Pre-Operative

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Pre-operative studies

To ensure an adequate analgesic effect in the immediate postoperative period, it may be necessary to administer analgesic medication prior to the postoperative period.

Data in this section are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that assessed pre-operative analgesia versus the same analgesia given postoperatively (to examine the concept of pre-emptive – or preventive – analgesia).

A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids (Ong 2005b). A previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures — such as orthopaedic, dental, gynaecological and abdominal — has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002).

PROSPECT recommendations

  • Pre-operative gabapentinoids cannot be recommended (Grade D, LoE 4) because there is no procedure-specific evidence and because the benefit:risk ratio is not sufficiently favourable for this ambulatory procedure, despite analgesic efficacy in other procedures (transferable evidence, LoE 1)

Clinical practice

  • None cited

Transferable evidence

  • Three systematic reviews and a meta-analysis evaluated the use of gabapentinoids for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls (
  • Two systematic reviews (
  • Two systematic reviews (

Haemorrhoid surgery-specific evidence

  • None cited

PROSPECT Recommendations

  • Based on transferable evidence showing analgesic efficacy (LoE 1), it is recommended (Grade B) that systemic conventional NSAIDs should be administered at the appropriate time to provide sufficient analgesia in the early recovery period
  • There is not enough evidence at this time to recommend the use of one NSAID over another
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (Grade B), including bleeding complications, actual or recent gastroduodenal ulcer history (transferable evidence, LoE 1), cardiovascular morbidity (LoE 4), aspirin-sensitive asthma, renal function and hepatic function (transferable evidence, LoE 3)

Clinical practice

  • The risk of bleeding complications from haemorrhoid surgery with pre-operative conventional NSAIDs is not a concern, as haemorrhoid surgery is a short, ambulatory procedure, and bleeding complications are minimal
  • Conventional NSAIDs should be administered at the appropriate time to provide sufficient analgesia when the patient wakes

Transferable evidence

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures (
  • In a randomized controlled trial of patients undergoing anorectal surgery, patients experienced less pain and required fewer rescue analgesics when treated with pre-operative ketorolac (either IV or as an infusion with a local anaesthetic solution) than when treated with placebo
  • A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritus, urinary retention or respiratory depression (
  • One randomised trial in patients undergoing vaginal hysterectomy or breast surgery showed that diclofenac was as effective as rofecoxib in terms of postoperative analgesia, but was associated with greater use of anti-emetics and more blood loss 
  • Two meta-analyses comparing pre-incisional and post-incisional NSAIDs/COX-2-selective inhibitors have found no significant benefit of pre-incisional administration for reducing pain scores (
  • Randomised endoscopic trials in healthy elderly volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use (
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo (
  • Meta-analyses of randomised controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls (
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease (
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported (with lumiracoxib; (
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients (
  • Chronic administration of conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication (

Haemorrhoid surgery-specific evidence

  • There were no significant differences between groups receiving IV or caudal ketorolac in VAS pain scores when sitting or supine at any time-point assessed (i.e. at 1, 1.5, 2, 2.5, 3, 4, 5, 6, 10 and 24 h) (
  • There were no significant differences between groups receiving IV or caudal ketorolac in the proportion of patients requiring IV pethidine injection, the number of pethidine doses requested, or the time to first request for rescue analgesia (
  • The incidence of bleeding disorders was significantly lower with caudal ketorolac compared with IV ketorolac (p=0.0098) (
  • The incidence of gastric upsets was significantly lower with caudal ketorolac versus IV ketorolac (p=0.0444) (
  • Study details Yosry 2004 Click here for more information

PROSPECT Recommendation

  • Based on transferable evidence showing analgesic efficacy (LoE 1), it is recommended (Grade B) that COX-2-selective inhibitors should be administered at the appropriate time to provide sufficient analgesia in the early recovery period
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B) (cardiovascular morbidity (transferable evidence, LoE 1), renal function and hepatic function (transferable evidence, LoE 3) or actual or recent gastroduodenal ulcer history (LoE 4)

