{ "slug": "why-does-it-hurt-to-sit-on-my-butt-after-pooping", "question": "Why does my anus hurt after pooping?", "shortTitle": "Anal Pain After Pooping", "clinicalQuestion": "In adults with pain localized to the anus during or after defecation, what are the most common underlying causes (e.g., anal fissure, hemorrhoids, proctalgia), and what clinical features distinguish them?", "pico": { "population": "Adults and adolescents experiencing anal or perianal pain during or after bowel movements", "intervention": "Clinical evaluation for underlying cause of post-defecation anal pain (e.g., anal fissure, hemorrhoids, abscess)", "comparator": "No pain with defecation / asymptomatic controls", "outcomes": [ "Diagnosis of anal fissure", "Diagnosis of hemorrhoids", "Presence of rectal bleeding", "Duration and timing of pain relative to defecation", "Resolution of pain with conservative treatment", "Need for surgical intervention" ] }, "category": "anorectal", "relatedConditions": [ "anal-fissure", "hemorrhoids", "anal-abscess", "proctalgia-fugax", "constipation" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "In these studies, pain right after a bowel movement is most often caused by an anal fissure — a small tear — while hemorrhoids themselves usually only hurt when a clot has formed inside them.", "detail": "Three well-conducted randomised trials show that creams like diltiazem, nifedipine, or GTN heal most anal fissures and ease pain within weeks, and surgery works even better when creams fail. But five other studies flagged real harms: a rare cancer was once mistaken for a hemorrhoid, sphincter-cutting surgery can cause gas or stool leakage, pre-surgery enemas increased pain, and hemorrhoids often came back years after surgery — so pain that doesn't fit the usual pattern, or doesn't settle, is worth having examined rather than assumed.", "studyIds": [ "pmid:42067175", "pmid:41989019", "pmid:35038820", "pmid:23737323", "pmid:40904593", "pmid:32904150", "pmid:29521831", "pmid:35729398" ] }, "strength": { "level": "high", "why": "3 well-conducted randomised trials address this question directly.", "override": null }, "direction": { "level": "harm-signal", "why": "5 studies reported harm or tissue damage, including laboratory evidence.", "override": null }, "counts": { "recordsRetrieved": 402, "recordsScreened": 198, "included": 185, "rcts": 56, "systematicReviews": 18, "observational": 58, "participants": 40779, "yearFrom": 2011, "yearTo": 2026, "registeredTrialsWithoutResults": 0 }, "excluded": [], "outcomes": [ { "name": "Diagnosis of anal fissure (sharp, tearing pain)", "status": "possible-improvement", "note": "A clinical practice guideline (not a trial) states that sharp pain starting during or right after a bowel movement is most often caused by a fissure, a small tear in the anal lining. This is expert opinion, not formally graded evidence.", "studyIds": [ "pmid:42067175" ] }, { "name": "Diagnosis of hemorrhoids as the cause of pain", "status": "insufficient", "note": "The same guideline states hemorrhoids usually only cause real pain when a clot forms inside them (thrombosis); otherwise they tend to cause bleeding, itching or a lump rather than pain. A separate study found that reported symptoms often didn't match what doctors found on examination, so symptoms alone are an unreliable way to diagnose the cause.", "studyIds": [ "pmid:42067175", "pmid:33958029" ] }, { "name": "Presence of rectal bleeding", "status": "insufficient", "note": "Bleeding was tracked as part of symptom scores in anal fissure treatment trials, but these studies do not compare it against hemorrhoid patients, so bleeding alone can't be used to tell the two conditions apart from this evidence.", "studyIds": [ "pmid:41989019", "pmid:35038820", "pmid:23737323" ] }, { "name": "Duration and timing of pain relative to defecation", "status": "insufficient", "note": "No trial here directly tracked how the timing of pain (during versus hours after a bowel movement) predicts the cause. The idea that fissure pain comes with passing stool while hemorrhoid pain only comes from a clot is based on clinical experience, not a study that tested timing itself.", "studyIds": [ "pmid:42067175" ] }, { "name": "Resolution of pain with conservative treatment", "status": "improvement", "note": "Randomised trials of topical creams (diltiazem, nifedipine, glyceryl trinitrate) found that pain scores dropped and about 51% to 77% of fissures healed within 6 to 8 weeks of treatment; a review of sitz baths found roughly 80% of fissures healed, but noted that surgical sphincterotomy achieved higher healing rates than conservative treatment overall.", "studyIds": [ "pmid:41989019", "pmid:35038820", "pmid:23737323", "pmid:28239267", "pmid:24054756", "pmid:36337820" ] }, { "name": "Need for surgical intervention", "status": "possible-improvement", "note": "When creams didn't work, trials found that cutting the anal sphincter muscle (sphincterotomy) healed fissures faster and more completely than continuing ointment, but it carried a small risk of gas or stool leakage that ointment did not.", "studyIds": [ "pmid:23737323", "pmid:32246662", "pmid:32904150", "pmid:33778381" ] }, { "name": "Rare serious conditions mistaken for hemorrhoids or fissures", "status": "not-studied", "note": "No trial screened for rare mimics. Case reports describe a cancer (melanoma), a benign tumor, and rectal polyps that were initially mistaken for ordinary hemorrhoids or fissures and found only after biopsy or surgery.", "studyIds": [ "pmid:40904593", "pmid:42746068", "pmid:40575234" ] } ], "benefits": [ { "text": "In randomised trials, topical diltiazem, nifedipine, or glyceryl trinitrate creams eased fissure pain within days to weeks, and healed roughly half to three-quarters of fissures after 3 to 8 weeks of treatment, with some trials finding no clear difference between the specific creams used.", "studyIds": [ "pmid:41989019", "pmid:35038820", "pmid:23737323", "pmid:28239267", "pmid:24054756" ] }, { "text": "Simple conservative steps — more fiber, fluids, and warm water (sitz) baths — relieved fissure pain and healed about 80% of fissures in one study.", "studyIds": [ "pmid:36337820" ] }, { "text": "When creams failed, surgery to cut the anal sphincter muscle healed fissures more completely and relieved pain faster than continuing with ointment alone.", "studyIds": [ "pmid:23737323", "pmid:32246662", "pmid:32904150" ] }, { "text": "An expert guideline states hemorrhoids themselves usually only cause real pain once a clot has formed inside them, which helps explain why ordinary hemorrhoids are often blamed for pain that actually has another cause.", "studyIds": [ "pmid:42067175" ] } ], "limitations": [ { "text": "Almost all of the 185 studies here looked at pain after hemorrhoid *surgery*, not the everyday pain of someone who just had a normal bowel movement — so most of this evidence doesn't directly answer why an unoperated person's anus hurts.", "studyIds": [ "pmid:42007108", "pmid:41894272", "pmid:41067778", "pmid:38652448" ] }, { "text": "The guideline that links symptom pattern to cause is expert opinion; it was not tested in a trial and is not formally graded for evidence quality.", "studyIds": [ "pmid:42067175" ] }, { "text": "A study comparing patients' reported symptoms to what was actually found on examination showed symptoms often don't match the underlying problem, so judging the cause from pain alone is unreliable.", "studyIds": [ "pmid:33958029" ] }, { "text": "Information on rare but serious causes comes only from single case reports, not from studies designed to measure how often they actually occur.", "studyIds": [ "pmid:40904593", "pmid:42746068", "pmid:40575234" ] } ], "risks": [ { "text": "A rare anal cancer (melanoma) caused pain after straining and was initially treated as a hemorrhoid before a biopsy found the true cause.", "studyIds": [ "pmid:40904593" ], "severity": "serious" }, { "text": "In one retrospective study, a small number of patients (0.4%) who had sphincterotomy surgery for chronic anal fissure developed gas incontinence that improved over time; a separate study found no significant difference in postoperative complication rates between sphincterotomy and botulinum toxin injection.", "studyIds": [ "pmid:32904150", "pmid:33778381" ], "severity": "minor" }, { "text": "Giving an enema right before hemorrhoid surgery was linked to more pain afterward, not less.", "studyIds": [ "pmid:35729398" ], "severity": "minor" } ], "whyPeopleTryIt": [ { "text": "Hemorrhoids are the condition most people have heard of, so many assume that's the cause without ever being examined." }, { "text": "Anal pain feels embarrassing to talk about, so people often reach for an over-the-counter cream before seeing a doctor." }, { "text": "The pain often eases between bowel movements, which makes it tempting to assume it will simply go away on its own." } ], "keyStudies": [ "pmid:42067175", "pmid:41989019", "pmid:35038820", "pmid:23737323", "pmid:40904593", "pmid:33958029", "pmid:32904150", "pmid:29521831" ], "studies": [ { "id": "pmid:42822092", "pmid": "42822092", "doi": "10.1016/j.jtv.2026.101056", "nctId": null, "pmcid": null, "title": "Clinical evidence and practice of moist wound healing in Hemorrhoidectomy: A narrative review", "firstAuthor": "Hu", "multipleAuthors": true, "journal": "J Tissue Viability", "year": 2026, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people recovering from hemorrhoidectomy surgery (not general post-poop anal pain)", "intervention": "moist wound dressings/management of the surgical wound", "comparator": "other dressing strategies or standard wound care", "primaryOutcome": "wound healing time (epithelialization) and postoperative pain", "result": "may speed wound healing but effect on pain is unclear, with limited surgery-specific evidence", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it's a narrative (not systematic) review of a surgical-wound topic, admitting the evidence is limited and studies are too small to rule out rare complications", "directness": "indirect", "limitations": "narrative (not systematic) review; procedure-specific comparative evidence is limited; studies are underpowered to exclude differences in uncommon complications; no cost-effectiveness data", "followUp": "", "plainFinding": "Unclear whether dressings reduce post-surgery pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42822092/", "sourceText": "Hemorrhoidectomy creates an open perianal wound that is repeatedly exposed to contamination, mechanical irritation during defecation, and substantial postoperative discomfort. Moist wound management aims to maintain an appropriate wound interface that supports re-epithelialization while balancing hydration, exudate control, wound protection, and patient comfort. This narrative review evaluates the biological rationale, clinical evidence, dressing selection, adjunctive therapies, and practical implementation of moist wound management after hemorrhoidectomy. A structured literature search prioritized randomized controlled trials, systematic reviews, meta-analyses, clinical guidelines, and recent comparative studies directly involving hemorrhoidectomy, while broader wound-healing evidence was used when procedure-specific data were unavailable. Current evidence suggests that selected dressing strategies may shorten epithelialization time, although direct hemorrhoidectomy-specific comparative evidence remains limited. In contrast, dressing-specific effects on postoperative pain are less certain, whereas topical pharmacological and sphincter-targeted interventions have separate evidence supporting analgesic benefit. Available studies provide some reassurance regarding early safety outcomes but are generally insufficiently powered to exclude differences in uncommon complications. Formal cost-effectiveness evidence comparing postoperative dressing strategies is also lacking. Moist dressings should therefore be considered within a multimodal postoperative approach that also addresses pain, sphincter spasm, hygiene, bowel regulation, and defecation-related mechanical stress. Future multicenter randomized trials should use standardized pain, epithelialization, complication, patient-reported, and health-economic outcomes to define which dressing strategies benefit specific patient groups.", "provenance": [ { "field": "population", "quote": "Hemorrhoidectomy creates an open perianal wound that is repeatedly exposed to contamination, mechanical irritation during defecation, and substantial postoperative discomfort." }, { "field": "intervention", "quote": "Moist wound management aims to maintain an appropriate wound interface that supports re-epithelialization while balancing hydration, exudate control, wound protection, and patient comfort." }, { "field": "comparator", "quote": "dressing-specific effects on postoperative pain are less certain" }, { "field": "primaryOutcome", "quote": "selected dressing strategies may shorten epithelialization time" }, { "field": "result", "quote": "Current evidence suggests that selected dressing strategies may shorten epithelialization time, although direct hemorrhoidectomy-specific comparative evidence remains limited." }, { "field": "result", "quote": "In contrast, dressing-specific effects on postoperative pain are less certain, whereas topical pharmacological and sphincter-targeted interventions have separate evidence supporting analgesic benefit." } ] }, { "id": "pmid:42812757", "pmid": "42812757", "doi": "10.3831/KPI.2026.29.3.", "nctId": null, "pmcid": "PMC13620397", "title": "Efficacy of an Herbal Cream on Patients with Hemorrhoids: a randomized triple-blind controlled trial", "firstAuthor": "Zohalinezhad", "multipleAuthors": true, "journal": "J Pharmacopuncture", "year": 2026, "design": "rct", "n": 110, "nField": "reported", "population": "outpatients with grade I-II hemorrhoids", "intervention": "herbal cream (common myrtle, chamomile, wild leek, Russian olive extracts)", "comparator": "conventional cream", "primaryOutcome": "anal pain, difficult defecation, burning, bleeding and itching scores", "result": "Both creams reduced symptoms over time but there was no significant difference between the herbal cream and conventional cream", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "Small trial with high dropout (only 49 of 110 analyzed) and no significant difference found between treatments, limiting confidence.", "directness": "direct", "limitations": "high dropout rates and limited sample size", "followUp": "28 days", "plainFinding": "No extra benefit over standard cream.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42812757/", "sourceText": "OBJECTIVES: Traditional Persian medicine offers various topical treatments for hemorrhoids. This study investigated the efficacy of an herbal cream (HC) containing common myrtle, chamomile, wild leek, and Russian olive extracts. METHODS: This randomized triple-blind controlled trial compared the effects of the HC and a conventional cream (CC) on hemorrhoids. Standardization involved measuring the total phenolic content (TPC) and analyzing the HC by gas chromatography. In total, 110 outpatients with hemorrhoids were randomly assigned to intervention (n = 58) and control (n = 52) groups. The outcomes were evaluated using the visual analog scale (VAS [1-10]); anal pain, difficult defecation, and burning sensation) and four-point Likert scale anal bleeding and anal pruritus) during the intervention phase (14 days) and follow-up (28 days). RESULTS: The HC was safe and well tolerated, with no major adverse effects observed in toxicological or clinical evaluations. Physicochemical assays confirmed the quality parameters, and the TPC was determined. In the clinical trial involving 49 patients, both HC and CC reduced hemorrhoidal symptoms over time (p = 0.011). However, no significant treatment-group effect (p = 0.50) or treatment-by-time interaction (p = 0.77) was observed. Exploratory analyses indicated that the HC produced clinically meaningful reductions in bleeding and anal pain from baseline. CONCLUSION: The HC was safe and well tolerated in patients with grade I-II hemorrhoids. Although it did not show statistical superiority over the CC, potentially due to high dropout rates and limited sample size, HC was associated with clinically meaningful improvements in anal bleeding and pain along with favorable changes in other symptoms. These findings suggest that the HC has potential as a safe herbal alternative for hemorrhoid symptom relief, without side effects and an acceptable safety profile.", "provenance": [ { "field": "n", "quote": "110 outpatients with hemorrhoids were randomly assigned to intervention (n = 58) and control (n = 52) groups" }, { "field": "population", "quote": "patients with grade I-II hemorrhoids" }, { "field": "intervention", "quote": "an herbal cream (HC) containing common myrtle, chamomile, wild leek, and Russian olive extracts" }, { "field": "comparator", "quote": "a conventional cream (CC)" }, { "field": "primaryOutcome", "quote": "anal pain, difficult defecation, and burning sensation) and four-point Likert scale anal bleeding and anal pruritus" }, { "field": "result", "quote": "both HC and CC reduced hemorrhoidal symptoms over time (p = 0.011). However, no significant treatment-group effect (p = 0.50) or treatment-by-time interaction (p = 0.77) was observed." }, { "field": "limitations", "quote": "potentially due to high dropout rates and limited sample size" }, { "field": "followUp", "quote": "follow-up (28 days)" } ] }, { "id": "pmid:42746068", "pmid": "42746068", "doi": "10.1155/carm/6733314", "nctId": null, "pmcid": "PMC13575778", "title": "Perianal Hidradenoma Papilliferum Mimicking a Chronic Hemorrhoid: A Case Report", "firstAuthor": "Bustamante", "multipleAuthors": true, "journal": "Case Rep Med", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "50-year-old woman with pain after straining to poop and a perianal lump for three years", "intervention": "surgical removal of the lump (excisional biopsy)", "comparator": "none", "primaryOutcome": "diagnosis and cure of the perianal lesion", "result": "surgery removed the lesion, which was confirmed as a rare benign tumor (hidradenoma papilliferum), not a hemorrhoid", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, which cannot show how common this cause is or how it compares to other treatments", "directness": "indirect", "limitations": "only one patient; no comparison group; findings may not generalize to typical post-defecation pain", "followUp": "", "plainFinding": "Rare tumor mimicked hemorrhoid, cured by surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42746068/", "sourceText": "Hidradenoma papilliferum (HP) is a rare, benign neoplasm classically originating from apocrine or mammary-like glands. While predominantly presenting in the vulvar region, its occurrence in the perianal location is exceptionally rare and frequently misdiagnosed as hemorrhoidal disease or other localized benign lesions. We present the case of a 50-year-old female patient reporting acute perianal pain following defecation straining, accompanied by the sensation of an asymptomatic perianal mass present for three years. Clinical examination identified a 1.5 cm well-circumscribed, reddish-brown nodule at the anal verge. Excisional biopsy was performed under local anesthesia with 1 cm margins, allowing the wound to heal by secondary intention. Histopathological evaluation confirmed perianal HP, characterized by an arboriform papillary architecture, a double-layered epithelium, and classic apocrine decapitation secretion without cytological atypia. Complete surgical excision remains the definitive, curative treatment. This case highlights the absolute necessity of histopathological evaluation for atypical, therapy-resistant perianal lesions to avoid diagnostic anchoring and to definitively rule out malignancy.", "provenance": [ { "field": "n", "quote": "a 50-year-old female patient" }, { "field": "population", "quote": "a 50-year-old female patient reporting acute perianal pain following defecation straining, accompanied by the sensation of an asymptomatic perianal mass present for three years" }, { "field": "intervention", "quote": "Excisional biopsy was performed under local anesthesia with 1 cm margins, allowing the wound to heal by secondary intention" }, { "field": "comparator", "quote": "Complete surgical excision remains the definitive, curative treatment." }, { "field": "primaryOutcome", "quote": "Histopathological evaluation confirmed perianal HP" }, { "field": "result", "quote": "Histopathological evaluation confirmed perianal HP, characterized by an arboriform papillary architecture, a double-layered epithelium, and classic apocrine decapitation secretion without cytological atypia." } ] }, { "id": "pmid:42085096", "pmid": "42085096", "doi": "10.4103/nah.nah_123_25", "nctId": null, "pmcid": "PMC13387455", "title": "Analgesic Efficacy of Shangdiao Music Combined with Diclofenac Sodium Suppositories after Mixed Haemorrhoid Surgery", "firstAuthor": "Lu", "multipleAuthors": true, "journal": "Noise Health", "year": 2026, "design": "retrospective", "n": 130, "nField": "reported", "population": "patients who had surgery for mixed hemorrhoids", "intervention": "Shangdiao music combined with diclofenac sodium suppositories", "comparator": "diclofenac sodium suppositories alone", "primaryOutcome": "pain levels after surgery measured by a pain scale", "result": "the group given music plus suppositories had significantly greater reductions in pain scores at all time points than suppositories alone", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective, non-randomized comparison of two treatment groups, which cannot rule out other differences between the groups explaining the result.", "directness": "indirect", "limitations": "Retrospective design, not randomized, so groups may differ in unmeasured ways; studies pain after hemorrhoid surgery rather than typical pain after a normal bowel movement.", "followUp": "7 days", "plainFinding": "Added music reduced pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42085096/", "sourceText": "OBJECTIVE: This study aimed to analyse the analgesic efficacy of Shangdiao music (a specific pentatonic modality) combined with diclofenac sodium suppositories after mixed haemorrhoid surgery. METHODS: The clinical data of 130 patients who underwent mixed haemorrhoid surgery at our institution between January 2023 and January 