in analgesia use. Fran-
ceschilli et al. [40] showed reduction in pain score up to
7 days post-operatively (p = 0.049) with 210 patients.
Gentile et al. [41] examined the effect of ligaSure haem-
orrhoidectomy on 52 patients followed up for 28 days;
there was significant reduction in pain scores at 1
(p = 0.0408), 3 (p = 0.0002), 4 (p = 0.0001), and 14 days
(p = 0.0042). Sakr et al. [42] compared ligaSure to open
haemorrhoidectomy showing reduced pain up to 48 h post-
operatively (p \ 0.0001) but not for 14 or 28 days. Bessa
et al. [43] studied 110 patients showing reduction in pain
with patients receiving ligaSure excision for up to 6 weeks
post-operatively (p \ 0.001). Another study by Altomare
et al. [44] of 272 patients showed reduction in pain from
day 3 to day 7 (p, 0.05) but not for 14, 21, or 28 days. Muzi
et al. [45] showed reduced pain at discharge (p = 0.01) and
first bowel motion (p \ 0.05) for ligaSure group in a study
of 250 patients. In two studies with a total of 116 patients,
ligaSure did not reduce pain compared to conventional
open haemorrhoidectomy [28, 46]. LigaSure also reduced
pain scores and analgesia requirement compared to closed
haemorrhoidectomy at 1 day (p = 0.006), 7 days
(p = 0.012), 14 days (p = 0.001) but not for 6 weeks in a
study of 80 patients [47]. There have been no cost
comparisons.
Radiofrequency scalpel (Surgitron) reduced pain com-
pared with closed haemorrhoidectomy at 1 and 2 days after
surgery (p \ 0.05 with 22 patients) [48]. Comparison of
CO2 laser and cold scalpel technique in 40 patients did not
demonstrate a significant difference in pain or analgesia
requirement between groups up to 14 days post-operatively
[49].
Discussion
The approach used in this systematic review provides the
basis for evidence-based recommendations for pain man-
agement in patients undergoing excisional haemor-
rhoidectomy. The reviewers and collaborators have
avoided discussion of pros and cons for different surgical
and non-surgical methods for treating haemorrhoids.
World J Surg (2017) 41:603–614
Hence, the review is primarily for excisional haemor-
rhoidectomy which differs from the previous review. The
opinion of the authors and the members of the PROSPECT
group is that the choice of haemorrhoid procedure should
be based on factors other than pain such as specific aspects
of pathology with patient and surgeon preference and
experience taken into account.
Given the safety and established role of paracetamol in
baseline pain management, we recommend its use, despite
there being no procedure-specific evidence available to
date (Grade B). However, considering the limited analgesic
effect of paracetamol in patients with severe pain, it is
reasonable to believe that paracetamol should be combined
with other systemic analgesics. We have found additional
evidence to support the use of non-steroidal anti-inflam-
matory drugs since the last review which recommended
their use (LoE 1), and we therefore still recommend their
use in the absence of contraindications (Grade A).
There has not been any specific evidence to date for the
use COX-2-selective inhibitors. We did not find any new
evidence for opioids, and the recommendations remain
unchanged from the last review: Because opioids can cause
constipation, nausea, vomiting, and urinary retention, non-
opioid analgesics should be used in preference (Grade B),
with weak opioids used for post-operative pain of low to
moderate intensity (VAS below 50 mm) (Grade B), and
strong opioids for post-operative pain of moderate to high
intensity (VAS 50 mm or above) (Grade B). Similarly,
parenteral glucocorticoids are recommended (Grade B),
based on limited procedure-specific (LoE 1 and LoE 2) for
analgesic efficacy from the last review.
Ketamine infusion is not recommended (Grade A), nor
is dextromethorphan (Grade D, LoE 4). Diosmin can be
used as an adjunct to non-opioid analgesia (Grade A). Due
to the lack of evidence since the last review, alpha-2-delta
receptor modulators (gabapentin, pregabalin) cannot be
recommended (Grade D, LoE 4).
The combination of topical 2 % lidocaine and 0.2 %
GTN, or 0.4 % GTN on its own, is recommended post-
operatively (Grade A), as is topical cholestyramine
(Grade A). Given the easier availability of the former
preparation, this may be used in preference, although
headache can be a problem with use. Topical EMLA and
nifedipine only reduce pain in the very short term (Grade
A), and are therefore less effective. There is lower
quality evidence for topical metronidazole (LoE 2), and
topical diltiazem is not recommended as it does not
reduce pain (Grade A). Prophylactic antibiotics and
bowel preparation did not reduce post-operative pain and
are not recommended (Grade A). Other analgesic
adjuncts carried over from the last review include laxa-
tives (Grade A, LoE 1) and oral metronidazole (Grade A,
LoE 1), both of which are recommended.