Clinical practice

  • COX-2-selective inhibitors should be administered at the appropriate time to provide sufficient analgesia when the patient wakes
  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries

Transferable evidence

  • One randomised trial in patients undergoing vaginal hysterectomy or breast surgery showed that rofecoxib was as effective as diclofenac in terms of postoperative analgesia, but was associated with less use of anti-emetics
  • Rofecoxib 50 mg and parecoxib 40 mg have an equipotent analgesic efficacy relative to traditional NSAIDs in postoperative pain after minor and major surgical procedures (
  • A systematic review to quantify the efficacy of single-dose oral valdecoxib and IV parecoxib demonstrated that both are effective treatments for acute postoperative pain, and show similar incidences of adverse effects
  • Randomised endoscopic trials in healthy elderly volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use (
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation or bleeding time compared with placebo Greenberg et al 2000 Click here for more information
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function (
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (
  • Two meta-analyses comparing pre-incisional and post-incisional conventional NSAIDs/COX-2-selective inhibitors have found no significant benefit of pre-incisional administration for reducing pain scores (
  • Two clinical trials showed that in patients who had undergone CABG surgery, COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo (
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents (
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported (with lumiracoxib; (
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients (
  • Chronic administration of COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication (

Haemorrhoid surgery-specific evidence

  • None cited

PROSPECT Recommendations

  • Pre-operative parenteral glucocorticoids are recommended (Grade B), based on limited procedure-specific (LoE 1 and 2) and transferable evidence (LoE 1) for analgesic efficacy

Clinical practice

  • None cited

Transferable evidence

  • Dexamethasone significantly reduced pain scores compared with placebo following laparoscopic cholecystectomy (
  • Dexamethasone was shown to prevent postoperative nausea and vomiting after surgery in a systematic review
  • A single prophylactic dose of dexamethasone (4–8 mg) is effective for preventing PONV in surgery associated with high emetic effects (
  • Meta-analyses of randomised controlled trials showed that peri-operative methylprednisolone was not associated with a significant increase in adverse effects after cardiac, non-cardiac and trauma surgery
  • A randomised controlled trial in patients undergoing anorectal surgery demonstrated that pre-operative IV dexamethasone did not increase the incidence of adverse events or the rate of wound infection compared with placebo
  • A randomised controlled trial in patients undergoing anorectal surgery reported comparable pain scores with pre-operative IV dexamethasone versus placebo

Haemorrhoid surgery-specific evidence

  • VAS pain scores were significantly lower with betamethasone versus placebo at 2 h (p<0.04), but not at 0, 1, 3, and 4 h. Verbal pain scores when sitting were significantly lower with betamethasone compared with placebo at 5–24 h (p<0.04), but verbal pain scores at rest were not significantly different at any time point (i.e. at 0, 1, 2, 3, 4 or 5–24 h) (
  • Pain scores (assessed using a verbal categorical scale, where 0=no pain, 1=mild pain, 2=moderate pain, and 3=severe pain) were lower with betamethasone compared with diclofenac, but no statistics were reported (
  • Significantly fewer patients required rescue analgesia (parenteral pethidine 50 mg) in a betamethasone group versus a diclofenac group (p<0.05) (
  • The incidence of postoperative nausea and vomiting was lower with betamethasone compared with placebo, although no statistics were reported (
  • A greater proportion of patients receiving betamethasone (75%) were discharged from hospital on the day of surgery compared with patients receiving diclofenac (0%), although no statistics were reported (
  • Time to eligibility for discharge and time to actual discharge from hospital were not significantly different between groups receiving either betamethasone or placebo (
  • Study details Aasboe 1998 Click here for more information

PROSPECT Recommendation

  • Ketamine cannot be recommended (Grade D, LoE 4) because there is no procedure-specific evidence and because the benefit:risk ratio is not sufficiently favourable for this ambulatory procedure, despite analgesic efficacy in other procedures (transferable evidence, LoE 1)
  • Dextromethorphan is not recommended (Grade D, LoE 4) based on inconclusive procedure-specific evidence and transferable evidence