2024 were retrospectively analysed. The participants were stratified into two groups according to postoperative analgesia protocols: a pharmacotherapy group ( n = 70) receiving diclofenac sodium suppositories alone and a combined therapy group ( n = 60) receiving diclofenac sodium suppositories combined with Shangdiao music. The treatment course was 7 days. Outcomes were as follows: postoperative pain conditions (Visual Analogue Scale [VAS]), urinary function, defecation function (Chinese version of the Patient Assessment of Constipation Quality of Life questionnaire [PAC-QOL]), negative emotions (Hospital Anxiety and Depression Scale - Anxiety Subscale [HADS-A] and Hospital Anxiety and Depression Scale - Depression Subscale [HADS-D]), quality of life (General Quality of Life Inventory-74 [GQOLI-74]) and incidence of adverse reactions. RESULTS: No significant differences in baseline characteristics were observed between the two groups ( P > 0.05; Cohen's d range: 0.00-1.00). Both groups demonstrated progressive reductions in VAS scores at 3, 5 and 7 days relative to their 12-hour and 1-day assessments, with the combined therapy group showing significantly greater reductions than the controls at all timepoints ( P < 0.001; Cohen's d : 1.78-3.91). At 7 days, both groups exhibited increased average urine flow rates and GQOLI-74 scores relative to their 1-day measurements, with the combined therapy group demonstrating significantly greater improvements than the controls. Similarly, PAC-QOL, HADS-D and HADS-A scores decreased in both groups at 7 days compared with baseline, with the combined therapy group exhibiting significantly greater reductions ( P < 0.001; Cohen's d : 0.93-1.86). CONCLUSION: The integration of Shangdiao music with diclofenac sodium suppositories remarkably enhances analgesia, accelerates the recovery of urinary/defecatory functions, mitigates negative psychological states and improves the quality of life of patients following mixed haemorrhoid surgery.", "provenance": [ { "field": "n", "quote": "a pharmacotherapy group ( n = 70) receiving diclofenac sodium suppositories alone and a combined therapy group ( n = 60) receiving diclofenac sodium suppositories combined with Shangdiao music" }, { "field": "population", "quote": "130 patients who underwent mixed haemorrhoid surgery" }, { "field": "intervention", "quote": "diclofenac sodium suppositories combined with Shangdiao music" }, { "field": "comparator", "quote": "diclofenac sodium suppositories alone" }, { "field": "primaryOutcome", "quote": "postoperative pain conditions (Visual Analogue Scale [VAS])" }, { "field": "result", "quote": "the combined therapy group showing significantly greater reductions than the controls at all timepoints ( P < 0.001; Cohen's d : 1.78-3.91)" } ] }, { "id": "pmid:42067175", "pmid": "42067175", "doi": "10.1016/j.cgh.2026.04.008", "nctId": null, "pmcid": null, "title": "AGA Clinical Practice Update on Diagnosis and Treatment of Hemorrhoids: Expert Review", "firstAuthor": "Qureshi", "multipleAuthors": true, "journal": "Clin Gastroenterol Hepatol", "year": 2026, "design": "guideline", "n": null, "nField": "not-reported", "population": "patients with symptoms such as bleeding, itching, discomfort, and pain around the anus", "intervention": "", "comparator": "", "primaryOutcome": "identifying the cause of anal pain after bowel movements", "result": "Hemorrhoids only cause significant pain when acutely thrombosed. Sharp pain on defecation is most likely anal fissure.", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is an expert opinion guideline based on review of literature and expert opinion, not a systematic review or trial, so it carries less weight as direct evidence.", "directness": "direct", "limitations": "Because systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.", "followUp": "", "plainFinding": "Sharp pain after pooping likely means fissure.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42067175/", "sourceText": "DESCRIPTION: Hemorrhoids are a common problem. The diagnosis and treatment can be challenging. Gastroenterologists have much to offer these patients. The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide best practice advice (BPA) covering the diagnosis and treatment of hemorrhoid disease. METHODS: This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These BPA statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BPA 1: The diagnosis and treatment of hemorrhoids is within the purview of the gastroenterologist. The diagnosis and grading of hemorrhoids is easily made by taking a history from the patient and examining the patient. Symptoms caused by hemorrhoids include bleeding, itching, discomfort, and/or prolapse. Hemorrhoids only cause significant pain when acutely thrombosed. Sharp pain on defecation is most likely anal fissure. BPA 2: Dietary and lifestyle modifications, including increasing fiber intake and avoiding straining or prolonged time on the toilet, are reasonable first-line therapies for symptomatic hemorrhoids. The use of sitz baths for symptom improvement in symptomatic hemorrhoids is often advised, but scientific data is limited. BPA 3: Topical treatments, including anesthetics, astringents (witch hazel), corticosteroids, and vasoactive agents, can be considered for treatment of symptomatic hemorrhoids, but there is little data to support efficacy. Topical steroids should not be used for more than 2 weeks at a time. BPA 4: Anoscopy should be performed, whenever possible, on every new patient with suspected hemorrhoids, prior to treatment, to ensure accurate diagnosis. BPA 5: Both hemorrhoid banding and infrared coagulation are safe, effective, and easy to perform in the office setting. Infrared coagulation and rubber band ligation have similar benefits in the short term. Rubber band ligation has longer-term benefits for treatment of prolapsing hemorrhoids and recurrent bleeding. Hemorrhoid banding or infrared coagulation should be employed prior to surgical hemorrhoidectomy for grades 1 to 3 hemorrhoids. BPA 6: As part of informed consent for hemorrhoid therapies, the patient must be made aware of the small possibility of pelvic sepsis as a complication. Patients should be counseled about the risk and instructed to present to the emergency department immediately for evaluation, if indicated. BPA 7: In patients with active Crohn's disease or ulcerative colitis, hemorrhoid disease management should be delayed until complete remission is achieved. BPA 8: Hemorrhoids occur in up to two-thirds of women during pregnancy. Treatment should generally involve conservative management, including fiber, treatment of constipation, and topical ointments. If symptoms persist postpartum, or if a woman is planning further pregnancies, standard treatment such as banding or infrared coagulation can be considered. BPA 9: Acute thrombosed hemorrhoids are often extremely painful. They are best treated surgically with incision and drainage. BPA 10: Consultation with a surgeon should be offered to patients with grade 3 internal hemorrhoids who fail banding procedures or have associated external hemorrhoids. Large skin tags can be removed without a hemorrhoidectomy if they are not associated with significant hemorrhoids. Grade 4 internal hemorrhoids require surgical hemorrhoidectomy. BPA 11: Patients with cirrhosis and hemorrhoids should be carefully examined so as not to confuse hemorrhoids with rectal varices. Hemorrhoids in patients with cirrhosis can be treated with banding or infrared coagulation. In patients with significant coagulopathy, infrared coagulation is preferred to banding. Concomitant portal hypertension should not alter this approach. For most clinicians, significant coagulopathy means a platelet count of less than 50,000 per microliter or international normalized ratio greater than 2.0. The presence of concomitant portal hypertension should not alter this approach.", "provenance": [ { "field": "result", "quote": "Hemorrhoids only cause significant pain when acutely thrombosed. Sharp pain on defecation is most likely anal fissure." }, { "field": "primaryOutcome", "quote": "Symptoms caused by hemorrhoids include bleeding, itching, discomfort, and/or prolapse." }, { "field": "population", "quote": "Symptoms caused by hemorrhoids include bleeding, itching, discomfort, and/or prolapse." }, { "field": "limitations", "quote": "Because systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations." } ] }, { "id": "pmid:42007108", "pmid": "42007108", "doi": "10.62347/OCJU5788", "nctId": null, "pmcid": "PMC13090907", "title": "Effect of transcutaneous electrical acupoint stimulation at Zusanli (ST36) on postoperative pain following mixed hemorrhoidectomy: a retrospective study", "firstAuthor": "Ma", "multipleAuthors": true, "journal": "Am J Transl Res", "year": 2026, "design": "retrospective", "n": 185, "nField": "reported", "population": "patients who had surgery to remove hemorrhoids", "intervention": "electrical stimulation at an acupuncture point (Zusanli/ST36) plus standard pain medication", "comparator": "fake (sham) stimulation plus standard pain medication", "primaryOutcome": "pain levels (at rest and during bowel movements) and recovery of gut function", "result": "patients getting the electrical acupoint stimulation had significantly less pain and faster gut recovery than those getting sham stimulation", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a retrospective study (not randomized) in people recovering from hemorrhoid surgery, so it carries less weight and may not reflect everyday post-poop pain unrelated to surgery.", "directness": "indirect", "limitations": "Retrospective design (not randomized), and population is specifically post-surgical hemorrhoidectomy patients rather than general anal pain after defecation.", "followUp": "", "plainFinding": "Less post-surgery pain with acupoint stimulation.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42007108/", "sourceText": "BACKGROUND: Post-hemorrhoidectomy affects patient rehabilitation. This study evaluated the auxiliary effect of transcutaneous electrical acupoint stimulation (TEAS) at Zusanli acupoint (ST36) on the analgesic effect of conventional non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: 185 patients undergoing hemorrhoidectomy were retrospectively enrolled and allocated to TEAS (95 cases receiving TEAS at ST36 post-operation) and control (90 cases receiving postoperative sham stimulation) groups. The two cohorts were comparatively assessed for pain (at rest and during defecation with the Visual Analogue Scale [VAS]), gastrointestinal function, recovery indices, gastrointestinal hormone levels, stress-induced inflammatory markers (cortisol [Cor], C-reactive protein [CRP], interleukin-6 [IL-6]), adverse events, and patient satisfaction. Finally, the correlation of the decrease in Cor, CRP, and IL-6 levels with the improvement of VAS scores and the gastrointestinal function recovery time was evaluated. RESULTS: In the TEAS group, postoperative pain was significantly reduced relative to the control group, together with accelerated gastrointestinal function and postoperative recovery, greater improvement of gastrointestinal hormone levels, higher patient satisfaction, and lower Cor, CRP, and IL-6 concentrations. The groups were similar in the adverse event rate. ΔCor/ΔCRP was primarily related to the relief of resting pain and gastrointestinal recovery, while ΔIL-6 was mainly associated with defecation pain alleviation and gastrointestinal recovery. CONCLUSION: Auxiliary TEAS at ST36 can safely and effectively enhance the analgesic effect of NSAIDs following hemorrhoidectomy and promote rehabilitation outcomes. Serum Cor, CRP, and IL-6, with dynamic changes in patients, are potential reference indexes for curative effect monitoring.", "provenance": [ { "field": "population", "quote": "185 patients undergoing hemorrhoidectomy were retrospectively enrolled" }, { "field": "intervention", "quote": "TEAS (95 cases receiving TEAS at ST36 post-operation)" }, { "field": "comparator", "quote": "control (90 cases receiving postoperative sham stimulation) groups" }, { "field": "primaryOutcome", "quote": "comparatively assessed for pain (at rest and during defecation with the Visual Analogue Scale [VAS]), gastrointestinal function, recovery indices" }, { "field": "result", "quote": "In the TEAS group, postoperative pain was significantly reduced relative to the control group, together with accelerated gastrointestinal function and postoperative recovery" }, { "field": "n", "quote": "185 patients undergoing hemorrhoidectomy were retrospectively enrolled" } ] }, { "id": "pmid:41989019", "pmid": "41989019", "doi": "10.1002/wjs.70361", "nctId": null, "pmcid": null, "title": "A Double-Blind Randomised Controlled Trial Comparing the Efficacy of Nifedipine and Diltiazem Ointments in the Treatment of Anal Fissure", "firstAuthor": "Kumar", "multipleAuthors": true, "journal": "World J Surg", "year": 2026, "design": "rct", "n": 110, "nField": "reported", "population": "people with anal fissures (short-term or long-term)", "intervention": "nifedipine with lidocaine ointment applied twice daily for 6 weeks", "comparator": "diltiazem with lidocaine ointment applied twice daily for 6 weeks", "primaryOutcome": "change in pain, bleeding and quality of life score (REALISE score) after 6 weeks", "result": "Both ointments reduced symptom scores similarly, with comparable healing rates (70.9% vs 67.3%) and few side effects", "resultDirection": "no-benefit", "quality": "moderate", "qualityWhy": "This was a well-designed double-blind randomized trial but of modest size and short follow-up, so it mainly shows the two treatments are about equally effective rather than how well either works compared to no treatment.", "directness": "direct", "limitations": "Short follow-up and single-centre study; long-term outcomes not assessed.", "followUp": "6 weeks", "plainFinding": "Both creams eased fissure pain equally.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41989019/", "sourceText": "BACKGROUND: Anal fissure, a common anorectal disorder, usually presents with pain, bleeding, and itching during or after defecation. These fissures can be classified as acute, chronic, or acute on chronic, depending on the duration of symptoms (6 weeks or less for acute and more than 6 weeks for chronic). Traditional treatment involves medical interventions to reduce sphincter tone and improve blood flow. Topical calcium channel blockers (CCBs) have shown promising results in conservative management. This study aimed to compare the efficacy and safety of Nifedipine versus Diltiazem ointments in treating anal fissures through a double-blind, randomized controlled trial conducted at a tertiary care centre. METHODS: From August 2022 to November 2023, 110 patients with acute, chronic, or acute-on-chronic anal fissures were randomized into two groups, receiving 1 g of either 0.3% Nifedipine and 2% lidocaine or 2% Diltiazem and 2% lidocaine ointments twice daily for 6 weeks. The primary outcome was assessed using the REALISE score, which measures pain, bleeding, and overall quality of life. Secondary outcomes included perianal irritation and adverse events. RESULTS: Both treatments significantly improved the REALISE scores, with reductions from baseline to 6 weeks indicating effective symptom relief. Nifedipine reduced the score from 17.7 ± 3.9 to 5.3 ± 1.8 (p = 0.0001), while Diltiazem reduced it from 16.3 ± 3.9 to 5.8 ± 2.3 (p = 0.0001). Healing rates were comparable between groups (70.9% for Nifedipine and 67.3% for Diltiazem), and both treatments were well-tolerated with minimal side effects. CONCLUSION: This study confirms that both Nifedipine and Diltiazem are effective first-line treatments for anal fissures, offering viable short-term non-surgical options. Further research with longer follow-up and multicentric studies is needed to evaluate long-term outcomes and treatment combinations. TRIAL REGISTRATION: This study was registered in the Indian Clinical Trials Registry under the code: CTRI/2022/04/042081. Registered on April 22, 2022 (URL: https://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=66601&EncHid=71722.40664&modid=1&compid=19).", "provenance": [ { "field": "population", "quote": "110 patients with acute, chronic, or acute-on-chronic anal fissures" }, { "field": "intervention", "quote": "0.3% Nifedipine and 2% lidocaine" }, { "field": "comparator", "quote": "2% Diltiazem and 2% lidocaine ointments twice daily for 6 weeks" }, { "field": "primaryOutcome", "quote": "The primary outcome was assessed using the REALISE score, which measures pain, bleeding, and overall quality of life." }, { "field": "result", "quote": "Healing rates were comparable between groups (70.9% for Nifedipine and 67.3% for Diltiazem), and both treatments were well-tolerated with minimal side effects." }, { "field": "n", "quote": "110 patients with acute, chronic, or acute-on-chronic anal fissures were randomized" } ] }, { "id": "pmid:41894272", "pmid": "41894272", "doi": "10.1097/MD.0000000000048004", "nctId": null, "pmcid": "PMC13034956", "title": "Clinical outcomes of arterial detection ligation technique for grade II/III versus grade IV hemorrhoidal disease", "firstAuthor": "Bilgiç", "multipleAuthors": true, "journal": "Medicine (Baltimore)", "year": 2026, "design": "retrospective", "n": 78, "nField": "reported", "population": "Patients who underwent ADL-mucopexy between July 2022 and March 2024", "intervention": "ADL-mucopexy surgery in patients with grade IV hemorrhoidal disease", "comparator": "ADL-mucopexy surgery in patients with grade II/III hemorrhoidal disease", "primaryOutcome": "Postoperative pain and recurrence", "result": "Grade IV patients required more opioid analgesia and reported higher 24-hour pain scores, but 1-month satisfaction and recurrence rates were similar between groups", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a retrospective study with unequal, fairly small groups comparing disease severity rather than testing a treatment against no treatment, so it can't explain general post-bowel-movement pain.", "directness": "indirect", "limitations": "Retrospectively analyzed; unequal group sizes (54 vs 24); short follow-up period", "followUp": "1 month", "plainFinding": "More early pain after larger hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41894272/", "sourceText": "Doppler-guided dearterialization with mucopexy is well established for grade II/III hemorrhoidal disease (HD), whereas evidence supporting its use in grade IV disease remains limited. The arterial detection ligation (ADL) system provides deeper Doppler penetration and improved arterial mapping, potentially enhancing outcomes in advanced disease. This study compared clinical outcomes of ADL-mucopexy between patients with grade II/III and grade IV HD. Patients who underwent ADL-mucopexy between July 2022 and March 2024 were retrospectively analyzed. Patients were classified into grade II/III and grade IV groups according to the Goligher classification. Primary outcomes included postoperative pain and recurrence, while secondary outcomes comprised operative time, tenesmus, bowel function parameters, and patient satisfaction. Seventy-eight patients were included (grade II/III: n = 54; grade IV: n = 24). Patients with grade IV disease had significantly longer baseline toilet sitting times and symptom duration. Operative time and hospital stay were also longer in the grade IV group, while the number of mucopexies and external excisions was similar. Postoperatively, grade IV patients required more opioid analgesia, experienced longer times to first flatus and defecation, and reported higher 24-hour visual analog scale pain scores. Tenesmus at 1 week was more common in grade IV patients. Despite these early differences, 1-month satisfaction scores were comparable between groups (8.8 vs 8.5). Recurrence was observed in 1 patient in each group during follow-up. ADL-mucopexy demonstrated comparable short-term clinical outcomes and patient satisfaction across different HD grades. Although patients with grade IV disease experienced greater early postoperative discomfort, recurrence rates and overall satisfaction were similar. ADL-mucopexy may be considered a potential minimally invasive surgical option in carefully selected patients with grade IV HD.", "provenance": [ { "field": "n", "quote": "Seventy-eight patients were included (grade II/III: n = 54; grade IV: n = 24)." }, { "field": "population", "quote": "Patients who underwent ADL-mucopexy between July 2022 and March 2024 were retrospectively analyzed." }, { "field": "intervention", "quote": "grade IV patients required more opioid analgesia, experienced longer times to first flatus and defecation, and reported higher 24-hour visual analog scale pain scores" }, { "field": "comparator", "quote": "Patients were classified into grade II/III and grade IV groups according to the Goligher classification." }, { "field": "primaryOutcome", "quote": "Primary outcomes included postoperative pain and recurrence" }, { "field": "result", "quote": "Despite these early differences, 1-month satisfaction scores were comparable between groups (8.8 vs 8.5). Recurrence was observed in 1 patient in each group during follow-up." } ] }, { "id": "pmid:41768320", "pmid": "41768320", "doi": "10.1093/jscr/rjag106", "nctId": null, "pmcid": "PMC12947789", "title": "Laser-based treatment of chronic anal fissures: a report of two cases", "firstAuthor": "Kumassah", "multipleAuthors": true, "journal": "J Surg Case Rep", "year": 2026, "design": "case-series", "n": 2, "nField": "reported", "population": "two men aged 28 and 47 with chronic anal fissures causing severe pain after bowel movements that hadn't improved with medical treatment", "intervention": "laser fissuroplasty (LaFiP), a minimally invasive laser procedure", "comparator": "none (no comparison group; patients had previously failed medical therapy)", "primaryOutcome": "healing of the fissure, symptom relief, and continence", "result": "both patients had rapid pain relief and complete healing within weeks, with no incontinence at 6 months", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is just two patients with no comparison group, so it can't reliably show the treatment works better than other options.", "directness": "direct", "limitations": "Only two cases, short six-month follow-up, long-term durability unknown", "followUp": "6 months", "plainFinding": "Laser