611
The findings of this review support the previous PRO-
SPECT recommendation that infiltration with long-acting
local anaesthetic is recommended for all patients under-
going haemorrhoidal surgery (Grade A). We have found
additional high-quality evidence that further confirms that
the use of perianal local anaesthetic infiltration provides
significant post-operative pain relief (LoE 1). However,
while the previous review recommended perianal local
anaesthetic infiltration over pudendal or ischiorectal block
because of the simplicity of administration (Grade D, LoE
4), we now would recommend the addition of pudendal
block as there is some evidence that it is more effective
than perianal administration (Grade B, LoE 2). Despite two
positive studies comparing liposomal bupivacaine with
plain bupivacaine and placebo, liposomal bupivacaine
cannot yet be recommended for routine use due to a lack of
inclusion of other recommended analgesic techniques and
cost issues.
The previous review suggested that no specific recom-
mendation can be made regarding the choice of anaesthetic
technique (local, spinal, caudal epidural, or general
anaesthesia) because of limited procedure-specific evi-
dence, but recommended local anaesthetic infiltration or
general anaesthesia (Grade D, LoE 4) over spinal and
caudal epidural anaesthesia, owing to the potential limita-
tions of the latter for outpatient procedures such as haem-
orrhoidal surgery. There have been two additional studies
comparing local anaesthesia with general anaesthesia with
either minor or no differences found in terms of analgesia.
In addition, there is also now good evidence that pudendal
block is preferable to spinal anaesthesia because of anal-
gesia of longer duration and less side effects (LoE 1).
Therefore, we would recommend pudendal block with or
without general anaesthesia as the modality of choice
(Grade A).
We found a large number of new studies evaluating both
established and new surgical techniques; however, in
general, haemorrhoid treatment must be tailored to the
severity of disease and the patient’s expectations [50].
Since the last PROSPECT review, there has been an
increase in the use of energy devices, with a high-quality
meta-analysis published in 2009 demonstrating reduced
pain compared to conventional haemorrhoidectomy [51].
However, the more recent evidence identified in the current
review is conflicting, and the cost-effectiveness and long-
term outcomes of energy devices for haemorrhoidectomy
have yet to be adequately addressed [52].
Open haemorrhoidectomy with electrocoagulation of the
pedicle reduces pain compared to pedicle ligation (LoE 1),
and there is lower level evidence that closed haemor-
rhoidectomy is less painful than open haemorrhoidectomy
(LoE 2). The addition of lateral internal sphincterotomy
also reduces post-operative pain (LoE 1) but is clinically
123
612
Fig. 2 Updated PROSPECT recommendations for pain management after haemorrhoidectomy. NSAID non-steroidal anti-inflammatory drug,
VAS visual analogue scale
counter-intuitive given the concern regarding sphincter
injury and continence after haemorrhoidectomy. Longer
term follow-up is required to establish the safety of this
practice. In summary, the authors currently recommend
either closed haemorrhoidectomy (Grade B), or open
haemorrhoidectomy with electrocoagulation of the pedicle
as the primary procedure for Grade 3 and 4 haemorrhoids
(Grade A).
The most significant changes in recommendations since
the last review are surgical, topical, and anaesthetic. From
this systematic review, the authors recommend pudendal
nerve block specifically over other types of local anaes-
thetic applications. Surgically the recommendations are for
either closed haemorrhoidectomy or open with electroco-
agulation of pedicles. Topical treatment with either GTN or
lignocaine is newly recommended in this review.
Similar to the last review, the major limitations were the
variability in the methodological quality of the randomized
trials and that quantitative analyses could not be performed
123
World J Surg (2017) 41:603–614
as a result of heterogeneity in study design and outcome
measures. In addition, we did not evaluate other treatment
options for haemorrhoids such as trans-anal haemorrhoidal
de-arterialization as this review focussed on pain relief
following excisional haemorrhoidectomy.
In summary, the recommended analgesic approach for
haemorrhoidectomy is shown in Fig. 2. The recommen-
dations for individual techniques are based on specific
interventional studies, while no firm evidence is available
on combination of techniques. Further research is needed in
the area of multimodal analgesia to support its use.
PROSPECT group (Collaborators) Professor Henrik Kehlet, Dr
Barrie Fischer, Professor Stephan Schug, Professor Girish Joshi,
Professor Marc Van de Velde, Professor Marcel Vercauteren, Dr
Philipp Lirk, Professor Narinder Rawal, and Professor Francis
Bonnet.
Compliance with ethical standards
World J Surg (2017) 41:603–614
Conflict of interest None.
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