Clinical practice

  • Administration of IM dextromethorphan is not widely used in clinical practice

Transferable evidence

  • Studies of ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain or opioid use when used as an adjunct to morphine (
  • Low-dose ketamine was associated with few and mild adverse effects, especially when administered in conjunction with general anaesthesia (
  • A systematic review found that dextromethorphan did not reduce postoperative pain scores with a clinically significant magnitude, and although significant decreases in supplemental opioid consumption were observed, these were of questionable clinical importance in most cases (
  • Two meta-analyses comparing pre-incisional and postincisional treatments found no significant analgesic benefit of pre-incisional administration of NMDA receptor antagonists (
  • Two systematic reviews of randomised controlled trials comparing magnesium with placebo demonstrated inconclusive results overall with regards to pain scores and supplemental analgesic use

Haemorrhoid surgery-specific evidence

  • Highest VAS pain scores were significantly lower with oral dextromethorphan 240 mg compared with placebo (p<0.001); there were no significant differences between oral dextromethorphan 120 mg and placebo groups (
  • Worst pain scores were significantly lower with IM dextromethorphan + CPM compared with CPM alone (p<0.001) (
  • In a group receiving IM dextromethorphan + CPM, the total pethidine consumption was significantly lower, compared with a group receiving CPM alone (p<0.001). The proportion of patients who required pethidine injection was significantly fewer with dextromethorphan + CPM versus CPM alone (p<0.005) (
  • Total pethidine consumption was significantly lower with oral dextromethorphan 240 mg compared with placebo (p<0.001); there were no significant differences between oral dextromethorphan 120 mg and placebo groups, and no significant differences in the proportion of patients who required pethidine injections between any of the three groups were observed (
  • The time to first pethidine injection was significantly longer with IM dextromethorphan + CPM compared with CPM alone (p=0.006) (
  • Patients receiving oral dextromethorphan 240 mg had a significantly longer time to first pethidine injection compared with patients receiving placebo (p<0.001); there were no significant differences between oral dextromethorphan 120 mg and placebo groups (
  • The incidence of pethidine-related side-effects (nausea, vomiting, dizziness and headache) was significantly lower with oral dextromethorphan 240 mg compared with placebo (p<0.05); the incidence was similar with oral dextromethorphan 120 mg and placebo (
  • The incidence of pethidine-related side-effects (such as nausea, vomiting, dizziness and headache) was similar with IM dextromethorphan + CPM and CPM alone (
  • The incidence of urinary retention was comparable between patients receiving IM dextromethorphan + CPM and those receiving CPM alone (
  • There was no significant difference in the incidence of postoperative bleeding in patients receiving IM dextromethorphan + CPM and those receiving CPM alone (
  • Study details Liu 2000 Click here for more information

PROSPECT Recommendations

  • Pre-incisional administration of strong opioids, including transdermal fentanyl, is not recommended (Grade D, LoE 4) due to lack of procedure-specific and transferable evidence

Clinical practice

  • The use of a transdermal patch is not feasible, as haemorrhoid surgery is an outpatient procedure and it is not practical to administer the patch 6 h prior to surgery
  • The use of transdermal fentanyl patches is contraindicated in settings of acute and postoperative pain, in particular in opioid-naiive patients, due to the risk of severe respiratory depression; fatal outcomes have been reported
  • Strong opioids cause constipation, which may hinder recovery
  • Non-opioid analgesics should be used instead of opioids to avoid the risk of constipation

Transferable evidence

  • Strong opioids are effective for reducing high- and moderate-intensity postoperative pain (
  • Pethidine induced significantly higher sedation and respiratory depression compared with tramadol (both 100 mg intravenously) in patients undergoing orthopaedic surgery (n=48) (
  • Strong opioids are associated with adverse effects, including nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention (

Haemorrhoid surgery-specific evidence

  • VAS pain scores were significantly lower with the fentanyl patch compared with the placebo patch at 12, 16 and 24 h (all p<0.05), but not at 6, 30, 36, 48 and 72 h (
  • Consumption of rescue analgesia was significantly lower with the fentanyl patch compared with the placebo patch (IM pethidine, and propoxyphene tablets from 24–72 h; both p<0.05) (
  •  No patients reported pruritus with the fentanyl patch and only one patient reported pruritus with the placebo patch (
  • The incidence of postoperative nausea and vomiting was similar with the fentanyl patch and the placebo patch (
  • The number of patients with urinary retention was similar with the fentanyl patch and the placebo patch (
  • Study details Kilbride 1994 Click here for more information

PROSPECT Recommendations

  • It is recommended (Grade B) that paracetamol should be administered at the appropriate time to provide sufficient analgesia in the early recovery period, based on transferable evidence showing efficacy for treating pain of moderate intensity (LoE 1)

Clinical practice

  • It is considered that paracetamol is ineffective as a single therapy for treatment of high-intensity pain (VAS >/=50 mm)

Transferable evidence

  • Paracetamol is an effective analgesic for the treatment of postoperative pain of moderate intensity (
  • There is evidence that concurrent use of paracetamol and conventional NSAIDs improves pain relief compared with paracetamol alone, but there is no evidence for a superior analgesic effect of the combination compared with conventional NSAIDs alone (

Haemorrhoid surgery-specific evidence

  • None cited

PROSPECT Recommendations

  • Laxatives are recommended (Grade A) in the days prior to surgery, as an adjunct to analgesic therapy, based on procedure-specific evidence (LoE 1 and 2)

Clinical Practice

  • Stool softeners are an alternative to laxatives in clinical practice

Transferable Evidence

  • None cited

Haemorrhoid surgery-specific evidence

  • Two studies out of two demonstrated that laxatives caused a significant reduction in pain scores on defecation compared with placebo/control London 1987 Click here for more information
  • There was a significant reduction in VAS pain scores on day 10 with Plantago ovata compared with control (p<0.01), but not on day 20 (
  • In one study, oral paracetamol requirements after defecation were significantly lower with lactulose compared with placebo (p<0.01), although IM papaveretum consumption was not significantly different between groups, and analgesic requirements before defecation (papaveretum and paracetamol) were similar (
  • Two studies out of two demonstrated a shorter length of hospital stay with laxatives compared with placebo/control (
  • The tenesmus rate in patients in a Plantago ovata group was significantly lower than in patients in a control group (p<0.01) (
  • The time to first bowel action was significantly shorter in patients receiving lactulose compared with patients receiving placebo (p=0.01), although the number of bowel actions in the first week was not significantly different between groups (p=0.05) (
  • There were no significant differences between groups treated with lactulose and placebo in VAS or VRS pain scores in the 24 h preceding defecation on POD 1–3 (
  • Study details London 1987 Click here for more information

PROSPECT Recommendations

  • Topical EMLA is not recommended (Grade B) based on limited procedure-specific evidence (LoE 1) showing a lack of analgesic benefit

Clinical Practice

  • None cited

Tranferable Evidence

  • None cited

Haemorrhoid surgery-specific evidence

  • Pain scores were not significantly different between groups receiving EMLA or placebo cream (
  • Patient satisfaction scores with the procedure as a whole were similar with EMLA cream and placebo cream (
  • Study details Roxas 2003 Click here for more information

PROSPECT Recommendations

  • When used as an adjunct to anaesthesia, perianal LA infiltration is recommended for intra- and postoperative analgesia (Grade A), based on procedure-specific evidence for analgesic efficacy (LoE 1)

Clinical Practice

  • Haemorrhoid surgery is a short procedure, and therefore the effects of LA infiltration may be most beneficial when administered pre-operatively
  • Long-acting local anaesthetics are preferred to short-acting local anaesthetics for analgesia by local injection
  • Epinephrine is commonly used for LA infiltration, as it is often combined in a preparation with lidocaine and some other LAs