treatment healed fissures, no incontinence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41768320/", "sourceText": "Chronic anal fissures (CAF) are painful and often resistant to medical therapy. While lateral internal sphincterotomy is effective, it carries a risk of incontinence. Laser Fissuroplasty (LaFiP) is a minimally invasive alternative gaining traction globally. We report two male patients aged 28 and 47 years, respectively, with CAF unresponsive to medical therapy. Both presented with severe post-defecation anal pain and were diagnosed with posterior midline fissures. LaFiP was performed under pudendal block using 350-400 joules of energy from a 1470 nm diode laser. Postoperatively, both experienced rapid symptom resolution and complete healing within weeks, with no incontinence at 6-month follow-up. LaFiP appears to be a safe and effective technique for managing CAF, particularly suitable for patients at risk of incontinence. Although limited by a short follow-up of six months, initial results from these two cases were promising. Nonetheless, the long-term durability of the intervention requires further study.", "provenance": [ { "field": "n", "quote": "We report two male patients aged 28 and 47 years, respectively, with CAF unresponsive to medical therapy" }, { "field": "population", "quote": "Both presented with severe post-defecation anal pain and were diagnosed with posterior midline fissures" }, { "field": "intervention", "quote": "LaFiP was performed under pudendal block using 350-400 joules of energy from a 1470 nm diode laser" }, { "field": "comparator", "quote": "Chronic anal fissures (CAF) are painful and often resistant to medical therapy" }, { "field": "primaryOutcome", "quote": "Postoperatively, both experienced rapid symptom resolution and complete healing within weeks, with no incontinence at 6-month follow-up" }, { "field": "result", "quote": "Postoperatively, both experienced rapid symptom resolution and complete healing within weeks, with no incontinence at 6-month follow-up" }, { "field": "followUp", "quote": "Although limited by a short follow-up of six months" } ] }, { "id": "pmid:41748755", "pmid": "41748755", "doi": "10.1007/s00384-026-05105-x", "nctId": null, "pmcid": "PMC12945974", "title": "Surgical management of anal stenosis following hemorrhoid treatment: a single-center case series", "firstAuthor": "Do", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2026, "design": "case-series", "n": 13, "nField": "reported", "population": "patients with anal narrowing (stenosis) after hemorrhoid surgery", "intervention": "surgery to release scar tissue, sometimes combined with tissue flap repair", "comparator": "no comparison group", "primaryOutcome": "normal pooping without pain or bleeding afterward", "result": "12 of 13 patients had good results, healing in about 2 months", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a very small, uncontrolled case series from one hospital, so it can't reliably prove the surgery works.", "directness": "indirect", "limitations": "Retrospective, no control group, only 13 patients, single center", "followUp": "13.3 months", "plainFinding": "Surgery fixed narrowing after hemorrhoid op", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41748755/", "sourceText": "OBJECTIVE: To describe the clinical characteristics, causes, classification, and surgical techniques used to treat anal stenosis following hemorrhoid surgery, as well as to evaluate the treatment outcomes based on specific clinical criteria. SUBJECTS AND METHODS: This retrospective case series included 13 patients with anal stenosis after hemorrhoidectomy. All underwent surgical treatment at Viet Duc University Hospital between January 2022 and June 2024. Surgical techniques applied were fibrotic ring release alone, fibrotic ring release with rectal mucosal advancement, fibrotic ring release with horizontal suturing of the rectal mucosa, and fibrotic ring release with V-Y flap reconstruction. Outcomes were assessed based on patients' ability to achieve normal defecation, stool caliber, and the absence of anal pain or bleeding postoperatively. Successful treatment was defined as normalized stool passage without pain or the need for stool softeners. RESULTS: Surgical outcomes were favorable in 12 out of 13 patients (92.3%), with an average healing time of 2.0 ± 1.1 months. The mean follow-up was 13.3 months (range 6-24 months; minimum 6 months). Patients treated with fibrotic ring release alone experienced the longest healing time, while those who underwent mucosal advancement or V-Y flap reconstruction had shorter recovery periods. Recurrence occurred in one patient who required reoperation. CONCLUSION: Anal stenosis is a rare but serious complication following hemorrhoid surgery. Surgical interventions, including fibrotic ring release and anoplasty, appeared to be effective and safe, with favorable short-term outcomes in most patients.", "provenance": [ { "field": "n", "quote": "This retrospective case series included 13 patients with anal stenosis after hemorrhoidectomy." }, { "field": "population", "quote": "13 patients with anal stenosis after hemorrhoidectomy" }, { "field": "intervention", "quote": "Surgical techniques applied were fibrotic ring release alone, fibrotic ring release with rectal mucosal advancement, fibrotic ring release with horizontal suturing of the rectal mucosa, and fibrotic ring release with V-Y flap reconstruction." }, { "field": "comparator", "quote": "This retrospective case series included 13 patients with anal stenosis after hemorrhoidectomy." }, { "field": "primaryOutcome", "quote": "Outcomes were assessed based on patients' ability to achieve normal defecation, stool caliber, and the absence of anal pain or bleeding postoperatively." }, { "field": "result", "quote": "Surgical outcomes were favorable in 12 out of 13 patients (92.3%), with an average healing time of 2.0 ± 1.1 months." }, { "field": "followUp", "quote": "The mean follow-up was 13.3 months (range 6-24 months; minimum 6 months)." } ] }, { "id": "pmid:41686620", "pmid": "41686620", "doi": "10.1097/MD.0000000000047613", "nctId": null, "pmcid": "PMC12908747", "title": "The effect of methylene blue infiltrating injection on anal pain after Milligan-Morgan surgery: A randomized controlled clinical study", "firstAuthor": "Zhu", "multipleAuthors": true, "journal": "Medicine (Baltimore)", "year": 2026, "design": "rct", "n": 60, "nField": "reported", "population": "patients with mixed hemorrhoids undergoing Milligan-Morgan surgery", "intervention": "methylene blue injection into the surgical wound during hemorrhoid surgery", "comparator": "same standard pain medication protocol without methylene blue injection", "primaryOutcome": "anal pain intensity measured by visual analog scale after surgery", "result": "study group had significantly lower pain scores and needed much less additional pain medication", "resultDirection": "benefit", "quality": "low", "qualityWhy": "small single trial of only 60 surgical patients, so results may not generalize or hold up in larger studies", "directness": "indirect", "limitations": "small sample size of 60 patients; studies a specific surgical population (hemorrhoidectomy patients), not general post-defecation anal pain", "followUp": "72 hours", "plainFinding": "Less pain after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41686620/", "sourceText": "BACKGROUND: To investigate the efficacy and safety of methylene blue infiltrating injection (MBI) in alleviating postoperative pain following hemorrhoidectomy. METHODS: In a randomized clinical trial, 60 patients with mixed hemorrhoids undergoing Milligan-Morgan surgery were divided into 2 groups: a study group (n = 30) and a control group (n = 30). Upon surgical completion, patients in the study group received an intraoperative MBI to the surgical incisions. All patients, in both groups, then received the same standard postoperative on-demand intravenous lornoxicam protocol. The primary outcome was anal pain intensity assessed by the visual analog scale scores at 6, 24, 48, and 72 hours. Secondary outcomes included limb movement score, incision edema, duration of the first postoperative defecation, supplemental analgesic consumption, length of hospital stay, hospitalization costs, and serum levels of substance P, 5-hydroxytryptamine, and prostaglandin E2. RESULTS: No significant differences were observed in baseline characteristics. The study group exhibited significantly lower visual analog scale scores at all time points (all P < .001) and required substantially less supplemental lornoxicam (22.67 ± 17.01 mg vs 56.80 ± 9.32 mg, P < .001). Patients in the study group also had better limb movement scores, less incision edema, a shorter duration of the first postoperative defecation, a reduced hospital stay, and lower medical costs (P < .01). Serum levels of substance P, 5-hydroxytryptamine, and prostaglandin E2 were significantly lower in the study group (all P < .05). No perianal cellulitis, skin necrosis, or thrombosis occurred in either group. CONCLUSION: MBI provides effective and safe analgesia after Milligan-Morgan surgery, significantly reducing pain, analgesic consumption, hospital stay, and cost.", "provenance": [ { "field": "n", "quote": "60 patients with mixed hemorrhoids undergoing Milligan-Morgan surgery were divided into 2 groups: a study group (n = 30) and a control group (n = 30)" }, { "field": "population", "quote": "60 patients with mixed hemorrhoids undergoing Milligan-Morgan surgery" }, { "field": "intervention", "quote": "patients in the study group received an intraoperative MBI to the surgical incisions" }, { "field": "comparator", "quote": "All patients, in both groups, then received the same standard postoperative on-demand intravenous lornoxicam protocol" }, { "field": "primaryOutcome", "quote": "The primary outcome was anal pain intensity assessed by the visual analog scale scores at 6, 24, 48, and 72 hours" }, { "field": "result", "quote": "The study group exhibited significantly lower visual analog scale scores at all time points (all P < .001) and required substantially less supplemental lornoxicam (22.67 ± 17.01 mg vs 56.80 ± 9.32 mg, P < .001)" } ] }, { "id": "pmid:41486911", "pmid": "41486911", "doi": "10.3393/ac.2025.00549.0078", "nctId": null, "pmcid": "PMC12766388", "title": "Cryotherapy reduces pain post-hemorrhoidectomy (CYPHER): a randomized, controlled, superiority trial of intra-anal ice after surgery for grade III hemorrhoids", "firstAuthor": "Seow-En", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2025, "design": "rct", "n": 50, "nField": "reported", "population": "patients having surgery for grade III hemorrhoids", "intervention": "ice placed in the anus after surgery (intra-anal cryotherapy)", "comparator": "standard post-surgery care without ice", "primaryOutcome": "pain at rest the day after surgery", "result": "no significant difference in rest pain on day 1, but less pain after bowel movements with cryotherapy", "resultDirection": "mixed", "quality": "low", "qualityWhy": "small trial of only 50 people and the main pain measure did not reach significance.", "directness": "indirect", "limitations": "small sample size; main outcome (rest pain day 1) not statistically significant; this studies post-surgical pain, not ordinary pain after a bowel movement without surgery", "followUp": "30 days", "plainFinding": "Less pain after pooping post-surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41486911/", "sourceText": "PURPOSE: We aimed to determine whether intra-anal cryotherapy reduces postoperative pain in patients undergoing hemorrhoidectomy. METHODS: This randomized controlled trial was conducted from January 2023 to August 2024. Patients with symptomatic grade III hemorrhoids were randomized 1:1 to receive either 1 minute of intra-anal cryotherapy or standard postoperative care. Because cryotherapy was applied before reversal of general anesthesia, patients were blinded to treatment allocation. The primary outcome was pain at rest on postoperative day (POD) 1. Secondary outcomes included pain after defecation, time to return to work or non-work activities, 30-day complications, and compliance with analgesia. Pain was measured using the visual analog scale. RESULTS: A total of 50 patients were randomized (25 per group). All 50 were included in the analysis. Baseline clinicodemographic characteristics were comparable between groups. The primary outcome, POD 1 pain at rest, did not demonstrate superiority of cryotherapy compared with standard care (median 3.0 vs. 4.0, P=0.062). However, the POD 1 pain score after defecation was significantly lower with cryotherapy than without (3.0 vs. 4.0, P=0.046). On POD 2, median pain scores at rest and after defecation were both significantly lower in the cryotherapy cohort (at rest: 2.0 vs. 4.0, P=0.043; after defecation: 2.0 vs. 5.0, P=0.001). CONCLUSION: Intra-anal cryotherapy significantly reduces pain after defecation in the early postoperative period following surgery for grade III hemorrhoids. Its therapeutic efficacy, ease of application, and safety support consideration for routine use. Trial registration ClinicalTrials.gov identifier: NCT06005727.", "provenance": [ { "field": "n", "quote": "A total of 50 patients were randomized (25 per group)." }, { "field": "population", "quote": "Patients with symptomatic grade III hemorrhoids were randomized 1:1" }, { "field": "intervention", "quote": "1 minute of intra-anal cryotherapy" }, { "field": "comparator", "quote": "standard postoperative care" }, { "field": "primaryOutcome", "quote": "The primary outcome was pain at rest on postoperative day (POD) 1." }, { "field": "result", "quote": "The primary outcome, POD 1 pain at rest, did not demonstrate superiority of cryotherapy compared with standard care (median 3.0 vs. 4.0, P=0.062). However, the POD 1 pain score after defecation was significantly lower with cryotherapy than without (3.0 vs. 4.0, P=0.046)." } ] }, { "id": "pmid:41275461", "pmid": "41275461", "doi": "10.1007/s10151-025-03230-3", "nctId": null, "pmcid": "PMC12669252", "title": "Treatment of chronic anal fissure in Crohn's disease patients with freshly collected autologous adipose tissue: a pilot study", "firstAuthor": "Sulaiman", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2025, "design": "case-series", "n": 9, "nField": "reported", "population": "patients with Crohn's disease who have chronic anal fissures", "intervention": "injection of freshly collected autologous fat tissue into the fissure", "comparator": "none (before-and-after comparison in same patients)", "primaryOutcome": "complete healing of the fissure (full re-epithelialization and no pain) at 3 months after last treatment", "result": "5 of 9 patients (56%) had complete healing; pain, discomfort, disease activity, and incontinence scores all improved significantly", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This was a tiny uncontrolled pilot study in only 9 people with no comparison group, so the improvement could be due to other factors.", "directness": "indirect", "limitations": "Small pilot study with no control group; patients had Crohn's disease specifically, not general post-defecation anal pain.", "followUp": "3 months", "plainFinding": "Fat injections healed fissures in Crohn's patients.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41275461/", "sourceText": "BACKGROUND: Chronic anal fissures in patients with Crohn's disease (CD) remain a significant therapeutic challenge, particularly when linked to active perianal disease. Conventional treatments often fail, highlighting the need for alternative approaches. This study explores the efficacy and safety of freshly collected autologous adipose tissue injection (AATI) for treating chronic fissures in patients with CD. METHODS: Nine patients with CD with anal fissures were included. The primary outcome was complete healing (CH) at 3 months after last AATI, defined as full fissure re-epithelialization and complete pain relief. Secondary outcomes included changes in defecation pain (visual analog scale [VAS]), anal discomfort (VAS), Perianal Disease Activity Index (PDAI), and St. Mark's Incontinence Score (SMIS). RESULTS: Five patients (56%) achieved CH after one (n = 4) or two (n = 1) AATI. Partial healing was observed in four patients (44%). Defecation pain improved from a VAS score of 7.5 (IQR 5.0-8.5) to 2.75 (0.0-4.5; p = 0.009), anal discomfort from VAS score of median 5.0 (2.5-6.5) to 1.0 (0.0-2.5; p = 0.014), PDAI from 5.0 (3.0-6.0) to 1.0 (1.0-2.0; p = 0.022), and SMIS from 7.0 (4.0-9.0) to 4.0 (0.0-4.0; p = 0.041). No treatment-related complications occurred. CONCLUSION: AATI may be a promising new treatment of chronic anal fissures in patients with CD. Effects of AATI should be explored further in controlled trials.", "provenance": [ { "field": "n", "quote": "Nine patients with CD with anal fissures were included." }, { "field": "population", "quote": "Nine patients with CD with anal fissures were included." }, { "field": "intervention", "quote": "freshly collected autologous adipose tissue injection (AATI)" }, { "field": "comparator", "quote": "Five patients (56%) achieved CH after one (n = 4) or two (n = 1) AATI." }, { "field": "primaryOutcome", "quote": "The primary outcome was complete healing (CH) at 3 months after last AATI, defined as full fissure re-epithelialization and complete pain relief." }, { "field": "result", "quote": "Five patients (56%) achieved CH after one (n = 4) or two (n = 1) AATI. Partial healing was observed in four patients (44%)." }, { "field": "followUp", "quote": "complete healing (CH) at 3 months after last AATI" } ] }, { "id": "pmid:41067778", "pmid": "41067778", "doi": "10.1136/bmjopen-2024-098484", "nctId": null, "pmcid": "PMC12517015", "title": "Liposomal bupivacaine versus ropivacaine perianal infiltration for postoperative analgesia of haemorrhoidectomy: a multicentre, randomised controlled trial", "firstAuthor": "Huang", "multipleAuthors": true, "journal": "BMJ Open", "year": 2025, "design": "rct", "n": 264, "nField": "reported", "population": "adults having surgery for grade III or IV mixed hemorrhoids", "intervention": "liposomal bupivacaine injected around the anus at the end of surgery", "comparator": "ropivacaine injected around the anus at the end of surgery", "primaryOutcome": "pain scores at rest after surgery, measured at several time points up to 72 hours", "result": "pain scores were lower with liposomal bupivacaine at rest, during exercise, during walking, and during bowel movements, and fewer patients needed extra pain medicine", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it is a reasonably large multicentre randomised trial, but it only studied pain after surgery for hemorrhoids, not everyday pain after a bowel movement, and the abstract does not mention blinding.", "directness": "indirect", "limitations": "abstract does not report blinding of patients or assessors, and population is limited to surgical hemorrhoidectomy patients rather than general anal pain after defecation", "followUp": "72 hours", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41067778/", "sourceText": "OBJECTIVES: To evaluate whether liposomal bupivacaine provides superior postoperative analgesia compared with ropivacaine following haemorrhoidectomy, reduces the need for rescue analgesics in patients with mixed haemorrhoids and maintains a comparable safety profile. DESIGN: Prospective, randomised controlled multicentre trial. SETTING: Three grade 3A general hospitals in Guangxi, China, conducted between September 2023 and July 2024. PARTICIPANTS: Eligible patients were aged 18-75 years undergoing elective external dissection and internal ligation for mixed haemorrhoids (grade III and IV mixed haemorrhoids). Key exclusion criteria were severe systemic diseases, history of substance abuse or known allergies to local anaesthetics. A total of 264 patients (male, n=162; mean age, 43.1±12.2 years) were enrolled and completed the study, with 132 randomised to each group. INTERVENTIONS: Patients received either ropivacaine (100 mg in 20 mL) or liposomal bupivacaine (226 mg in 20 mL) through local infiltration at the end of surgery. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were the resting numerical rating scale (NRS) pain scores (0-10) at postoperative 1, 5, 7, 9, 11, 24, 36, 48 and 72 hours. The secondary outcomes included the following: (1) exercise NRS pain scores at the same time points; (2) time to first ambulation, ambulation NRS pain scores on postoperative days 1, 2 and 3 and the proportion of patients having ambulation NRS pain scores ≥4; (3) defecation NRS pain scores and the proportion of of patients having score ≥4; (4) the time to the first administration of rescue analgesics and proportion of patients requiring rescue analgesics; (5) proportion of pain-free patients (NRS pain scores ≤1) 0-24, 24-72 and 0-72 hour after surgery; (6) incision assessments on postoperative days 1, 3 and 7 and postoperative adverse events (AEs); and (7) patients' and researchers' satisfaction with pain management. RESULTS: Resting NRS pain scores were significantly lower in the liposomal bupivacaine group at all time points (median, 0-2.0 vs 2.0-4.0 for ropivacaine, p<0.001). Exercise NRS pain scores were also significantly lower in the liposomal bupivacaine group (median, 0-2.0 vs 2.0-5.0, p<0.001). Additionally, median ambulation NRS pain scores were reduced in the liposomal bupivacaine group on postoperative days 1-3 (median, 1.0-2.0 vs 3.0-5.0, p<0.001). By 72 hours after surgery, 78.8% of the patients in the liposomal bupivacaine group had defecated, reporting lower defecation NRS pain scores (median, 3.0 vs 5.0, p<0.001). Fewer patients in this group required rescue analgesics (43.9% vs 83.3%, p<0.001). Incision assessment scores were comparable between groups, with no significant difference in AE rates (3.8% vs 1.5%, p=0.444). CONCLUSIONS: Perianal infiltration of liposomal bupivacaine significantly alleviates postoperative resting and exercise pain in patients undergoing surgery for mixed haemorrhoids, enhances comfort during ambulation and defecation, reduces the need for additional analgesics and demonstrates a safety profile comparable to that of ropivacaine. TRIAL REGISTRATION: chictr.org.cn # ChiCTR2300075276.", "provenance": [ { "field": "population", "quote": "Eligible patients were aged 18-75 years undergoing elective external dissection and internal ligation for mixed haemorrhoids (grade III and IV mixed haemorrhoids)." }, { "field": "n", "quote": "A total of 264 patients (male, n=162; mean age, 43.1±12.2 years) were enrolled and completed the study, with 132 randomised to each group." }, { "field": "intervention", "quote": "Patients received either ropivacaine (100 mg in 20 mL) or liposomal bupivacaine (226 mg in 20 mL) through local infiltration at the end of surgery." }, { "field": "comparator", "quote": "Patients received either ropivacaine (100 mg in 20 mL) or liposomal bupivacaine (226 mg in 20 mL) through local infiltration at the end of surgery." }, { "field": "primaryOutcome", "quote": "The primary outcomes were the resting numerical rating scale (NRS) pain scores (0-10) at postoperative 1, 5, 7, 9, 11, 24, 36, 48 and 72 hours." }, { "field": "result", "quote": "Resting NRS pain scores were significantly lower in the liposomal bupivacaine group at all time points (median, 0-2.0 vs 2.0-4.0 for ropivacaine, p<0.001)." }, { "field": "result", "quote": "By 72 hours after surgery, 78.8% of the patients in the liposomal bupivacaine group had defecated, reporting lower defecation NRS pain scores (median, 3.0 vs 5.0, p<0.001)." }, { "field": "result", "quote": "Fewer patients in this group required rescue analgesics (43.9% vs 83.3%, p<0.001)." } ] }, { "id": "pmid:41064523", "pmid": "41064523", "doi": "10.1159/000545793", "nctId": null, "pmcid": "PMC12503519", "title": "Incidence, Diagnosis, and Management of Proctological Conditions during Pregnancy", "firstAuthor": "Schmuck", "multipleAuthors": true, "journal": "Visc Med", "year": 2026, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "pregnant and postpartum women with proctological problems", "intervention": "conservative treatment such as fluids, stool softeners, and topical ointments", "comparator": "surgical treatment", "primaryOutcome": "cause and management of anal pain after bowel movements", "result": "anal pain is linked to constipation, straining, hemorrhoids, anal fissures and perianal thrombosis, and usually improves with conservative care", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a general narrative review about pregnancy-related conditions, not a controlled study testing a specific treatment, and it focuses on pregnant women rather than the general population.", "directness": "indirect", "limitations": "Abstract does not report study methodology, sample size, or comparative outcome data; focused specifically on pregnancy.", "followUp": "", "plainFinding": "Straining causes fissures and hemorrhoids that hurt.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41064523/", "sourceText": "BACKGROUND: Proctological diseases are highly prevalent during pregnancy, with reported incidence rates ranging from 45% to 68%. The true prevalence is likely higher due to underreporting. These conditions frequently persist into the postpartum period, causing significant discomfort and emotional distress. Physiological changes in the maternal body - including hormonal, metabolic, immunological, and cardiovascular alterations - play a central role in the development of these disorders. The enlargement of the uterus, increased blood volume, and elevated pressure in the pelvic veins contribute to venous stasis in the hemorrhoidal plexus, thereby predisposing pregnant individuals to symptomatic hemorrhoids and perianal thromboses. SUMMARY: The most frequently reported symptoms are anal pain and constipation. Anal pain, which is often intense, is commonly associated with constipation and is due to the high density of sensory nerve endings in the anal canal. Constipation affects more than 60% of pregnant women, primarily as a result of hormonal changes, decreased physical activity, and iron supplementation. Straining during defecation further aggravates proctological conditions, facilitating the development of hemorrhoids, anal fissures, and perianal thrombosis. Diagnosis should include a thorough medical history, physical examination, and proctoscopy. In selected cases, additional imaging may be warranted. Conservative treatment is the mainstay of management, with a focus on symptom control and regulation of bowel habits. Hemorrhoidal disease is particularly common during pregnancy. Conservative treatment includes increased fluid intake, the use of stool softeners, and local cooling measures. Surgical interventions should be reserved for refractory cases and only considered when absolutely necessary. Anal fissures, the second most prevalent condition after hemorrhoids, are primarily caused by constipation. First-line treatment involves stool regulation, analgesic therapy, and the application of topical ointments. While chronic fissures may occasionally require surgical intervention, noninvasive approaches are strongly preferred to minimize risks. Perianal thrombosis, often misdiagnosed as thrombosed external hemorrhoids, typically occurs in the third trimester or shortly after delivery. Conservative therapy is generally effective, focusing on pain control. In selected cases, surgical excision of thrombosed nodules may be indicated. KEY MESSAGES: In summary, proctological conditions during pregnancy are common but usually manageable through accurate diagnosis, conservative treatment, and empathetic patient support. Prioritizing symptom relief and avoiding unnecessary surgical interventions are essential to achieving favorable outcomes.", "provenance": [ { "field": "population", "quote": "Proctological diseases are highly prevalent during pregnancy" }, { "field": "intervention", "quote": "Conservative treatment includes increased fluid intake, the use of stool softeners, and local cooling measures." }, { "field": "comparator", "quote": "Surgical interventions should be reserved for refractory cases and only considered when absolutely necessary." }, { "field": "primaryOutcome", "quote": "Anal pain, which is often intense, is commonly associated with constipation and is due to the high density of sensory nerve endings in the anal canal." }, { "field": "result", "quote": "Straining during defecation further aggravates proctological conditions, facilitating the development of hemorrhoids, anal fissures, and perianal thrombosis." } ] }, { "id": "pmid:40949368", "pmid": "40949368", "doi": "10.4240/wjgs.v17.i8.107476", "nctId": null, "pmcid": "PMC12427071", "title": "Analysis of recurrence after stapled hemorrhoidopexy in grade IV hemorrhoid disease", "firstAuthor": "Erkek", "multipleAuthors": true, "journal": "World J Gastrointest Surg", "year": 2025, "design": "retrospective", "n": 77, "nField": "reported", "population": "adults with grade III or IV hemorrhoids who had stapled hemorrhoidopexy surgery", "intervention": "stapled hemorrhoidopexy surgery", "comparator": "grade III hemorrhoids compared with grade IV hemorrhoids", "primaryOutcome": "hemorrhoid recurrence and complications after surgery", "result": "23.6% of grade IV patients had recurrence, while none of the grade III patients did; both groups had complications like bleeding, incontinence, and anal fissure", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small, single-center look-back study with no comparison to other treatments, so it can't prove cause and effect.", "directness": "indirect", "limitations": "Retrospective, single-center design; small sample size; no control group treated with a different method.", "followUp": "", "plainFinding": "High recurrence after stapling for severe hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40949368/", "sourceText": "BACKGROUND: Stapled hemorrhoidopexy (SH) is one of the most commonly used surgical techniques for hemorrhoidal disease, being particularly effective for grade III and IV hemorrhoids. The procedure is associated with better short-term outcomes, including less postoperative pain, shorter operative time, faster return to work, and higher patient satisfaction. However, there is a risk-benefit debate surrounding SH due to significant complications from the procedure, such as anal stenosis, rectovaginal fistula, fecal incontinence, and recurrence. AIM: To evaluate recurrence rates and factors influencing surgical outcomes following SH in patients with grade III and IV hemorrhoids. METHODS: This retrospective, single-center study enrolled a total of 77 patients with grade III/IV hemorrhoids for analysis. Early (less than 7 days after SH) and late (7 or more days after SH) complications were analyzed. Recurrence rates were calculated as well. RESULTS: Patients were categorized by hemorrhoid grade and showed no differences in demographic data between the two groups. Recurrence was observed in 4 patients (23.6%) with grade IV hemorrhoids, and no recurrence was noted in patients with grade III hemorrhoids. Postoperative bleeding, incomplete defecation, urgent defecation, incontinence, skin tags, and anal fissure were complications reported by both groups. CONCLUSION: Due to the high recurrence rate, SH is not an appropriate treatment option for patients with grade IV hemorrhoids. Open surgery may be a more suitable option for these patients.", "provenance": [ { "field": "n", "quote": "This retrospective, single-center study enrolled a total of 77 patients with grade III/IV hemorrhoids for analysis." }, { "field": "population", "quote": "patients with grade III/IV hemorrhoids" }, { "field": "intervention", "quote": "Stapled hemorrhoidopexy (SH) is one of the most commonly used surgical techniques for hemorrhoidal disease" }, { "field": "comparator", "quote": "Patients were categorized by hemorrhoid grade and showed no differences in demographic data between the two groups." }, { "field": "primaryOutcome", "quote": "To evaluate recurrence rates and factors influencing surgical outcomes following SH in patients with grade III and IV hemorrhoids." }, { "field": "result", "quote": "Recurrence was observed in 4 patients (23.6%) with grade IV hemorrhoids, and no recurrence was noted in patients with grade III hemorrhoids." }, { "field": "result", "quote": "Postoperative bleeding, incomplete defecation, urgent defecation, incontinence, skin tags, and anal fissure were complications reported by both groups." } ] }, { "id": "pmid:40904593", "pmid": "40904593", "doi": "10.1093/jscr/rjaf700", "nctId": null, "pmcid": "PMC12401871", "title": "Malignant melanoma of the anal canal: a case report", "firstAuthor": "Parajuli", "multipleAuthors": true, "journal": "J Surg Case Rep", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "a 71-year-old male with a year-long history of perianal pain and painful defecation", "intervention": "hemorrhoidectomy for presumed hemorrhoids", "comparator": "", "primaryOutcome": "diagnosis of the cause of anal pain", "result": "histopathology revealed invasive malignant melanoma", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how it compares to other causes.", "directness": "indirect", "limitations": "Limited to case reports, the literature offers little guidance on standardized treatment.", "followUp": "", "plainFinding": "Rare case: melanoma, not hemorrhoids", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40904593/", "sourceText": "Anal melanoma is a rare and aggressive malignancy with early local invasion and high metastatic potential, leading to poor outcomes. Limited to case reports, the literature offers little guidance on standardized treatment. We report a case of a 71-year-old male with a year-long history of perianal pain and painful defecation, following decades of mild anal discomfort. He underwent hemorrhoidectomy for presumed hemorrhoids, but histopathology revealed invasive malignant melanoma. On presentation, per rectal exam showed perianal satellite nodules and black pigmentation of the anal canal. Imaging confirmed anal canal thickening with hepatic and pulmonary metastases. Given the advanced stage and positive margins, the patient was managed palliatively with systemic chemotherapy.", "provenance": [ { "field": "n", "quote": "a 71-year-old male" }, { "field": "population", "quote": "a 71-year-old male with a year-long history of perianal pain and painful defecation" }, { "field": "intervention", "quote": "He underwent hemorrhoidectomy for presumed hemorrhoids" }, { "field": "primaryOutcome", "quote": "histopathology revealed invasive malignant melanoma" }, { "field": "result", "quote": "histopathology revealed invasive malignant melanoma" }, { "field": "limitations", "quote": "Limited to case reports, the literature offers little guidance on standardized treatment." } ] }, { "id": "pmid:40834876", "pmid": "40834876", "doi": "10.1055/a-2587-5592", "nctId": null, "pmcid": null, "title": "Paeonia officinalis for Acute Anal Fissure: A Prospective, Single-Group, Open-Label, Pre-Post Comparison Study", "firstAuthor": "Dixit", "multipleAuthors": true, "journal": "Homeopathy", "year": 2026, "design": "case-series", "n": 34, "nField": "reported", "population": "people with acute anal fissures", "intervention": "oral homeopathic Paeonia officinalis tincture plus dietary/supportive care", "comparator": "no separate control group; outcomes compared before and after treatment in the same patients", "primaryOutcome": "pain intensity during and after bowel movements, measured on a pain scale", "result": "pain scores dropped sharply, straining decreased, and most fissures healed by 12 weeks", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this was a small, uncontrolled, open-label study where everyone knew they were getting treatment, so it cannot show the remedy itself caused the improvement.", "directness": "indirect", "limitations": "no control group, not blinded, small number of patients, and the authors themselves note other factors could explain the improvement.", "followUp": "12 weeks", "plainFinding": "Less pain, fissures mostly healed", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40834876/", "sourceText": "BACKGROUND: Acute anal fissure (AF) causes significant pain and discomfort, sometimes requiring invasive treatment. This study evaluates the usefulness and safety of homeopathic Paeonia officinalis mother tincture (Q) in the management of acute AF. METHODS: An open-label, prospective, pre-post comparison cohort study was conducted on 34 participants diagnosed with acute AF. Paeonia officinalis Q was administered orally (10 drops in 50 mL of water, once daily) for 12 weeks alongside supportive care that included dietary advice. Outcome measures were: pain intensity assessed using a Visual Analog Scale (VAS; range: 0-10); level of strain during defecation using the Defecation Strain Score (DSS); Outcome Related to Impact on Daily Living (ORIDL) score for main complaint and overall well-being; and degree of healing of fissure (HoF) by visual clinical examination. RESULTS: VAS score reduced significantly from baseline (8.94 ± 0.81) at 12 weeks (0.11 ± 0.32), with a mean decrease of 8.82 ± 0.13 (p < 0.001), while DSS decreased from a median of 3 to 0 (change, 3; inter-quartile range [IQR], 2-3; p < 0.001). ORIDL scores for main complaint increased from 2 to 4 (change, 1; IQR, 1-2) and well-being from 3 to 4 (change, 1; IQR, 1-1; p < 0.001). By 12 weeks, fissures healed completely in 30 (88.2%) participants, with no serious adverse events reported. CONCLUSION: Homeopathic Paeonia officinalis Q, combined with concomitant care advice, appears useful in reducing pain and straining while promoting fissure healing in acute AF patients. The potential influence of confounders limits attribution of positive outcomes to the homeopathic intervention alone.", "provenance": [ { "field": "n", "quote": "conducted on 34 participants diagnosed with acute AF" }, { "field": "population", "quote": "participants diagnosed with acute AF" }, { "field": "intervention", "quote": "Paeonia officinalis Q was administered orally (10 drops in 50 mL of water, once daily) for 12 weeks alongside supportive care that included dietary advice" }, { "field": "comparator", "quote": "open-label, prospective, pre-post comparison cohort study" }, { "field": "primaryOutcome", "quote": "pain intensity assessed using a Visual Analog Scale (VAS; range: 0-10)" }, { "field": "result", "quote": "VAS score reduced significantly from baseline (8.94 ± 0.81) at 12 weeks (0.11 ± 0.32), with a mean decrease of 8.82 ± 0.13 (p < 0.001)" }, { "field": "result", "quote": "By 12 weeks, fissures healed completely in 30 (88.2%) participants, with no serious adverse events reported." } ] }, { "id": "pmid:40824576", "pmid": "40824576", "doi": "10.1001/jama.2025.13083", "nctId": null, "pmcid": null, "title": "Hemorrhoidal Disease: A Review", "firstAuthor": "Ashburn", "multipleAuthors": false, "journal": "JAMA", "year": 2025, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "People with hemorrhoidal disease, a condition of the anal canal tissue", "intervention": "Various treatments for hemorrhoids, including fiber and water intake, phlebotonics, rubber band ligation, sclerotherapy, infrared coagulation, and surgery", "comparator": "No single comparator; review compares treatment effects to no treatment or to stopping treatment", "primaryOutcome": "Symptoms such as bleeding, anal pain, irritation, and tissue prolapse", "result": "Different treatments show different results: for example, excisional hemorrhoidectomy achieves low recurrence (2%-10%) but longer recovery (9-14 days), while rubber band ligation resolves symptoms in 89% of patients", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "This is a general clinical overview summarizing many studies rather than a systematic review with its own pooled analysis, so it carries moderate weight for guiding specific treatment decisions.", "directness": "direct", "limitations": "The abstract does not explicitly state limitations of the underlying evidence or the review methodology.", "followUp": "", "plainFinding": "Hemorrhoids can cause anal pain and bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": true, "url": "https://pubmed.ncbi.nlm.nih.gov/40824576/", "sourceText": "IMPORTANCE: Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US. Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse. OBSERVATIONS: Hemorrhoids are classified as internal, external, or mixed (concurrent internal and external hemorrhoidal disease). Internal hemorrhoids originate above the dentate line, the boundary between the upper and lower anal canal, and may cause rectal bleeding, discomfort, and tissue prolapse from the anal canal. Internal hemorrhoid prolapse is classified as grade I (into anal canal), grade II (beyond the anus with spontaneous reduction), grade III (requiring manual reduction), and grade IV (irreducible). External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed. Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation. Phlebotonics (eg, flavonoids [thought to improve venous tone]) reduce bleeding, rectal pain, and swelling, although symptom recurrence reaches 80% within 3 to 6 months after treatment cessation. If dietary modification and phlebotonics are ineffective, grade I to grade III internal hemorrhoidal disease can be treated with office-based interventions. Rubber band ligation-placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow-resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%. Sclerotherapy, which induces fibrosis with a sclerosant injection, is efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients. Infrared coagulation uses heat to coagulate hemorrhoidal tissue, yielding 70% to 80% success in reducing bleeding and prolapse. Excisional hemorrhoidectomy, for disease unresponsive to office-based therapy or for mixed hemorrhoidal disease, achieves low recurrence (2%-10%), although with longer recovery (9-14 days). External hemorrhoidal disease rarely requires surgery unless acutely thrombosed. Outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis. Patients presenting more than 72 hours after external hemorrhoid acute thrombosis should receive medical treatment (eg, stool softeners, oral and topical analgesics such as 5% lidocaine). CONCLUSIONS AND RELEVANCE: Hemorrhoidal disease affects 10 million people in the US. First-line treatment is increased fiber intake, avoidance of straining during defecation, and phlebotonics. In-office rubber band ligation for grade I to III internal hemorrhoid disease is first-line procedural treatment for persistent symptoms despite conservative therapies. Excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches.", "provenance": [ { "field": "population", "quote": "Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US." }, { "field": "intervention", "quote": "Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation." }, { "field": "comparator", "quote": "although symptom recurrence reaches 80% within 3 to 6 months after treatment cessation" }, { "field": "primaryOutcome", "quote": "Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse." }, { "field": "result", "quote": "Excisional hemorrhoidectomy, for disease unresponsive to office-based therapy or for mixed hemorrhoidal disease, achieves low recurrence (2%-10%), although with longer recovery (9-14 days)." }, { "field": "result", "quote": "Rubber band ligation-placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow-resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%." } ] }, { "id": "pmid:40813828", "pmid": "40813828", "doi": "10.1007/s00431-025-06392-2", "nctId": null, "pmcid": "PMC12354542", "title": "Pediatric external hemorrhoids: clinical characteristics and outcomes of conservative treatment versus injection sclerotherapy", "firstAuthor": "Docter", "multipleAuthors": true, "journal": "Eur J Pediatr", "year": 2025, "design": "retrospective", "n": 44, "nField": "reported", "population": "children with external hemorrhoids (swelling near the anus)", "intervention": "injection sclerotherapy", "comparator": "conservative management (watchful waiting)", "primaryOutcome": "resolution of symptoms/treatment success", "result": "Sclerotherapy resolved the hemorrhoid in 90.3% of children after two injections but caused skin erosion in over a third; watchful waiting led to symptom resolution within a year, though the lump often remained", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a small retrospective review of children's records, not a controlled trial comparing the two treatments directly.", "directness": "indirect", "limitations": "Retrospective design, small sample, diagnosis often based on parent photos rather than exams, no randomization between treatment groups", "followUp": "", "plainFinding": "Hemorrhoid treatment works but has trade-offs.