Pre‐emptive analgesia and metronidazole on post‐haemorrhoidectomy pain control

Abstract

Background: Post-haemorrhoidectomy wound pain is often the focus of concern for patients as well as their clinicians. Despite the recent enthusiasm brought about by stapled haemorrhoidectomy, conventional haemorrhoidectomy still remains the mainstay of surgical treatment for symptomatic third and fourth degree haemorrhoids in places where healthcare funding cannot afford these expensive devices. The present study aims at evaluating the effectiveness of pre-emptive analgesia and oral metronidazole in reducing wound pain and complications after open haemorrhoidectomy. Method: Patients with symptomatic third or fourth degree haemorrhoids undergoing open haemorrhoidectomy were randomized into four groups. Group 1 received pre-emptive analgesia (0.5% bupivacaine). Group 2 received oral metronidazole (400 mg three times daily for 1 week). Group 3 received both treatments while group 4 was the control group. Results: Number of patients recruited was 105. There was no significant difference among the four groups in terms of pain scores on the first three postoperative days, analgesic requirements, hospital stay and the time to return to normal daily activities. Patients who received oral metronidazole had significantly less pain at the time of the first bowel motion (P = 0.037). Conclusion: Oral metronidazole significantly reduces pain during the first bowel motion after open haemorrhoidectomy. Pre-emptive analgesia with 0.5% bupivacaine does not reduce postoperative pain.

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

“…demonstrated a reduction in pain on days 1 and 4 but found no difference on days 5–7 and thus concluded that metronidazole did not reduce postoperative pain. These differences are surprising given the significant overlap in the studies considered by these two reviews and we would suggest that the differences are probably the result of several methodological differences between the two analyses.…”

“…Of the nine papers progressing to full text review one was excluded for not providing data on metronidazole alone as an intervention. A total of eight RCTs [17][18][19][20][21][22][23][24] were therefore included in this review with an aggregated population of 437 patients. Three of the studies used closed approaches [18,19,24] with the remaining five [17,[20][21][22][23] using open haemorrhoidectomy approaches.…”

“…A total of eight RCTs [17][18][19][20][21][22][23][24] were therefore included in this review with an aggregated population of 437 patients. Three of the studies used closed approaches [18,19,24] with the remaining five [17,[20][21][22][23] using open haemorrhoidectomy approaches. Seven studies [18][19][20][21][22][23][24] reported the severity of haemorrhoidal disease with five studies including only Grade III-IV [19][20][21][22]24], one using Grade II-III [18] and one Grade II-IV [23].…”

“…Type of sedation varied between studies. Six of the studies used general anaesthesia [17][18][19][20][21][22], one used spinal anaesthesia [23] and one study failed to specify the techniques used [24] (Table 2).…”

“…Two studies [19,23] used a topical preparation (10%) with the remaining six using oral preparations. Duration of treatment was variable with five studies using 7 day courses [17,18,20,21,24], one 3 days [22] and two studies not reporting durations [19,23] (Table 2).…”