Transferable Evidence

  • There is evidence from a variety of surgical procedures that the efficacy of local anaesthetics for postoperative analgesia is similar following pre-operative or post-incisional administration
  • A systematic review of local anaesthesia infiltration showed inconclusive evidence of analgesic efficacy in hysterectomy, open cholecystectomy and a variety of other surgical procedures, but consistent and clinically relevant pain relief in herniorraphy (Moiniche 1998). Also see the Herniorraphy review at www.postoppain.org: Pre-operative or Intra-operative section, Local Anaesthetic Techniques, Inguinal nerve block/field block/infiltration and instillation

Haemorrhoid surgery-specific evidence

  • Two studies out of two demonstrated lower VAS pain scores at rest with LA infiltration compared with placebo Morisaki 1996 Click here for more information
  • One study out of one reported significantly lower VAS pain scores during coughing with LA infiltration compared with placebo on POD3 (p<0.05), but not on POD1–2 (
  • One study out of two demonstrated lower VAS pain scores on first bowel movement with LA (lidocaine) infiltration compared with placebo (p<0.05;
  • In two studies out of two, rescue analgesic requirements were lower with LA infiltration compared with placebo Morisaki 1996 Click here for more information
  • In one study out of one, the time to first analgesic request was significantly longer with LA infiltration compared with placebo (p=0.02;
  • In one study out of one, the time to first passage of faeces was similar with LA infiltration and placebo (
  • In one study out of one, micturition difficulties occurred with a similar frequency in patients receiving LA infiltration or placebo, and there was no reported incidence of nausea or vomiting in either group (
  • Study details Morisaki 1996 Click here for more information

PROSPECT Recommendations

  • Nerve blocks (perineal, pudendal, ischiorectal fossa blocks), as adjuncts to anaesthesia, are recommended for intra- and postoperative analgesia (Grade A) based on procedure-specific evidence for analgesic efficacy (LoE 1)
  • No recommendation can be made regarding the choice of nerve block at this time due to a lack of procedure-specific evidence directly comparing different blocks
  • Perianal LA infiltration may be preferable to nerve blocks because of the simplicity of administration (Grade D, LoE 4) but there is a lack of procedure-specific evidence comparing these techniques

Clinical Practice

  • Perineal and pudendal nerve blocks require clinical experience, and their risks and benefits have not yet been evaluated in comparison with perianal LA infiltration

Transferable Evidence

  • A randomised study reported similar pain scores, satisfaction scores and incidences of urinary retention and bleeding with local perianal nerve block and with regional anaesthesia (spinal or caudal), in patients undergoing a variety of anorectal procedures (including haemorrhoidectomy, fistulectomy, lateral sphincterotomy, excision of anal polyps, and drainage of abscesses)