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40813828/", "sourceText": "UNLABELLED: Pediatric external hemorrhoids are rare and often misdiagnosed. This study assesses clinical presentation, risk factors, and treatment outcomes, comparing conservative management with injection sclerotherapy. A retrospective cohort study (2007-2024) was conducted at a tertiary pediatric hospital, including pediatric patients treated with conservative therapy (watchful waiting) or injection sclerotherapy for external hemorrhoids. Data from medical records were analyzed for patient history, presentation, treatment outcomes, and complications. Forty-four patients (86.4% male) were included. Mean age at symptom onset and presentation was respectively 4.0 (range 0-11) and 5.8 (range 2-13) years, with a median diagnostic delay of 20.5 months. All reported anal protrusion/swelling during/after defecation, though this was only visible on examination in 11.4%; diagnosis was otherwise based on parent-provided photographs (63.6%) or reference images (25.0%). Additional symptoms included pain (45.5%), bleeding (18.2%), anal itching (13.6%), anxiety (9.1%) and tenesmus (6.8%). Thirty-one patients (70.5%) underwent injection sclerotherapy, with a 69.2% success rate after one, and 90.3% after two injections. Thirteen patients (29.5%) were treated conservatively with watchful waiting, with symptoms resolving within one year, although the lesion(s) persisted. Skin erosion occurred in 35.5% of patients treated with injection sclerotherapy, leading to constipation and defecation anxiety in 9.1% of patients. CONCLUSION: Pediatric external hemorrhoids present as anal protrusion/swelling, often accompanied by anorectal pain. Diagnosis is often delayed due to its intermittent nature. Parent-provided photographs can confirm diagnosis. Both conservative management and injection sclerotherapy are viable treatments; injection sclerotherapy offers a definitive resolution but carries risks of relapse and complications. WHAT IS KNOWN: • Pediatric external hemorrhoids are often misdiagnosed and mismanaged. WHAT IS NEW: • Due to the intermittent nature of external hemorrhoids, diagnosis is often delayed, making parent-provided photographs highly valuable for accurate assessment. • Both conservative management and injection sclerotherapy are viable treatments. • Injection sclerotherapy carries risks of relapse and complications.", "provenance": [ { "field": "n", "quote": "Forty-four patients (86.4% male) were included." }, { "field": "population", "quote": "Pediatric external hemorrhoids are rare and often misdiagnosed." }, { "field": "intervention", "quote": "injection sclerotherapy" }, { "field": "comparator", "quote": "conservative therapy (watchful waiting)" }, { "field": "primaryOutcome", "quote": "treatment outcomes, and complications" }, { "field": "result", "quote": "with a 69.2% success rate after one, and 90.3% after two injections" }, { "field": "result", "quote": "Thirteen patients (29.5%) were treated conservatively with watchful waiting, with symptoms resolving within one year, although the lesion(s) persisted" }, { "field": "result", "quote": "Skin erosion occurred in 35.5% of patients treated with injection sclerotherapy, leading to constipation and defecation anxiety in 9.1% of patients" } ] }, { "id": "pmid:40575234", "pmid": "40575234", "doi": "10.7759/cureus.84866", "nctId": null, "pmcid": "PMC12198920", "title": "A Rare Presentation of Juvenile Rectal Polyps in an Adolescent Male With Rectal Bleeding: A Case Report", "firstAuthor": "Hemantha Kumar", "multipleAuthors": true, "journal": "Cureus", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "13-year-old boy with years of difficulty pooping and rectal bleeding", "intervention": "surgical removal of rectal polyps", "comparator": "none", "primaryOutcome": "diagnosis and treatment of rectal bleeding and mass", "result": "polyps were found and surgically removed, confirming diagnosis of juvenile rectal polyps", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether a treatment works for most people", "directness": "indirect", "limitations": "single case report with no comparison group, describing a rare diagnosis rather than typical post-defecation pain", "followUp": "", "plainFinding": "Rare polyps, not hemorrhoids, caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40575234/", "sourceText": "Juvenile rectal polyps are hamartomatous growths commonly occurring in the colon and rectum, characterized by cystic dilation of glandular structures within the lamina propria. They are typically under 10 years of age, but may also be seen in adolescents. This case report describes a 13-year-old boy with a five-year history of difficulty in defecation, intermittent rectal bleeding that progressively worsened over the past year, along with abdominal pain and prolapse of a rectal mass. Initial evaluations by multiple clinicians misdiagnosed the condition as hemorrhoids, delaying the correct diagnosis. Colonoscopy revealed multiple large polyps in the lower rectoanal region. Surgical excision was performed, and histopathological examination confirmed the presence of juvenile rectal (retention) polyps with unusual features, including torsion and mucin extravasation. This case underscores the importance of considering juvenile polyps in the differential diagnosis of rectal bleeding in pediatric patients and highlights the necessity for early and accurate diagnosis to prevent complications. Histopathological analysis plays a crucial role in guiding the management and ensuring appropriate treatment.", "provenance": [ { "field": "population", "quote": "a 13-year-old boy with a five-year history of difficulty in defecation, intermittent rectal bleeding that progressively worsened over the past year, along with abdominal pain and prolapse of a rectal mass" }, { "field": "intervention", "quote": "Surgical excision was performed" }, { "field": "comparator", "quote": "Initial evaluations by multiple clinicians misdiagnosed the condition as hemorrhoids, delaying the correct diagnosis." }, { "field": "primaryOutcome", "quote": "Colonoscopy revealed multiple large polyps in the lower rectoanal region." }, { "field": "result", "quote": "histopathological examination confirmed the presence of juvenile rectal (retention) polyps with unusual features, including torsion and mucin extravasation" }, { "field": "n", "quote": "a 13-year-old boy" } ] }, { "id": "pmid:40530787", "pmid": "40530787", "doi": "10.1097/SLE.0000000000001381", "nctId": null, "pmcid": "PMC12303241", "title": "The Comparison Between Endoscopic Ligation and Sclerotherapy on the Treatment Effect and Anorectal Function in Patients With Internal Hemorrhoids", "firstAuthor": "Zhang", "multipleAuthors": true, "journal": "Surg Laparosc Endosc Percutan Tech", "year": 2025, "design": "rct", "n": 32, "nField": "reported", "population": "people with internal hemorrhoids", "intervention": "endoscopic ligation of hemorrhoids", "comparator": "cap-assisted endoscopic sclerotherapy (CAES)", "primaryOutcome": "treatment effect, symptom relief, complications, psychological condition, and anorectal function", "result": "no significant difference between the two procedures overall, though each had some specific advantages (ligation better for constipation, sclerotherapy better for pain/bleeding)", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Very small study with only 32 patients split into two small groups, short 3-month follow-up, and it's not clear from the abstract that patients were randomly assigned.", "directness": "indirect", "limitations": "Small sample size (14 vs 18 patients), short follow-up of 3 months, and this concerns treatment of diagnosed internal hemorrhoids rather than general post-defecation pain of unclear cause.", "followUp": "3-month follow-up", "plainFinding": "Both procedures similarly effective; pain improved more with sclerotherapy.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40530787/", "sourceText": "OBJECTIVE: To evaluate the treatment effect of endoscopic ligation and cap-assisted endoscopic sclerotherapy (CAES) for patients with internal hemorrhoids, symptom relief, complication rate and psychological condition, and the anorectal function were observed. METHODS: Thirty-two patients who underwent minimally invasive endoscopic treatment for internal hemorrhoids were recruited, with a 3-month follow-up. Patients were divided into 2 groups, with Group A undergoing endoscopic ligation (n=14) and Group B receiving CAES (n=18). The Clinical efficacy and anorectal function between the 2 groups before and after treatment were compared, and the psychological changes in patients before and after treatment were evaluated by various scales. RESULTS: There was no significant difference in the treatment effect of postoperative bleeding, prolapse, constipation, and complications between the 2 groups. However, Group A has certain advantages in the treatment of prolapse and constipation before and after treatment, and Group B has certain advantages in bleeding. The comprehensive multiscale psychological evaluation showed no significant difference between the 2 groups before and after treatment, but the psychological condition of patients in both groups was significantly improved after treatment. Besides, patients in Group A were better in the improvement of constipation scale, and patients in Group B had a greater improvement in the pain scale. As for anorectal function, there was no significant difference before and after treatment, except for the squeeze duration before treatment. In the comparison pretreatment and post-treatment, patients in Group A had significant differences in resting (average), first defecation and squeeze (average), while patients in Group B had significant differences in resting (average) and first defecation. CONCLUSIONS: Two endoscopic therapies were effective in treating internal hemorrhoids, with no significant difference in terms of treatment effect, symptom relief, complication rate, psychological condition, and anorectal function when compared between 2 groups. However, when compared within each group, the different methods had their own advantages in the evaluation of treatment effect and anorectal function.", "provenance": [ { "field": "population", "quote": "patients with internal hemorrhoids" }, { "field": "n", "quote": "Thirty-two patients who underwent minimally invasive endoscopic treatment for internal hemorrhoids were recruited" }, { "field": "intervention", "quote": "Group A undergoing endoscopic ligation (n=14)" }, { "field": "comparator", "quote": "Group B receiving CAES (n=18)" }, { "field": "primaryOutcome", "quote": "Clinical efficacy and anorectal function between the 2 groups before and after treatment were compared" }, { "field": "result", "quote": "There was no significant difference in the treatment effect of postoperative bleeding, prolapse, constipation, and complications between the 2 groups. However, Group A has certain advantages in the treatment of prolapse and constipation before and after treatment, and Group B has certain advantages in bleeding." }, { "field": "followUp", "quote": "with a 3-month follow-up" } ] }, { "id": "pmid:40346473", "pmid": "40346473", "doi": "10.1186/s12876-025-03963-3", "nctId": null, "pmcid": "PMC12063411", "title": "Milligan-Morgan hemorrhoidectomy combined with rubber band ligation and polidocanol foam sclerotherapy for the management of grade III/IV hemorrhoids: a retrospective study", "firstAuthor": "Long", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2025, "design": "retrospective", "n": 255, "nField": "reported", "population": "adults with grade III/IV hemorrhoids who had surgery", "intervention": "Milligan-Morgan hemorrhoidectomy plus rubber band ligation and polidocanol foam sclerotherapy", "comparator": "Milligan-Morgan hemorrhoidectomy alone", "primaryOutcome": "recurrence rate, hemorrhoid severity score, and patient satisfaction at 12 months after surgery", "result": "recurrence was lower and satisfaction was higher with the combined procedure, with no difference in severity score; pain scores at the first postoperative bowel movement and on days 1, 3, and 7 were also lower with the combined procedure", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a retrospective, single-center study comparing two surgical techniques, not a randomized trial, so bias cannot be ruled out.", "directness": "indirect", "limitations": "retrospective design, single center, and comparison is between two surgical techniques for severe hemorrhoids rather than addressing general post-defecation anal pain in the broader population", "followUp": "12 months after surgery", "plainFinding": "Less pain after combined hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40346473/", "sourceText": "BACKGROUND: Hemorrhoids are one of the most common and annoying benign diseases in the field of colorectal surgery. A Milligan-Morgan hemorrhoidectomy (MMH) is the most frequently applied surgical technique due to its clear efficacy and high success rate, but the reported postoperative complications remain a major problem. This study aimed to retrospectively evaluate the efficacy and safety of a MMH combined with rubber band ligation and polidocanol foam sclerotherapy (MMH + RBL + PFS) for the management of grade III/IV hemorrhoids. METHODS: This was a single-center retrospective study. A total of 255 patients with grade III/IV hemorrhoids who underwent MMH + RBL + PFS (n = 128) or MMH (n = 127) between May 2022 and June 2023 were included in the study. The primary outcomes included recurrence rates, hemorrhoid severity score (HSS), and patient satisfaction 12 months after surgery. Secondary outcomes included intraoperative outcomes and postoperative outcomes. RESULTS: Follow-up was conducted by telephone or outpatient visit 12 months after surgery. The recurrence rate was lower in the MMH + RBL + PFS group than in the MMH group (p < 0.05). The patient satisfaction score was higher in the MMH + RBL + PFS group than in the MMH group (p < 0.05), and there was no significant difference in the HSS between the two groups (p > 0.05). The median operation time in the two groups was similar (16 min (15-20 min) vs.16 min (15-18 min), p > 0.05). The median number of incisions in the the MMH + RBL + PFS group was 3 (2-3), while that in the MMH group was 3 (3-4) (p < 0.05). There was no significant difference in intraoperative blood loss between the two groups (p > 0.05). Visual analog scale pain scores were lower in the MMH + RBL + PFS group than in the MMH group at the first postoperative defecation at 12 h and at 1, 3, and 7 days (all p < 0.05). The wound healing time was shorter in the MMH + RBL + PFS group than in the MMH group (27.62 ± 3.74 vs. 28.73 ± 4.48 days, respectively, p < 0.05). The incidence of urinary retention was lower in the MMH + RBL + PFS group than in the MMH group (5.47% vs. 12.60, respectively, p < 0.05). Nine patients (one case in the MMH + RBL + PFS group and eight cases in the MMH group (p < 0.05)) had delayed bleeding and were successfully controlled with manual compression or surgical hemostasis. No cases had anal stenosis in the MMH + RBL + PFS group, and six cases (4.72%) had it in the MMH group, all with mild anal stenosis and successfully treated by dilatation alone (p < 0.01). No incision infection or anal incontinence occurred in either group. At the 12-month follow-up after surgery, the recurrence rate was lower in the MMH + RBL + PFS group (0.78%) than in the MMH group (7.09%) (p < 0.05). The patient satisfaction score was higher in the MMH + RBL + PFS group (91.41%) than in the MMH group (81.10%) (p < 0.05), and there was no significant difference in the HSS between the two groups (p > 0.05). CONCLUSIONS: Compared with the MMH, the MMH + RBL + PFS surgical procedure is safe and effective for grade III/IV hemorrhoids, which is associated with a lower recurrence rate, a higher patient satisfaction score, a lower postoperative pain score, fewer postoperative complications, and a shorter wound healing time.", "provenance": [ { "field": "n", "quote": "A total of 255 patients with grade III/IV hemorrhoids who underwent MMH + RBL + PFS (n = 128) or MMH (n = 127)" }, { "field": "population", "quote": "A total of 255 patients with grade III/IV hemorrhoids who underwent MMH + RBL + PFS (n = 128) or MMH (n = 127) between May 2022 and June 2023 were included in the study." }, { "field": "intervention", "quote": "This study aimed to retrospectively evaluate the efficacy and safety of a MMH combined with rubber band ligation and polidocanol foam sclerotherapy (MMH + RBL + PFS) for the management of grade III/IV hemorrhoids." }, { "field": "comparator", "quote": "between May 2022 and June 2023 were included in the study." }, { "field": "primaryOutcome", "quote": "The primary outcomes included recurrence rates, hemorrhoid severity score (HSS), and patient satisfaction 12 months after surgery." }, { "field": "result", "quote": "The recurrence rate was lower in the MMH + RBL + PFS group than in the MMH group (p < 0.05)." }, { "field": "result", "quote": "Visual analog scale pain scores were lower in the MMH + RBL + PFS group than in the MMH group at the first postoperative defecation at 12 h and at 1, 3, and 7 days (all p < 0.05)." }, { "field": "followUp", "quote": "Follow-up was conducted by telephone or outpatient visit 12 months after surgery." } ] }, { "id": "pmid:40210842", "pmid": "40210842", "doi": "10.1007/s13304-025-02202-4", "nctId": null, "pmcid": null, "title": "The comparison of doppler-guided haemorrhoidal artery ligation and the tissue selecting technique for patients with grade III/IV haemorrhoids: a retrospective cohort study", "firstAuthor": "Liu", "multipleAuthors": true, "journal": "Updates Surg", "year": 2025, "design": "retrospective", "n": 251, "nField": "reported", "population": "adults with grade III or IV hemorrhoids", "intervention": "Doppler-guided hemorrhoid artery ligation (DG-HAL) surgery", "comparator": "tissue-selecting technique (TST) surgery", "primaryOutcome": "pain after bowel movements, complications, and hemorrhoid recurrence after surgery", "result": "DG-HAL caused less pain and fewer complications right after surgery, but more hemorrhoids came back by 3 years compared to TST", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a retrospective, non-randomized comparison of two surgeries, so differences could be due to other factors rather than the treatment itself.", "directness": "indirect", "limitations": "Retrospective design without randomization, comparing two specific surgical techniques rather than addressing general causes of post-defecation anal pain.", "followUp": "3 years", "plainFinding": "Both surgeries help; techniques trade pain versus recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40210842/", "sourceText": "This study aimed to evaluate the efficacy and the safety of Doppler-guided hemorrhoid artery ligation (DG-HAL) and tissue-selecting technique (TST) in patients with grade III/IV hemorrhoids. We conducted a retrospective analysis of 251 patients with grade III/IV hemorrhoids between January 2019 and January 2021. Among them, 119 patients had received TST, and the remaining 132 patients received DG-HAL. We collected and compared clinical characteristics of both groups, including post-operative visual analog scale (VAS) for pain, post-operative bleeding, post-operative defecation, urinary retention, and recurrence rate (prolapse and bleeding). The VAS pain score of the first post-operative defecation and at the post-operative day (POD)1 and 2 for the DG-HAL group was lower than those for the TST group (P = 0.006 and P = 0.029). The incidence of post-operative complications (including bleeding, urinary retention and sensation of rectal tenesmus) in the DG-HAL group was lower than that in the TST group (P = 0.021, P = 0.035 and P = 0.047). At follow-up by telephone or outpatient 3 years after surgery, the recurrence rate (prolapse) was lower in the TST group than in the DG-HAL group (P = 0.013). Subgroup analysis showed a higher prolapse recurrence rate in grade IV patients than grade III patients after DG-HAL (P = 0.013). DG-HAL had fewer complications, lower bleeding rates, and less early post-operative pain but showed a higher recurrence rate than TST at the 3-year follow-up, especially in grade IV patients.", "provenance": [ { "field": "n", "quote": "We conducted a retrospective analysis of 251 patients with grade III/IV hemorrhoids between January 2019 and January 2021." }, { "field": "population", "quote": "patients with grade III/IV hemorrhoids" }, { "field": "intervention", "quote": "Doppler-guided hemorrhoid artery ligation (DG-HAL)" }, { "field": "comparator", "quote": "tissue-selecting technique (TST)" }, { "field": "primaryOutcome", "quote": "post-operative visual analog scale (VAS) for pain, post-operative bleeding, post-operative defecation, urinary retention, and recurrence rate (prolapse and bleeding)" }, { "field": "result", "quote": "DG-HAL had fewer complications, lower bleeding rates, and less early post-operative pain but showed a higher recurrence rate than TST at the 3-year follow-up, especially in grade IV patients." } ] }, { "id": "pmid:40192825", "pmid": "40192825", "doi": "10.1007/s10151-025-03137-z", "nctId": null, "pmcid": "PMC11976758", "title": "Botulinum toxin injection for management of post-haemorrhoidectomy pain: an updated systematic review and meta-analysis of randomised clinical trials", "firstAuthor": "Quinn", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2025, "design": "meta-analysis", "n": 340, "nField": "reported", "population": "people who had surgical removal of haemorrhoids (grade III-IV)", "intervention": "botulinum toxin injection given during surgery", "comparator": "placebo", "primaryOutcome": "pain levels after surgery, measured daily", "result": "botulinum toxin reduced pain on days 1, 2 and 4 after surgery but not after day 14, with no increase in incontinence or urinary retention", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "This pools seven randomized trials but the total number of patients is small and the benefit faded by two weeks.", "directness": "indirect", "limitations": "The abstract notes results were short-lived and calls for further, more robust randomised controlled trials.", "followUp": "14 days", "plainFinding": "Less pain, but only