Haemorrhoid surgery-specific evidence

  • VAS pain scores were significantly lower with posterior perineal block compared with no injection at 1, 2, 4, 8 and 24 h (all p=0.001), but not at 12 h (
  • Consumption of IV morphine in the PACU and 24 h morphine consumption were significantly lower with posterior perineal block compared with no injection (both p<0.001) (
  • Patients receiving posterior perineal block had a shorter duration of PACU stay compared with patients receiving no injection (p<0.001), although duration of hospital stay was not significantly different between groups (
  • Patient satisfaction scores were significantly higher with posterior perineal block compared with no injection (p<0.05) (
  • Two out of two studies demonstrated significantly lower VAS pain scores with GA plus pudendal nerve block compared with GA plus placebo nerve blocks or GA alone Naja 2005 Click here for more information
  • Two out of two studies demonstrated that patients receiving GA plus pudendal nerve block had significantly fewer days of pain during walking (p=0.001) and while sitting (p=0.0001) compared with patients receiving GA plus placebo nerve blocks or GA alone (
  • Two out of two studies showed that significantly fewer patients required opioid-containing analgesics during the first 6 days after surgery with GA plus pudendal nerve block compared with GA plus placebo nerve blocks and/or GA alone (IM pethidine 1 mg/kg if VAS >/=40, oral dextropropoxifen 30 mg + paracetamol 400 mg if VAS<40) (
  • One study out of two showed that the incidence of urinary retention was significantly lower with GA plus pudendal nerve block compared with GA alone (p=0.004), although the incidence of urinary incontinence was similar between groups ( Naja 2005 Click here for more information
  • Two studies out of two reported that the length of hospital stay was significantly shorter with GA plus pudendal nerve block compared with GA plus placebo nerve blocks and/or GA alone (
  • Two out of two studies showed that patients receiving GA plus pudendal nerve block resumed normal activities in a significantly shorter period of time compared with GA plus placebo nerve blocks and/or GA alone (
  • Two studies out of two demonstrated that patient satisfaction was significantly higher with GA plus pudendal nerve block compared with GA plus placebo nerve blocks and/or GA alone (
  • VAS pain scores were significantly lower with ischiorectal fossa block compared with no block at 30 min (p=0.0313), 4 h (p=0.0144) and 24 h (p=0.0015), but not at 2 h (
  • Patients treated with either posterior perineal block or no injection had a similar time to first bowel action (
  • There were no incidences of nausea or vomiting, fecaloma or urinary retention in patients receiving either posterior perineal block or no injection (
  • Two studies out of two reported that the incidences of nausea and vomiting were similar with GA plus pudendal nerve block compared with GA plus placebo nerve blocks and/or GA alone (
  • There were no significant differences in parenteral fentanyl, oral oxycodone, or 'simple analgesia' (dextropropoxyphene + paracetamol, or paracetamol alone) requirements, in patients treated with either ischiorectal fossa block or no block
  • The length of hospital stay was similar with ischiorectal fossa block and no block (
  • Posterior perineal injection versus no treatment (GA in both groups)
  • Study details Brunat 2003 Click here for more information
  • Pudendal nerve block versus placebo nerve block/no treatment (GA in all groups)
  • Study details Naja 2005 Click here for more information
  • Ischiorectal fossa block versus no block (perianal infiltration and GA in both groups)
  • Study details Luck 2000 Click here for more information

PROSPECT Recommendations

  • Caudal LA or opioid reduces postoperative pain (procedure-specific evidence, LoE 1 and 2), but is not recommended (Grade D, LoE 4), due to an insufficient risk:benefit ratio

Clinical Practice

  • The risk of side-effects associated with caudal analgesia may outweigh the analgesic benefits in routine haemorrhoid surgery

Transferable evidence

  • In a randomised study of elective perianal surgery, patients who received either a caudal injection of bupivacaine or diamorphine had better analgesia than patients receiving a control injection. Side-effects were less frequent with caudal diamorphine compared with caudal bupivacaine or control; 41% of patients treated with caudal bupivacaine experienced urinary retention and one patient required temporary catheterisation

Haemorrhoid surgery-specific evidence

  • On POD1, pain scores were significantly lower with caudal infiltration of bupivacaine versus lidocaine (p<0.05), morphine versus lidocaine (p<0.05), and morphine-lidocaine versus lidocaine (p<0.01). On POD2, pain scores were significantly lower with caudal infiltration of bupivacaine versus lidocaine (p<0.01), morphine versus lidocaine (p<0.05), and no injection versus lidocaine (p<0.01). There were no significant differences in pain scores between any other groups (
  • The proportion of patients requiring postoperative opiates was significantly fewer with the group receiving caudal infiltration of morphine and the group receiving caudal infiltration of morphine-lidocaine compared with the group receiving caudal injection of lidocaine (both p<0.05); there were no significant differences between any other groups (
  • Patients in a morphine caudal infiltration group and in a bupivacaine caudal infiltration group had a significantly longer duration of analgesia compared with patients receiving no injection (p<0.01), or patients in a lidocaine caudal infiltration group (p<0.01). Patients receiving caudal infiltration of morphine-lidocaine had a significantly longer duration of analgesia compared with those receiving no injection (p<0.05). There were no significant differences between any other groups (
  • The incidence of gastric upsets was significantly lower with caudal ketorolac versus IV ketorolac (p=0.0444) (
  • The incidence of bleeding disorders was significantly lower with caudal ketorolac compared with IV ketorolac (p=0.0098) (
  • VAS pain scores were significantly lower with caudal injection compared with local infiltration on awakening, at 3 h (both p<0.05), at 6 h (p<0.01) and at first bowel action (p<0.05), but not at 12, 24 and 48 h or on pack removal (
  • The number of patients reporting no pain was significantly fewer with caudal injection compared with local infiltration on awakening (p<0.05) and at 3 and 6 h (both p<0.01), but not at 12, 24 and 48 h, on pack removal, or at first bowel action (
  • There were no significant differences in nausea or micturition scores between groups receiving a caudal injection of bupivacaine, lidocaine, morphine, morphine-lidocaine, or no injection (
  • The requirement for urinary catheterisation was higher with groups receiving a caudal injection compared with those receiving no injection, but no statistics were reported (
  • There were no significant differences between groups receiving caudal or IV ketorolac in VAS pain scores when sitting or supine at any time-point assessed (i.e. at 1, 1.5, 2, 2.5, 3, 4, 5, 6, 10 and 24 h) (
  • There were no significant differences between groups receiving caudal or IV ketorolac in the proportion of patients requiring IV pethidine injection, the number of pethidine doses requested, or the time to first request for rescue analgesia (
  • There were no significant differences between patients receiving caudal injection or local infiltration in number of patients requiring supplementary analgesia (IM papaveretum or oral coproxamol), the mean number of requests for analgesia, or the time to first analgesia (
  • The time to first bowel action was similar with caudal injection and local infiltration (
  • There was no significant difference in the length of hospital stay with caudal injection and local infiltration (
  • The postoperative complication rate (including urinary retention, haemorrhage and infection) was similar with caudal injection and local infiltration (
  • Caudal infiltration with or without opioid or LA, versus placebo (GA in all groups)
  • Study details Pybus 1983 Click here for more information
  • Caudal NSAID versus IV NSAID
  • Study details Yosry 2004 Click here for more information
  • Caudal LA injection versus local wound infiltration (GA in both groups)
  • Study details Pryn 1989 Click here for more information

PROSPECT Recommendations

  • No recommendation can be made regarding the choice of anaesthetic technique (local anaesthesia versus spinal anaesthesia [appropriate ‘short-duration’ spinal] versus general anaesthesia), due to limited procedure-specific evidence
  • Addition of adjuncts to the spinal LA solution is not recommended (Grade D, LoE 4) due to potential side-effects

Clinical Practice

  • The type of spinal anaesthesia used should be appropriate for ambulatory procedures
  • As haemorrhoid surgery is performed on an outpatient basis, there may be safety concerns regarding administration of spinal opioids, such as the potential for delayed respiratory depression
  • Epinephrine is commonly used for LA infiltration, as it is often combined in a preparation with lidocaine and some other LAs
  • Perineal and pudendal nerve blocks require clinical experience, and their risks and benefits have not yet been evaluated in comparison with perianal LA infiltration
  • The questions around neurotoxicity of midazolam are not yet resolved and it should not be used spinally or epidurally in view of uncertain safety

Transferable Evidence

  • A randomised study reported similar pain scores, satisfaction scores and incidences of urinary retention and bleeding with regional anaesthesia (spinal or caudal) and with local perianal nerve block, in patients undergoing a variety of anorectal procedures (including haemorrhoidectomy, fistulectomy, lateral sphincterotomy, excision of anal polyps, and drainage of abscesses)
  • Spinal administration of strong opioids is associated with side-effects including pruritus, PONV, urinary retention, and respiratory depression (