briefly", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40192825/", "sourceText": "INTRODUCTION: Excisional haemorrhoidectomy remains the gold-standard treatment for grade III-IV haemorrhoids owing to the high success rate. However, post-operative pain management is an ongoing challenge. Botulinum toxin injection is thought to improve pain by targeting the internal anal sphincter spasm which occurs following haemorrhoidectomy. This systematic review and meta-analysis examines the effects of concurrent botulinum toxin injection on post-haemorrhoidectomy pain. METHODS: A search of MEDLINE, EMBASE and Cochrane Databases for randomised controlled trials (RCTs) of botulinum toxin injection compared with placebo for management of post-haemorrhoidectomy pain was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Outcomes assessed included daily post-operative pain scores assessed using an analogue scale (0-10), pain at first defecation, analgesia use, complication rates and time to return to work. RESULTS: A total of seven RCTs assessing 340 patients who underwent an excisional haemorrhoidectomy were included. In total, seven studies (n = 340) found significant reduction in pain post-procedure with botulinum toxin use on day 1 (mean difference, MD -1.53; 95% confidence intervals, CI -2.12, -0.94; p < 0.00001), with similar findings on day 2 and 4 (MD -1.84, 95% CI -3.28, -0.41; p = 0.01 and MD -1.63, 95% CI -2.15, -1.09; p < 0.00001, respectively). However, the analgesic effects were not seen on subsequent analyses up to day 14. Botulinum toxin was seen to be safe, with no significant difference in faecal incontinence (MD 1.05, 95% CI 0.40, 2.75; p = 0.93) or urinary retention (MD 0.37, 95% CI 0.09, 1.53; p = 0.17). CONCLUSIONS: Botulinum toxin use for pain relief post-excisional haemorrhoidectomy is safe and effective in the initial peri-operative period; however, the results were short-lived. Further, more robust randomised controlled trials are needed to strengthen these findings and determine the utility of botulinum toxin in this setting. TRIAL REGISTRATION: PROSPERO Register for Systematic Reviews Registration Number - CRD42024541351 on April 29 2024.", "provenance": [ { "field": "population", "quote": "seven RCTs assessing 340 patients who underwent an excisional haemorrhoidectomy" }, { "field": "intervention", "quote": "concurrent botulinum toxin injection" }, { "field": "comparator", "quote": "botulinum toxin injection compared with placebo for management of post-haemorrhoidectomy pain" }, { "field": "primaryOutcome", "quote": "daily post-operative pain scores assessed using an analogue scale (0-10), pain at first defecation, analgesia use, complication rates and time to return to work" }, { "field": "n", "quote": "seven RCTs assessing 340 patients" }, { "field": "result", "quote": "found significant reduction in pain post-procedure with botulinum toxin use on day 1 (mean difference, MD -1.53; 95% confidence intervals, CI -2.12, -0.94; p < 0.00001), with similar findings on day 2 and 4" }, { "field": "result", "quote": "However, the analgesic effects were not seen on subsequent analyses up to day 14." }, { "field": "result", "quote": "no significant difference in faecal incontinence (MD 1.05, 95% CI 0.40, 2.75; p = 0.93) or urinary retention (MD 0.37, 95% CI 0.09, 1.53; p = 0.17)" } ] }, { "id": "pmid:40125221", "pmid": "40125221", "doi": "10.7759/cureus.79305", "nctId": null, "pmcid": "PMC11927931", "title": "A Comparative Analysis of Gastrointestinal Recovery and Pain Management Outcomes in Stapled Versus Open Hemorrhoidectomy: A Meta-Analysis", "firstAuthor": "Khalid", "multipleAuthors": true, "journal": "Cureus", "year": 2025, "design": "meta-analysis", "n": 292, "nField": "reported", "population": "adults with grade III and IV hemorrhoids undergoing surgery", "intervention": "stapled hemorrhoidectomy", "comparator": "open hemorrhoidectomy", "primaryOutcome": "pain after surgery and how fast bowel function returns", "result": "stapled surgery caused less pain, quicker recovery, and fewer bowel-control problems, but hemorrhoids came back more often later", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it pools only seven small studies (292 patients) about surgical patients, which doesn't address ordinary post-bowel-movement anal pain.", "directness": "indirect", "limitations": "small number of studies and patients, only covers surgical hemorrhoid patients, not people with everyday anal pain after defecation", "followUp": "12-18 months", "plainFinding": "Not about everyday pooping pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40125221/", "sourceText": "Stapled hemorrhoidectomy (SH) and open hemorrhoidectomy (OH) are widely used surgical techniques for managing hemorrhoidal disease. SH is often preferred for its potential benefits, such as reduced postoperative pain and faster recovery, while OH is traditionally employed in advanced or complex cases. However, the comparative impact of these techniques on gastrointestinal function and pain management remains unclear, necessitating further evaluation. This meta-analysis is aimed at comparing the clinical outcomes of SH and OH in patients with grade III and IV hemorrhoids, focusing on operative parameters, postoperative pain, recovery, complications, and recurrence. A systematic search was performed across PubMed, Cochrane CENTRAL, Scopus, ProQuest, and Google Scholar, using relevant keywords and Medical Subject Headings (MeSH) terms. Studies included were randomized controlled trials, cohort studies, and quasi-experimental studies published in English until July 2023, comparing gastrointestinal recovery and pain outcomes between SH and OH. The primary outcomes were gastrointestinal recovery, measured by time to resumption of normal diet and bowel movements, and pain management, assessed by postoperative pain scores. Secondary outcomes included hospital stay, complication rates, and recurrence. Data from eligible studies were pooled, and random-effects models were used to estimate the weighted mean differences and odds ratios (OR) for each outcome. Statistical heterogeneity was assessed using Cochran's Q and I² tests. Seven studies involving 292 patients met the inclusion criteria. SH consistently demonstrated advantages over OH regarding pain management, gastrointestinal recovery, and hospital stay. SH patients reported significantly lower pain scores, reduced analgesic use by 35% on average, and faster recovery, with statistically significant results (p<0.05). SH patients also had a shorter time to the first bowel movement, with a reduced OR (OR=0.60, 95% CI: 0.38-0.98) compared to OH. Regarding complications, SH had lower incontinence rates (OR=0.48, 95% CI: 0.26-0.88), though a higher recurrence rate was noted in the SH group, especially at 12-18 months post-surgery. The risk of bias was generally low in most studies, with only a few showing moderate concerns. SH offers significant short-term benefits over OH, including reduced postoperative pain, faster recovery, and fewer complications. However, the higher recurrence rates in SH suggest that clinicians should carefully consider long-term outcomes when choosing the optimal surgical approach for hemorrhoidectomy.", "provenance": [ { "field": "n", "quote": "Seven studies involving 292 patients met the inclusion criteria." }, { "field": "population", "quote": "patients with grade III and IV hemorrhoids" }, { "field": "intervention", "quote": "Stapled hemorrhoidectomy (SH)" }, { "field": "comparator", "quote": "open hemorrhoidectomy (OH)" }, { "field": "primaryOutcome", "quote": "The primary outcomes were gastrointestinal recovery, measured by time to resumption of normal diet and bowel movements, and pain management, assessed by postoperative pain scores." }, { "field": "result", "quote": "SH patients reported significantly lower pain scores, reduced analgesic use by 35% on average, and faster recovery, with statistically significant results (p<0.05)." }, { "field": "result", "quote": "though a higher recurrence rate was noted in the SH group, especially at 12-18 months post-surgery" }, { "field": "followUp", "quote": "especially at 12-18 months post-surgery" } ] }, { "id": "pmid:40103253", "pmid": "40103253", "doi": "10.17116/hirurgia2025031112", "nctId": null, "pmcid": null, "title": "[Treatment of acute hemorrhoids according to the results of a multicenter observational study]", "firstAuthor": "Groshilin", "multipleAuthors": true, "journal": "Khirurgiia (Mosk)", "year": 2025, "design": "prospective-cohort", "n": 220, "nField": "reported", "population": "adults aged 18 to 64 with grade I-II acute hemorrhoids (thrombosed hemorrhoidal nodes, with or without bleeding)", "intervention": "Phlebodia 600 (diosmin) tablets taken for at least 35-40 days", "comparator": "none (before-and-after comparison within the same patients, no control group)", "primaryOutcome": "resolution of symptoms such as pain, bleeding, itching and hemorrhoidal node size, plus quality of life (SF-36)", "result": "Pain, discomfort, itching and blood streaks during defecation decreased by day 7 of treatment, hemorrhoidal node size was reduced in 73% of patients, and quality of life improved significantly by day 30, with no reported side effects.", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was an observational study with no comparison group, so improvements over time cannot be separated from the drug's effect.", "directness": "indirect", "limitations": "No control or placebo group was used, so it cannot be determined whether improvement was due to the drug or natural resolution over time.", "followUp": "30 days", "plainFinding": "Hemorrhoid drug reduced pain and swelling.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40103253/", "sourceText": "BACKGROUND: The issue of improving hemorrhoid treatment outcomes in outpatient practice is one of the most pressing in the daily work of coloproctologists today. Advances in the treatment of hemorrhoidal disease, the most common pathological condition in general proctology, in recent decades have been associated not only with the adoption of minimally invasive surgical techniques but also with the enhancement of pharmacological therapy. A key component of systemic pharmacotherapy for chronic and acute hemorrhoids is the use of venotonic drugs, including flavonoids which are included in the clinical guidelines. Therefore, a comprehensive and reliable evaluation of the clinical efficacy of diosmin is an important area of research, especially in cases of acute hemorrhoids. OBJECTIVE: The study aimed to assess the effectiveness of using Phlebodia 600 and evaluate the dynamics of patients' quality of life with acute hemorrhoids of grades I-II in outpatient practice without employing minimally invasive surgical methods. MATERIAL AND METHODS: A Russian multicenter prospective observational study was conducted involving an adult population of patients with grade I-II acute hemorrhoids in the city of Rostov-on-Don and the Rostov region. Outpatients (both men and women) aged 18 to 64 with a confirmed diagnosis of grade I-II acute hemorrhoids (thrombosis of external or internal hemorrhoidal nodes, including those with bleeding) established through standardized clinical examination were included. Therapy with Phlebodia 600 (diosmin) commenced no later than three days after the onset of clinical symptoms, which included a dominant set of symptoms such as enlarged hemorrhoidal nodes, pain, bleeding, anal itching, burning, or discomfort. The total sample size analyzed was 220 patients, and the medication was administered for at least 36 days. RESULTS: The use of Phlebodia 600 for grade I-II acute hemorrhoids allowed for the resolution of complaints and stabilization of all key clinical parameters within the timeframes set by the study design. Following the proposed treatment regimen, early resolution and reduction of complaints such as pain, discomfort, itching, and blood streaks during defecation were observed by the control visit after seven days of therapy, compared to baseline. In 73% of cases, a reduction in the size of hemorrhoidal nodes was noted within this period. The proposed treatment regimen can be considered rational since, after 30 days, not only was there consistent resolution of complaints in the majority of patients, but there was also a significant improvement in quality of life (SF-36). No cases of intolerance to Phlebodia 600 or adverse reactions associated with its use were identified, indicating a high safety profile. CONCLUSIONS: A 35-40 day course of Phlebodia 600 administered continuously according to the manufacturer's recommended regimen effectively reduces the severity and frequency of major complaints in patients with grade I-II acute hemorrhoids. This is achieved through improved microcirculation, venotonic, anti-inflammatory, and anti-edema effects. Diosmin (Phlebodia 600) favourable safety profile has been demonstrated. in acute hemorrhoids.", "provenance": [ { "field": "n", "quote": "The total sample size analyzed was 220 patients" }, { "field": "population", "quote": "Outpatients (both men and women) aged 18 to 64 with a confirmed diagnosis of grade I-II acute hemorrhoids" }, { "field": "intervention", "quote": "Therapy with Phlebodia 600 (diosmin) commenced no later than three days after the onset of clinical symptoms" }, { "field": "comparator", "quote": "RESULTS: The use of Phlebodia 600 for grade I-II acute hemorrhoids allowed for the resolution of complaints and stabilization of all key clinical parameters" }, { "field": "primaryOutcome", "quote": "evaluate the dynamics of patients' quality of life with acute hemorrhoids of grades I-II" }, { "field": "result", "quote": "early resolution and reduction of complaints such as pain, discomfort, itching, and blood streaks during defecation were observed by the control visit after seven days of therapy, compared to baseline. In 73% of cases, a reduction in the size of hemorrhoidal nodes was noted within this period." } ] }, { "id": "pmid:40009123", "pmid": "40009123", "doi": "10.1007/s00384-025-04823-y", "nctId": null, "pmcid": "PMC11865108", "title": "Retrospective analysis on the efficacy of botulinum toxin alone versus combined botulinum toxin and topical diltiazem", "firstAuthor": "Arslan", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2025, "design": "retrospective", "n": 217, "nField": "reported", "population": "patients with chronic anal fissures", "intervention": "botulinum toxin injection plus topical diltiazem applied after injection", "comparator": "botulinum toxin injection alone", "primaryOutcome": "fissure healing at 2 months and days until pain-free bowel movements", "result": "both treatments led to similar healing rates (about 74%) and about 7 days to pain-free defecation, with no added benefit from diltiazem", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This was a retrospective study without a placebo group, so it can't fully prove whether the added drug truly makes no difference.", "directness": "indirect", "limitations": "Retrospective design and no placebo control for the topical diltiazem.", "followUp": "53 (22-101) months", "plainFinding": "Adding diltiazem didn't help fissure healing.", "retracted": false, "expressionOfConcern": false, "hasErratum": true, "url": "https://pubmed.ncbi.nlm.nih.gov/40009123/", "sourceText": "OBJECTIVE: This study aims to compare the short- and long-term outcomes of botulinum toxin (BT) alone versus BT combined with topical diltiazem (TD) in the treatment of chronic anal fissures (CAF). DESIGN: The study is designed as a retrospective analysis, reviewing data from 1296 patients diagnosed with anal fissures who presented to our clinic between 2017 and 2022. SETTING: Single center (University hospital). PATIENTS: A total of 217 patients who met the inclusion criteria were analyzed, with 143 receiving BT alone and 74 receiving the combination of BT + TD. INTERVENTIONS: BT was administered as 100 IU injected into four quadrants. TD was applied twice daily for 10 days immediately following the BT injection. MAIN OUTCOME MEASURES: Primary outcome measures were fissure healing at 2 months and days to pain-free defecation. Secondary outcome measures were complete healing and recurrence rates at 24 months. RESULTS: There were no significant differences in demographic characteristics and symptom duration between the BT and BT + TD groups. The median time to pain-free defecation was 7 days across the entire series, with no statistical difference between groups. At 2 months, complete healing was observed in 74.4% of patients, with no significant difference between groups: 74.8% for BT and 74.3% for BT + TD. During a median follow-up of 53 (22-101) months, a recurrence rate of 26.3% was observed, and TD showed no effect on complete healing and recurrence rates. LIMITATIONS: The most significant limitation of our study is its retrospective design and the absence of a placebo control for TD. CONCLUSION: The study demonstrates that BT is an effective and safe treatment for CAF, with or without the addition of TD. The combination therapy did not show superior outcomes.", "provenance": [ { "field": "population", "quote": "217 patients who met the inclusion criteria were analyzed" }, { "field": "intervention", "quote": "TD was applied twice daily for 10 days immediately following the BT injection" }, { "field": "comparator", "quote": "143 receiving BT alone" }, { "field": "primaryOutcome", "quote": "Primary outcome measures were fissure healing at 2 months and days to pain-free defecation" }, { "field": "result", "quote": "At 2 months, complete healing was observed in 74.4% of patients, with no significant difference between groups: 74.8% for BT and 74.3% for BT + TD" }, { "field": "result", "quote": "The median time to pain-free defecation was 7 days across the entire series, with no statistical difference between groups" }, { "field": "n", "quote": "A total of 217 patients who met the inclusion criteria were analyzed" }, { "field": "followUp", "quote": "median follow-up of 53 (22-101) months" }, { "field": "limitations", "quote": "its retrospective design and the absence of a placebo control for TD" } ] }, { "id": "pmid:39899833", "pmid": "39899833", "doi": "10.2196/63063", "nctId": null, "pmcid": "PMC11833261", "title": "Efficacy and Safety of Murivenna Anal Infiltration Compared to Diltiazem Topical Application in Chronic Anal Fissure: Protocol for a Prospective, Randomized, Open-Label Clinical Trial", "firstAuthor": "Shankar Km", "multipleAuthors": true, "journal": "JMIR Res Protoc", "year": 2025, "design": "registered-trial-no-results", "n": 66, "nField": "reported", "population": "people with chronic anal fissure (a tear in the anal lining causing pain after pooping)", "intervention": "murivenna oil injected into the anal area (Ayurvedic treatment)", "comparator": "diltiazem cream applied topically", "primaryOutcome": "proportion of participants with complete healing after 4 weeks of treatment", "result": "This is a trial protocol; recruitment is ongoing and results are not yet available", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is only a study protocol with no results reported yet, so no conclusions about effectiveness can be drawn.", "directness": "direct", "limitations": "Open-label design (no blinding); results not yet available as recruitment and data analysis are still in progress.", "followUp": "4 weeks", "plainFinding": "No results yet available.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39899833/", "sourceText": "BACKGROUND: Anal fissure is a common proctologic condition that causes significant pain and anguish to patients, significantly impacting their quality of life and well-being. There are various treatment options for anal fissure, ranging from pharmacological agents that reduce anal sphincter tone to surgical interventions for cases resistant to medical management. Ayurvedic treatments have shown potential for the therapeutic management of anal fissure. OBJECTIVE: This clinical study aims to analyze the efficacy and safety of murivenna anal infiltration compared to diltiazem topical application in chronic anal fissure. METHODS: This is an open-labeled, randomized, controlled parallel group clinical trial with a sample size of 66 participants to be randomized and allocated in a 1:1 ratio to 2 groups. The intervention group will be treated with murivenna anal infiltration, and the control group will be treated with topical application of diltiazem for a period of 4 weeks. The primary outcome will be the proportion of participants demonstrating complete healing after 4 weeks of treatment. The secondary outcomes will be the proportion of participants demonstrating complete healing after 7 days and 14 days of treatment, change in pain at or after defecation, cessation of bleeding, and any recurrence during the study period. Any adverse events will also be recorded during the trial period. RESULTS: The project was funded in July 2023, and the study period is 24 months. Participant recruitment started in December 2023. As of August 2024, we have enrolled 50 participants. The data analysis will be complete by June 2025, and the results are expected to be published by August 2025. CONCLUSIONS: High recurrence rates, adverse effects, incomplete healing, and the negative impact on patients' daily activities and quality of life underscore the need for alternative therapeutic options. Ayurveda offers potential for more sustainable relief with fewer adverse effects. Murivenna oil is a time-tested medicated oil effectively used by Ayurvedic physicians for various ulcers of traumatic and pathological origin. This study will provide scientific evidence on the efficacy and safety of murivenna anal infiltration; further, it can be incorporated into the cost-effective management of chronic anal fissure. TRIAL REGISTRATION: Clinical Trials Registry India CTRI/2023/09/057330; https://tinyurl.com/y4ut9e8p. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/63063.", "provenance": [ { "field": "n", "quote": "a sample size of 66 participants" }, { "field": "population", "quote": "chronic anal fissure" }, { "field": "intervention", "quote": "murivenna anal infiltration" }, { "field": "comparator", "quote": "topical application of diltiazem" }, { "field": "primaryOutcome", "quote": "The primary outcome will be the proportion of participants demonstrating complete healing after 4 weeks of treatment." }, { "field": "result", "quote": "The data analysis will be complete by June 2025, and the results are expected to be published by August 2025." } ] }, { "id": "pmid:39872768", "pmid": "39872768", "doi": "10.4240/wjgs.v17.i1.99464", "nctId": null, "pmcid": "PMC11757188", "title": "Clinical observation on prognosis of mixed hemorrhoids treated with polidocanol injection combined with automatic elastic thread ligation operation", "firstAuthor": "Huang", "multipleAuthors": true, "journal": "World J Gastrointest Surg", "year": 2025, "design": "rct", "n": 100, "nField": "reported", "population": "patients diagnosed with mixed hemorrhoids", "intervention": "polidocanol foam injection combined with automatic elastic thread ligation (RPH)", "comparator": "procedure for prolapse and hemorrhoids (PPH) surgery", "primaryOutcome": "pain after surgery, including first bowel movement pain, plus healing time and complications", "result": "Treatment group had lower pain scores at 24 hours and at first defecation after surgery, faster healing, shorter hospital stay, higher effective rate, and fewer complications, with no difference in bleeding, anal stenosis, or recurrence", "resultDirection": "benefit", "quality": "low", "qualityWhy": "It was randomized but used dice rolling for allocation, had no blinding described, and is a single-center study, which limits confidence in the results.", "directness": "direct", "limitations": "Randomization by dice rolling, no mention of blinding, single hospital, and short follow-up for recurrence assessment despite claiming long-term prognosis.", "followUp": "1 year post-operatively", "plainFinding": "Less pain after bowel movements", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39872768/", "sourceText": "BACKGROUND: A total of 100 patients diagnosed with mixed hemorrhoids from October 2022 to September 2023 in our hospital were randomly divided into groups by dice rolling and compared with the efficacy of different treatment options. AIM: To analyze the clinical effect and prognosis of mixed hemorrhoids treated with polidocanol injection combined with automatic elastic thread ligation operation (RPH). METHODS: A total of 100 patients with mixed hemorrhoids who visited our hospital from October 2022 to September 2023 were selected and randomly divided into the control group (n = 50) and the treatment group (n = 50) by rolling the dice. The procedure for prolapse and hemorrhoids (PPH) was adopted in the control group, while polidocanol foam injection + RPH was adopted in the treatment group. The therapeutic effects, operation time, wound healing time, hospital stay, pain situation (24 hours post-operative pain score, first defecation pain score), quality of life (QOL), incidence of complications (post-operative hemorrhage, edema, infection), incidence of anal stenosis 3 months post-operatively and recurrence rate 1 year post-operatively of the two groups were compared. RESULTS: Compared with the control group, the total effective rate of treatment group was higher, and the difference was significant (P < 0.05). The operation time/wound healing time/hospital stay in the treatment group were shorter than those in the control group (P < 0.05). The pain scores at 24 hours after operation/first defecation pain score of the treatment group was significantly lower than those in the control group (P < 0.05). After surgery, the QOL scores of the two groups decreased, with the treatment group having higher scores than that of the control group (P < 0.05). Compared with the control group, the incidence of postoperative complications in the treatment group was lower, and the difference was significant (P < 0.05); However, there was no significant difference in the incidence of postoperative bleeding between the two groups (P > 0.05); There was no significant difference in the incidence of anal stenosis 3 months after operation and the recurrence rate 1 year after operation between the two groups (P > 0.05). CONCLUSION: For patients with mixed hemorrhoids, the therapeutic effect achieved by using polidocanol injection combined with RPH was better. The wounds of the patients healed faster, the postoperative pain was milder, QOL improved, and the incidence of complications was lower, and the short-term and long-term prognosis was good.", "provenance": [ { "field": "population", "quote": "patients with mixed hemorrhoids" }, { "field": "intervention", "quote": "polidocanol foam injection + RPH" }, { "field": "comparator", "quote": "The procedure for prolapse and hemorrhoids (PPH) was adopted in the control group" }, { "field": "primaryOutcome", "quote": "pain situation (24 hours post-operative pain score, first defecation pain score)" }, { "field": "result", "quote": "The pain scores at 24 hours after operation/first defecation pain score of the treatment group was significantly lower than those in the control group (P < 0.05)" }, { "field": "n", "quote": "A total of 100 patients with mixed hemorrhoids who visited our hospital from October 2022 to September 2023 were selected and randomly divided into the control group (n = 50) and the treatment group (n = 50) by rolling the dice" } ] }, { "id": "pmid:39710449", "pmid": "39710449", "doi": "10.3760/cma.j.cn441530-20240918-00322", "nctId": null, "pmcid": null, "title": "[Somatic symptoms often comorbid with benign anorectal disorders: a study of their significance]", "firstAuthor": "Zhao", "multipleAuthors": true, "journal": "Zhonghua Wei Chang Wai Ke Za Zhi", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anorectal conditions like fissures, hemorrhoids, or defecation problems who still have discomfort after treatment", "intervention": "treating psychological/somatic symptom disorder before or alongside anorectal treatment", "comparator": "surgical treatment alone without addressing psychological symptoms", "primaryOutcome": "improvement in patient discomfort and rehabilitation outcomes", "result": "the article recommends treating somatic symptom disorder first, before surgery, when anorectal disease coexists with psychological disorders, but reports no data or outcomes", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is an opinion/narrative piece with no patient data, trial, or measured outcomes, so it can't show whether anything actually works.", "directness": "indirect", "limitations": "no study data, no defined population size, no outcome measurements; it is a conceptual/opinion article rather than original research", "followUp": "", "plainFinding": "Persistent pain may be psychological, not physical", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39710449/", "sourceText": "Benign anorectal diseases represent a prevalent and intricate category of gastrointestinal disorders, encompassing conditions such as anal fissures, fistulas, hemorrhoids, incontinence, pain, and defecation disorders. These conditions include both anatomical abnormalities and functional disorders. Some patients continue to experience discomfort such as perianal discomfort, perineal heaviness, defecation difficulties, and abdominal bloating even after anatomical issues have been addressed, severely impairing social functioning. Generally, colorectal surgeons have paid little attention to somatic symptom disorder (SSD). This article introduced the manifestation of SSD in benign anorectal diseases from a psychosomatic perspective, advocating for the establishment of a biopsychosocial medical model in the diagnosis and treatment of these conditions to enhance patient rehabilitation outcomes. It is recommended that when benign anal diseases coexist with psychological disorders, SSD treatment should be used as a prerequisite. Surgical treatment should be considered only after the improvement of psychological disorders and SSD.", "provenance": [ { "field": "population", "quote": "Some patients continue to experience discomfort such as perianal discomfort, perineal heaviness, defecation difficulties, and abdominal bloating even after anatomical issues have been addressed, severely impairing social functioning." }, { "field": "intervention", "quote": "advocating for the establishment of a biopsychosocial medical model in the diagnosis and treatment of these conditions to enhance patient rehabilitation outcomes" }, { "field": "comparator", "quote": "Surgical treatment should be considered only after the improvement of psychological disorders and SSD." }, { "field": "primaryOutcome", "quote": "to enhance patient rehabilitation outcomes" }, { "field": "result", "quote": "It is recommended that when benign anal diseases coexist with psychological disorders, SSD treatment should be used as a prerequisite." } ] }, { "id": "pmid:39563748", "pmid": "39563748", "doi": "10.3748/wjg.v30.i42.4583", "nctId": null, "pmcid": "PMC11572621", "title": "Endoscopic polidocanol foam sclerobanding for treatment of internal hemorrhoids: A novel outpatient procedure", "firstAuthor": "Mou", "multipleAuthors": true, "journal": "World J Gastroenterol", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with internal hemorrhoids (grades II and III)", "intervention": "endoscopic polidocanol foam sclerobanding (EFSB), a procedure that injects foam and bands hemorrhoids", "comparator": "endoscopic rubber band ligation (ERBL) alone", "primaryOutcome": "pain after the procedure and return of prolapse", "result": "EFSB was linked to less pain after the procedure and less return of prolapse compared with banding alone, but the abstract says larger and longer studies are needed", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a commentary discussing another study's results rather than original data, and the commentary itself says the findings need confirmation in bigger, longer trials", "directness": "indirect", "limitations": "the abstract states that future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings", "followUp": "one-year follow-up", "plainFinding": "New banding method may cut procedural pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39563748/", "sourceText": "In the study, we comment on the article by Qu et al. Internal hemorrhoids are the most common anorectal disorders worldwide with bleeding, prolapse, and difficulty in defecation. Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure. The main goal of ERBL is to alleviate prolapse, but the high incidence of recurrence and post-procedural pain are of clinical concern. Polidocanol foam as a local hemostatic and anesthetic agent could reduce the rates of post-procedural pain and bleeding. Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach that could lift the mucosa for easy ligation and promote increased scarring in the submucosal tissue which translates into long-term relief from prolapse recurrence and reduced 24-h post-procedural pain. The study by Qu et al is a novel multi-center prospective randomized study to compare ERBL and EFSB in patients with grades II and III internal hemorrhoids with one-year follow-up. Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings.", "provenance": [ { "field": "population", "quote": "patients with grades II and III internal hemorrhoids" }, { "field": "intervention", "quote": "Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach" }, { "field": "comparator", "quote": "Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure" }, { "field": "primaryOutcome", "quote": "reduced 24-h post-procedural pain" }, { "field": "result", "quote": "Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings" }, { "field": "followUp", "quote": "one-year follow-up" } ] }, { "id": "pmid:39480607", "pmid": "39480607", "doi": "10.1007/s10151-024-03028-9", "nctId": null, "pmcid": null, "title": "Feasibility of IAPWG protocol in performing high-definition three-dimensional anorectal manometry: A prospective, multicentric italian study", "firstAuthor": "Della Casa", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2024, "design": "prospective-cohort", "n": 290, "nField": "reported", "population": "patients referred for anorectal testing for reasons including constipation, fecal incontinence, anal pain, and other anorectal problems", "intervention": "3D high-definition anorectal manometry using a standardized testing protocol", "comparator": "none; no comparison group", "primaryOutcome": "whether the standardized testing protocol could be successfully completed", "result": "the full test protocol was completed in 97.9% of patients and was described as easy to perform and not time-consuming", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a feasibility study of a diagnostic test's practicality, not a study testing treatments or causes of anal pain after bowel movements", "directness": "indirect", "limitations": "this abstract does not evaluate causes or treatments for anal pain after defecation; only 3.1% of patients were referred for anal pain, and no outcomes specific to anal pain are reported", "followUp": "", "plainFinding": "Study of a diagnostic test, not pain causes.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39480607/", "sourceText": "BACKGROUND: The International Anorectal Physiology Working Group (IAPWG) suggests a standardized protocol to perform high-resolution anorectal manometry. The applicability and possible limitations of the IAPWG protocol in performing three-dimensional high-definition anorectal manometry (3D-ARM) have still to be extensively evaluated. METHODS: The IAPWG protocol was applied in performing 3D-ARM. Anorectal manometry (ARM) and a balloon expulsion test (BET) were performed according to IAPGW protocol in 290 patients. KEY RESULTS: A total of 84 males and 206 females (mean age 57.1 ± 15.7 years) were enrolled in six Italian centers. The reasons for which the patients were sent to perform 3D-ARM were: constipation (53.1%), fecal incontinence (26.9%), anal pain (3.1%), postsurgical (3.8%) and presurgical evaluation (4.8%), prolapse (3.4%), anal fissure (2.8%), and other (2.1%). Due to organic and functional conditions (low rectal anterior resections, rectal prolapses, and J-pouch after colectomy), we were unable to perform a complete 3D-ARM on six patients. Overall, a complete 3D-ARM and BET following IAPWG protocol was carried out in 284 patients (97.9%). The following were recorded: rest pressure (81.9 ± 32.0 mmHg) and length of the anal sphincter (37.0 ± 6.2 cm), maximum anal squeeze pressure (201.6 ± 81.3 mmHg), squeeze duration (22.0 ± 8.8 s), maximum rectal (48.7 ± 41.0 mmHg) and minimum anal pressure (73.3 ± 36.5 mmHg) during push, presence/absence of a dyssynergic pattern, cough reflex and rectal sensations (first constant sensation 48.4 ± 29.5 mL, desire to defecate 83.7 ± 52.1 mL, and maximum tolerated volume 149.5 ± 72.6 mL), and presence/absence of rectoanal inhibitory reflex. Mean 3D-ARM registration time was 14 min 7 s ± 3 min 12 s. CONCLUSIONS: This is the first multicentric study that evaluates the applicability of the IAPWG protocol in 3D-ARM performed in different manometric laboratories (both gastroenterological and surgical). The IAPWG protocol was easy to perform and was not time consuming. A diagnosis according to the London Classification was easily obtained in most patients in which 3D-ARM was carried out. No clear limitations to the applicability of the IAPWG protocol were detected.", "provenance": [ { "field": "n", "quote": "A total of 84 males and 206 females (mean age 57.1 ± 15.7 years) were enrolled in six Italian centers." }, { "field": "population", "quote": "The reasons for which the patients were sent to perform 3D-ARM were: constipation (53.1%), fecal incontinence (26.9%), anal pain (3.1%), postsurgical (3.8%) and presurgical evaluation (4.8%), prolapse (3.4%), anal fissure (2.8%), and other (2.1%)." }, { "field": "intervention", "quote": "The IAPWG protocol was applied in performing 3D-ARM." }, { "field": "comparator", "quote": "Anorectal manometry (ARM) and a balloon expulsion test (BET) were performed according to IAPGW protocol in 290 patients." }, { "field": "primaryOutcome", "quote": "The applicability and possible limitations of the IAPWG protocol in performing three-dimensional high-definition anorectal manometry (3D-ARM) have still to be extensively evaluated." }, { "field": "result", "quote": "Overall, a complete 3D-ARM and BET following IAPWG protocol was carried out in 284 patients (97.9%)." } ] }, { "id": "pmid:38999495", "pmid": "38999495", "doi": "10.3390/jcm13133930", "nctId": null, "pmcid": "PMC11242537", "title": "Anal Fissure and Its Treatments: A Historical Review", "firstAuthor": "Riboni", "multipleAuthors": true, "journal": "J Clin Med", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal fissure (a tear near the anus)", "intervention": "historical review of medical and surgical treatments for anal fissure", "comparator": "no comparator; historical overview", "primaryOutcome": "how understanding and treatment of anal fissure changed over time", "result": "the abstract traces the history of understanding and treating anal fissure without reporting outcome data", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a historical narrative review, not a study measuring outcomes, so it cannot show whether any treatment works", "directness": "indirect", "limitations": "no patient data, no outcome measures, and no comparison of treatment effectiveness are reported; it is a historical summary only", "followUp": "", "plainFinding": "Explains fissures, no treatment results", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38999495/", "sourceText": "Anal fissure is one of the most common proctological pathologies. It consists of the formation of a longitudinal tear in the anoderm, causing pain and bleeding during and after defecation. When chronic, it can significantly negatively impact the quality of life of the affected patient. Currently, multiple therapeutic options are available, both medical and surgical. The objective of this article is to highlight the historical evolution in the physiopathological understanding and treatment of this disease, underlining the key moments in this history. This is the first article to summarize the milestones in the treatment of anal fissure from ancient to current times.", "provenance": [ { "field": "population", "quote": "Anal fissure is one of the most common proctological pathologies." }, { "field": "intervention", "quote": "The objective of this article is to highlight the historical evolution in the physiopathological understanding and treatment of this disease, underlining the key moments in this history." }, { "field": "comparator", "quote": "This is the first article to summarize the milestones in the treatment of anal fissure from ancient to current times." }, { "field": "primaryOutcome", "quote": "the historical evolution in the physiopathological understanding and treatment of this disease" }, { "field": "result", "quote": "Currently, multiple therapeutic options are available, both medical and surgical." } ] }, { "id": "pmid:38965992", "pmid": "38965992", "doi": "10.5604/01.3001.0054.4819", "nctId": null, "pmcid": null, "title": "Hemorrhoidal laser ablation procedure: a minimally invasive treatment for grades II, III, and IV using a 1470 nm diode laser", "firstAuthor": "Kavraal", "multipleAuthors": true, "journal": "Pol Przegl Chir", "year": 2024, "design": "retrospective", "n": 138, "nField": "reported", "population": "adults with symptomatic internal hemorrhoids (grades II, III, and IV)", "intervention": "laser treatment to shrink hemorrhoids (hemorrhoidal laser ablation with a 1470 nm diode laser)", "comparator": "none (single group, before/after outcomes only)", "primaryOutcome": "symptom relief, hemorrhoid shrinkage, recurrence, and safety after the procedure", "result": "no complications during surgery, only mild symptoms for about a week, symptoms mostly resolved by six months, low recurrence, and 95% patient satisfaction", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective study without a comparison group, so it can't prove the laser caused the improvement.", "directness": "indirect", "limitations": "Retrospective design with no control/comparison group; relies on data collected after the fact from three centers.", "followUp": "up to five years", "plainFinding": "Laser hemorrhoid treatment, high satisfaction, few problems", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38965992/", "sourceText": "<b>Indroduction:</b> Hemorrhoids often cause pain, and achieving painless outcomes through surgery is challenging. Hemorrhoidal Laser Ablation, a method for treating severe hemorrhoids, has limited documentation in clinical trials.</br> <br><b>Aim:</b> This retrospective study aimed to present our experience with Hemorrhoidal Laser Ablation in symptomatic grade II, III, and IV internal hemorrhoids and evaluate the efficacy and safety of this relatively recent technique.</br> <br><b>Material and methods:</b> The cohort included 138 patients with symptomatic hemorrhoids who underwent Hemorrhoidal Laser Ablation at three different medical centers in 2017-2022. Patients were treated with a 1470 nm diode laser. Data were collected on clinical and perioperative characteristics and outcomes.</br> <br><b>Results:</b> No evidence of intraoperative complications occurred. There was no rectal tenesmus or alteration of defecation habits. Early mild postoperative symptoms were observed for an average of one week after the operation. The plateau of symptom resolution and downgrading of hemorrhoid size reached approximately six months post-procedure. The short- -term recurrence rate was 0.8% within roughly a month after the laser surgery, while the long-term recurrence rate was 5% over up to five years of follow-up. The overall satisfaction rate was 95% with symptomatic relief.</br> <br><b>Conclusions:</b> Hemorrhoidal Laser Ablation is a painless outpatient technique that does not require general anesthesia. It is an easy-to-perform, convenient, safe, and efficient modality in reducing symptoms and complications of grades II, III, and IV internal hemorrhoids. Hemorrhoidal Laser Ablation limits postoperative discomfort and allows the patient to return to daily routines quickly.