Haemorrhoid surgery-specific evidence

  • The maximal VAS pain score was significantly lower with pudendal nerve block compared with spinal anaesthesia (p<0.001;
  • The number of patients requiring analgesics and the total number of injections administered were significantly lower with pudendal nerve block compared with spinal anaesthesia (both p<0.001;
  • The time to first experiencing postoperative pain was significantly longer with pudendal nerve block compared with spinal anaesthesia (p<0.001;
  • A significantly lower number of patients required urinary catheterisation with pudendal nerve block compared with spinal anaesthesia (p<0.001;
  • Pain scores (assessed on a scale from 0–3) were significantly lower with spinal bupivacaine + morphine compared with spinal bupivacaine alone at 4 (p<0.05) and 6 h (p<0.001), but not at 2, 8, 10 or 12 h (
  • Fewer patients receiving spinal bupivacaine + morphine requested supplementary morphine (10 mg IM) compared with patients receiving spinal bupivacaine alone, but no statistics were reported (
  • The number of administrations of oral analgesic tablets requested in 24 h was significantly fewer with spinal bupivacaine + 1 mg midazolam and spinal bupivacaine + 2 mg midazolam compared with spinal bupivacaine + saline (both p<0.01) (two paracetamol 300 mg + codeine 30 mg tablets taken every 4 h as needed) (
  • The time to the first administration of pain medication was significantly longer with spinal bupivacaine + 1 mg midazolam and spinal bupivacaine + 2 mg midazolam compared with spinal bupivacaine + saline (both p<0.01), and significantly longer with spinal bupivacaine + 2 mg midazolam compared with spinal bupivacaine + 1 mg midazolam (p<0.05;
  • There were no significant differences in pain scores after infiltration of local anaesthetic or immediately after the operation in patients undergoing the Nivatvongs technique versus conventional LA infiltration (
  • The incidence of persistent pain or discomfort was similar with the Nivatvongs technique and conventional LA infiltration (
  • The incidence of fecal impaction was similar with the Nivatvongs technique and conventional LA infiltration (
  • Patient satisfaction with the anaesthesia and with the whole procedure were similar with the Nivatvongs technique and conventional LA infiltration (
  • VAS pain scores at 6 and 24 h were not significantly different between patients undergoing local anaesthetic infiltration or spinal anaesthesia (
  • The number of days that patients required analgesics (paracetamol 1 g and codeine 16 mg every 6 h) was similar with local anaesthetic infiltration and spinal anaesthesia (
  • The incidence of urinary retention was not significantly different with local anaesthetic infiltration (n=0) and spinal anaesthesia (n=1) (
  • The incidence of bleeding was not significantly different with local anaesthetic infiltration (n=1) and spinal anaesthesia (n=2) (
  • The incidence of urinary retention was similar with spinal bupivacaine + morphine and spinal bupivacaine alone (
  • VAS pain scores at the time of the first administration of pain medication were not significantly different between groups treated with spinal bupivacaine + 1 mg midazolam, spinal bupivacaine + 2 mg midazolam, and spinal bupivacaine + saline (
  • The time to first self-voiding was similar with spinal bupivacaine + 1 mg midazolam, spinal bupivacaine + 2 mg midazolam, and spinal bupivacaine + saline (
  • The incidences of urinary retention, sedation and nausea/vomiting were similar with spinal bupivacaine + 1 mg midazolam, spinal bupivacaine + 2 mg midazolam, and spinal bupivacaine + saline (
  • Intra-anal injection (Nivatvongs technique) versus conventional local anaesthetic infiltration
  • Study details Roxas 2006 Click here for more information
  • Local anaesthetic infiltration versus spinal anaesthesia
  • Study details Ong 2005 Click here for more information
  • Pudendal nerve block versus spinal anaesthesia
  • Study details Kim 2005 Click here for more information
  • Spinal LA with or without morphine
  • Study details Amanor-Boadu 1992 Click here for more information
  • Spinal LA with or without midazolam
  • Study details Kim 2001 Click here for more information