</br>.", "provenance": [ { "field": "n", "quote": "The cohort included 138 patients with symptomatic hemorrhoids who underwent Hemorrhoidal Laser Ablation" }, { "field": "population", "quote": "symptomatic grade II, III, and IV internal hemorrhoids" }, { "field": "intervention", "quote": "Hemorrhoidal Laser Ablation, a method for treating severe hemorrhoids" }, { "field": "intervention", "quote": "Patients were treated with a 1470 nm diode laser." }, { "field": "comparator", "quote": "This retrospective study aimed to present our experience with Hemorrhoidal Laser Ablation" }, { "field": "primaryOutcome", "quote": "evaluate the efficacy and safety of this relatively recent technique" }, { "field": "result", "quote": "No evidence of intraoperative complications occurred." }, { "field": "result", "quote": "The overall satisfaction rate was 95% with symptomatic relief." }, { "field": "result", "quote": "the long-term recurrence rate was 5% over up to five years of follow-up" }, { "field": "design", "quote": "This retrospective study aimed to present our experience with Hemorrhoidal Laser Ablation" } ] }, { "id": "pmid:38940246", "pmid": "38940246", "doi": "10.5604/01.3001.0054.6443", "nctId": null, "pmcid": null, "title": "The influence of supportive therapy with a six-component myophlebotropic preparation on the reduction of symptoms in patients with symptoms of hemorrhoidal disease", "firstAuthor": "Kwiatkowska", "multipleAuthors": true, "journal": "Pol Przegl Chir", "year": 2024, "design": "prospective-cohort", "n": 61, "nField": "reported", "population": "adults with stage II or III hemorrhoids who had pain, burning, itching or bleeding", "intervention": "a six-component myophlebotropic dietary supplement added to standard local hemorrhoid treatment", "comparator": "standard local treatment plus a placebo supplement", "primaryOutcome": "severity of hemorrhoid symptoms such as pain, burning, itching and bleeding, measured over 30 days", "result": "Patients on the active supplement had significantly greater improvement in pain, burning, itching and bleeding during defecation than those on placebo after 30 days", "resultDirection": "benefit", "quality": "low", "qualityWhy": "The study was small, did not clearly state it was randomized or blinded, so results may be less reliable.", "directness": "direct", "limitations": "Abstract does not mention randomization procedure, blinding method, or any adverse effects, and the sample size was small.", "followUp": "30 days", "plainFinding": "Less pain, burning and itching with supplement.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38940246/", "sourceText": "<b>Introduction:</b> Hemorrhoidal disease is the most common disease treated in proctology ambulatories. Conservative treatment is the basic form of treatment for this disease. One of the elements of treatment may be preparations with myoand phlebotropic effects.<b>Aim:</b> To assess the effect of a multi-ingredient myophlebotropic dietary supplement used as an adjunct on the rate and effectiveness of symptom relief in patients with stage II and III hemorrhoidal disease.<b>Material and method:</b> Patients with stage II and III hemorrhoidal disease with clinical symptoms such as pain, burning, itching and bleeding were qualified for the study. The patients were divided into two groups. The control group (Group I) of 29 patients receiving standard local treatment plus placebo and the study group (Group II) of 32 patients receiving the same local treatment and a six-component myophlebotropic product. Symptoms were analyzed at the time of inclusion in the study (day 0), after 4 and 10 days of therapy. The severity of hemorrhoidal disease and the feeling of relief were assessed on the day of inclusion (W0) and after 30 days of therapy.<b>Results:</b> There were no statistical differences between the groups in terms of disease advancement, age, gender, and duration of symptoms. Compared to the moment of inclusion in the study (W0), after 4 days (W1), after 10 days (W2) of taking the multi- -component product, there was a statistically significant improvement in the VAS scale: spontaneous pain and pain during defecation. In the qualitative assessment (yes/no), there were statistically significantly fewer cases of burning in the anus and itching. The treatment did not affect the rate of spontaneous bleeding, which was low at the beginning of the study, but significantly reduced the rate of bleeding during defecation. After 30 days of observation, it was found that the improvement in the severity of hemorrhoidal disease symptoms was significantly higher in the group using the tested preparation. Relief after a month of the study (one-question method) was noted in the group of patients receiving the tested product.<b>Conclusions:</b> The tested six-component myophlebotropic product proved to be effective in reducing the severity of symptoms such as spontaneous pain, pain during defecation, burning/burning in the anus and bleeding during defecation. Statistical significance was demonstrated in the symptom's relief and reduction in the severity of hemorrhoidal disease.", "provenance": [ { "field": "n", "quote": "29 patients" }, { "field": "n", "quote": "32 patients" }, { "field": "population", "quote": "Patients with stage II and III hemorrhoidal disease with clinical symptoms such as pain, burning, itching and bleeding were qualified for the study." }, { "field": "intervention", "quote": "a six-component myophlebotropic product" }, { "field": "comparator", "quote": "receiving standard local treatment plus placebo" }, { "field": "primaryOutcome", "quote": "Symptoms were analyzed at the time of inclusion in the study (day 0), after 4 and 10 days of therapy." }, { "field": "result", "quote": "there was a statistically significant improvement in the VAS scale: spontaneous pain and pain during defecation" }, { "field": "followUp", "quote": "After 30 days of observation" } ] }, { "id": "pmid:38871679", "pmid": "38871679", "doi": "10.1097/DCR.0000000000003419", "nctId": null, "pmcid": null, "title": "A Randomized Controlled Trial of Topical Analgesia Posthemorrhoidectomy (TAPH Trial)", "firstAuthor": "Jin", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2024, "design": "rct", "n": 192, "nField": "reported", "population": "adults recovering after hemorrhoidectomy surgery", "intervention": "topical metronidazole combined with diltiazem and/or lidocaine applied to the anal area", "comparator": "topical metronidazole alone", "primaryOutcome": "pain level on day 4 after surgery", "result": "adding diltiazem or lidocaine to metronidazole did not significantly reduce pain or improve recovery compared to metronidazole alone", "resultDirection": "no-benefit", "quality": "moderate", "qualityWhy": "it was a well-designed multicenter randomized double-blind trial, but the comparison group used an active drug rather than a true placebo, which limits certainty.", "directness": "indirect", "limitations": "Topical metronidazole was used in the control group rather than a pure placebo.", "followUp": "", "plainFinding": "No extra pain relief after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38871679/", "sourceText": "BACKGROUND: Postoperative pain remains the greatest problem after hemorrhoidectomy. Pain is hypothesized to arise from bacterial infection, sphincter spasm, and local inflammation. OBJECTIVE: This trial was conducted to assess the effects of metronidazole, diltiazem, and lidocaine on posthemorrhoidectomy pain. DESIGN: A double-blinded randomized controlled factorial trial. SETTINGS: This multicenter trial was conducted in Auckland, New Zealand. PATIENTS: A total of 192 participants were randomly assigned (1:1:1:1) into 4 parallel arms. INTERVENTIONS: Participants were randomly assigned into 1 of 4 groups receiving topical treatment with 10% metronidazole, 10% metronidazole + 2% diltiazem, 10% metronidazole + 4% lidocaine, or 10% metronidazole + 2% diltiazem + 4% lidocaine. Participants were instructed to apply treatment to the anal verge 3 times daily for 7 days. MAIN OUTCOME MEASURES: The primary outcome was pain on the visual analog scale on day 4. The secondary outcomes included analgesia usage, pain during bowel movement, and functional recovery index. RESULTS: There was no significant difference in the pain and recovery scores when diltiazem or lidocaine was added to metronidazole (score difference between presence and absence of diltiazem in the formulation: -3.69; 95% CI, -13.3 to 5.94; p = 0.46; between presence and absence of lidocaine: -5.67; 95% CI, -15.5 to 3.80; p = 0.24). The combination of metronidazole + diltiazem + lidocaine did not further reduce pain. Secondary analysis revealed a significant difference between the best (metronidazole + lidocaine) and worst (metronidazole + diltiazem + lidocaine) groups in both pain and functional recovery scores. There were no significant differences in analgesic usage, complications, or return to work between the groups. No clinically important adverse events were reported. The adverse event rate did not change in the intervention groups. LIMITATIONS: Topical metronidazole was used in the control group rather than a pure placebo. CONCLUSIONS: There was no significant difference in pain when topical diltiazem, lidocaine, or both were added to topical metronidazole. See Video Abstract . CLINICALTRIALSGOV IDENTIFIER: NCT04276298. ENSAYO CONTROLADO ALEATORIZADO DE ANALGESIA TPICA POSTERIOR A HEMORROIDECTOMA ENSAYO TAPH: ANTECEDENTES:El dolor postoperatorio sigue siendo el mayor problema tras hemorroidectomía. La hipótesis es que el dolor se debe a infección bacteriana, el espasmo esfínteriano e inflamación local.OBJETIVO:Se realizó un ensayo factorial aleatorizado y controlado para evaluar los efectos del metronidazol, el diltiazem y la lidocaína en el dolor posthemorroidectomía.DISEÑO:Ensayo factorial controlado aleatorizado doble ciego.ESCENARIO:Se realizó un ensayo multicéntrico en Auckland, Nueva Zelanda.PACIENTES:Se aleatorizó a 192 participantes (1:1:1:1) en cuatro brazos paralelos.INTERVENCIONES:Los participantes se asignaron aleatoriamente a uno de los cuatro grupos que recibieron tratamiento tópico con metronidazol al 10% (M), metronidazol al 10% + diltiazem al 2% (MD), metronidazol al 10% + lidocaína al 4% (ML), o metronidazol al 10% + diltiazem al 2% + lidocaína al 4% (MDL). Se indicó a los participantes que lo aplicaran en el margen anal 3 veces al día durante 7 días.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el dolor en la escala analógica visual en el día 4. Los resultados secundarios incluyeron el uso de analgesia, el dolor al defecar y el índice de recuperación funcional.RESULTADOS:No hubo diferencias significativas en las puntuaciones de dolor y recuperación cuando se añadió diltiazem o lidocaína al metronidazol (diferencia de puntuación entre la presencia y la ausencia de D en la formulación: -3.69; IC del 95%: -13.3; 5.94; p = 0.46; entre la presencia y la ausencia de L: -5.67; IC del 95%: -15.5; 3.80; p = 0.24). La combinación de MDL no redujo más el dolor. El análisis secundario reveló una diferencia significativa entre los grupos mejor (ML) y peor (MDL) tanto en las puntuaciones de dolor como en las de recuperación funcional. No hubo diferencias significativas en el uso de analgésicos, las complicaciones o la reincorporación al trabajo entre los grupos. No se notificaron eventos adversos clínicamente importantes. La tasa de eventosadversos no cambió en los grupos de intervención.LIMITACIONES:Se utilizó metronidazol tópico en el grupo de control, en lugar de un placebo puro.CONCLUSIONES:No hubo diferencias significativas en el dolor cuando se añadió diltiazem tópico o lidocaína, o ambos, al metronidazol tópico. ( Traducción-Dr. Jorge Silva Velazco )Identificador de registro del ensayo clínico:NCT04276298.", "provenance": [ { "field": "n", "quote": "A total of 192 participants were randomly assigned (1:1:1:1) into 4 parallel arms." }, { "field": "population", "quote": "Postoperative pain remains the greatest problem after hemorrhoidectomy." }, { "field": "intervention", "quote": "Participants were randomly assigned into 1 of 4 groups receiving topical treatment with 10% metronidazole, 10% metronidazole + 2% diltiazem, 10% metronidazole + 4% lidocaine, or 10% metronidazole + 2% diltiazem + 4% lidocaine." }, { "field": "comparator", "quote": "Topical metronidazole was used in the control group rather than a pure placebo." }, { "field": "primaryOutcome", "quote": "The primary outcome was pain on the visual analog scale on day 4." }, { "field": "result", "quote": "There was no significant difference in the pain and recovery scores when diltiazem or lidocaine was added to metronidazole" } ] }, { "id": "pmid:38652448", "pmid": "38652448", "doi": "10.23736/S0375-9393.24.17780-2", "nctId": null, "pmcid": null, "title": "Ultrasound-guided intersphincteric space block combined with spinal anesthesia for hemorrhoidectomy: a randomized clinical trial", "firstAuthor": "Liang", "multipleAuthors": true, "journal": "Minerva Anestesiol", "year": 2024, "design": "rct", "n": 50, "nField": "reported", "population": "adults having surgery to remove hemorrhoids", "intervention": "nerve block near the anal muscle plus a low dose of spinal anesthesia", "comparator": "standard dose of spinal anesthesia alone", "primaryOutcome": "pain level after surgery, including at the first bowel movement", "result": "lower pain scores and less urinary retention with the nerve block plus low-dose spinal anesthesia", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial but small, with only 50 patients, which limits how confident we can be in the findings", "directness": "indirect", "limitations": "small sample size; abstract does not mention blinding or multiple study centers", "followUp": "48 hours", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38652448/", "sourceText": "BACKGROUND: We aimed to compare the analgesic effects and incidence of urinary retention between ultrasound-guided intersphincteric space block combined with low-dose ropivacaine spinal anesthesia and conventional-dose ropivacaine spinal anesthesia post-hemorrhoidectomy. METHODS: Fifty patients aged 20-65 years who underwent elective hemorrhoidectomy were stochastically assigned to one of two groups. Spinal anesthesia was induced with 8 mg ropivacaine, combined with ultrasound-guided intersphincteric space block in the treatment group. Spinal anesthesia was induced with 12 mg ropivacaine in the control group. The primary outcome was the postoperative pain score, measured using the Visual Analog Scale (VAS) at 4, 8, 12, 24, and 48 hours and at the first defecation postoperatively. Secondary outcomes included urinary retention, extent of anal sphincter relaxation, and the time required to lift the lower limbs out of bed postoperatively. RESULTS: The treatment group showed markedly lower VAS scores than those of the control group at 8, 12, 24, and 48 h, and at the first postoperative defecation time (P<0.05). The incidence of urinary retention was considerably lower in the treatment group than in the control group (24% vs. 52%, P=0.04). No remarkable difference in the degree of anal sphincter relaxation was observed between the two groups (P=0.556). The time taken by the treatment group patients to lift their lower limbs off the bed was much shorter than that in the control group (1.3±0.6 h vs. 3.2±1.2 h, P<0.001). CONCLUSIONS: Ultrasound-guided intersphincteric space block combined with low-dose ropivacaine spinal anesthesia provides good anesthesia and analgesia for hemorrhoidectomy.", "provenance": [ { "field": "n", "quote": "Fifty patients aged 20-65 years who underwent elective hemorrhoidectomy were stochastically assigned to one of two groups." }, { "field": "population", "quote": "patients aged 20-65 years who underwent elective hemorrhoidectomy" }, { "field": "intervention", "quote": "ultrasound-guided intersphincteric space block combined with low-dose ropivacaine spinal anesthesia" }, { "field": "comparator", "quote": "conventional-dose ropivacaine spinal anesthesia" }, { "field": "primaryOutcome", "quote": "The primary outcome was the postoperative pain score, measured using the Visual Analog Scale (VAS) at 4, 8, 12, 24, and 48 hours and at the first defecation postoperatively." }, { "field": "result", "quote": "The treatment group showed markedly lower VAS scores than those of the control group at 8, 12, 24, and 48 h, and at the first postoperative defecation time (P<0.05)." } ] }, { "id": "pmid:38601399", "pmid": "38601399", "doi": "10.7759/cureus.55929", "nctId": null, "pmcid": "PMC11004848", "title": "Manual Reduction of Strangulated Internal Hemorrhoids Using Sugar: A Case Report", "firstAuthor": "Fujimoto", "multipleAuthors": false, "journal": "Cureus", "year": 2024, "design": "case-series", "n": 1, "nField": "reported", "population": "51-year-old woman with internal hemorrhoids that prolapsed every time she had a bowel movement, for 20 years", "intervention": "applying sugar directly to the hemorrhoids to shrink them before manually pushing them back in", "comparator": "lidocaine gel and hydrocortisone ointment alone (tried first, did not work)", "primaryOutcome": "whether the prolapsed hemorrhoids could be manually pushed back in and pain improved", "result": "after sugar was applied, the swelling went down enough that the hemorrhoids could be pushed back in, and her pain improved", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether this works reliably for others.", "directness": "direct", "limitations": "only one patient was described, there was no comparison group, and this was an emergency strangulated hemorrhoid situation rather than everyday post-bowel-movement pain.", "followUp": "2 weeks", "plainFinding": "Sugar helped shrink severe prolapsed hemorrhoid.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38601399/", "sourceText": "Emergency hemorrhoidectomy for strangulated internal hemorrhoids should be avoided when possible. Manual reductions can relieve pain and prevent the need for emergency surgery. Herein, we present a 51-year-old female patient. Over the preceding 20 years, she experienced prolapsed internal hemorrhoids every time she defecated and had been performing manual reductions herself. Due to significant pain and difficulty during the manual reduction of the hemorrhoids, she was transported to the emergency room. Anal inspection revealed prolapsed internal hemorrhoids and partial congestion. After 10 minutes of applying Lidocaine Hydrochloride Jelly 2% and Escherichia coli culture suspension/hydrocortisone ointment, the manual reduction was still difficult. Based on previous reports of using sugar to reduce stomal prolapse, we applied sugar directly to the hemorrhoids. Ten minutes later, the number of prolapsed hemorrhoids decreased, and manual reduction was possible. After one day of hospitalization for bed rest, the patient was discharged once it was confirmed that there was no prolapse of the internal hemorrhoids and that her pain had improved. Two weeks later, a grade III internal hemorrhoid was observed, which had markedly reduced in size compared with the time of admission. Using sugar to reduce strangulated internal hemorrhoids manually can be useful due to its simplicity, minimal invasiveness, and cost-effectiveness.", "provenance": [ { "field": "population", "quote": "a 51-year-old female patient. Over the preceding 20 years, she experienced prolapsed internal hemorrhoids every time she defecated" }, { "field": "intervention", "quote": "we applied sugar directly to the hemorrhoids" }, { "field": "comparator", "quote": "After 10 minutes of applying Lidocaine Hydrochloride Jelly 2% and Escherichia coli culture suspension/hydrocortisone ointment, the manual reduction was still difficult." }, { "field": "primaryOutcome", "quote": "the manual reduction was still difficult" }, { "field": "result", "quote": "Ten minutes later, the number of prolapsed hemorrhoids decreased, and manual reduction was possible." }, { "field": "result", "quote": "the patient was discharged once it was confirmed that there was no prolapse of the internal hemorrhoids and that her pain had improved" }, { "field": "n", "quote": "we present a 51-year-old female patient" }, { "field": "followUp", "quote": "Two weeks later, a grade III internal hemorrhoid was observed, which had markedly reduced in size compared with the time of admission." } ] }, { "id": "pmid:38496090", "pmid": "38496090", "doi": "10.7759/cureus.54152", "nctId": null, "pmcid": "PMC10940957", "title": "Efficacy and Safety of Oral Euphorbia prostrata Tablet and Topical Cream in the Management of Hemorrhoids During Pregnancy: Results From a Prospective Multicenter Study", "firstAuthor": "Porwal", "multipleAuthors": true, "journal": "Cureus", "year": 2024, "design": "case-series", "n": 100, "nField": "reported", "population": "pregnant women with hemorrhoids", "intervention": "Euphorbia prostrata oral tablet and topical cream", "comparator": "none (single-arm, no comparison group)", "primaryOutcome": "reduction in hemorrhoid symptoms like bleeding, pain during defecation, itching, swelling", "result": "Significant reduction in pain at defecation and other symptoms over eight weeks, with no adverse events", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This was a single-arm study with no comparison group, so improvement cannot be confidently attributed to the treatment alone.", "directness": "indirect", "limitations": "Non-randomized, open-label, single-arm design without a control group to rule out natural improvement or placebo effect.", "followUp": "eight weeks", "plainFinding": "Less pain and bleeding over time.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38496090/", "sourceText": "This is a non-randomized, open-label, prospective single-arm interventional multicentric study conducted between 2021 and 2022 at three different centers situated in Pune, India. It was conducted to evaluate the efficacy and safety of the Sitcom® tablet (Euphorbia prostrata 100 mg) once daily and Sitcom® cream (Euphorbia prostrata 1%w/w) for 14 days in hemorrhoids during pregnancy. The endpoints were to assess hemorrhoidal symptoms relief during the follow-up periods (one, two, four, and eight weeks and 30 days postpartum), relapse of symptoms, improvement in the disease condition at week two and 30 days postpartum, and adverse events. A total of 100 patients (mean age 24.1 years) were included; the majority (71.0%) had mild per-rectal bleeding, 69.0% with mild itching and 46.0% with moderate pain during defecation. The mean score of per-rectal bleeding and pain at defecation showed a significant reduction at each visit (86.6% and 49.3% (two weeks), 95.3% and 59.9% (four weeks), and 100% and 77.6% (eight weeks)). The mean pain score at defecation, itching, exudates, and swelling showed a significant reduction of 77.6%, 96.9%, 100%, and 84.5% at eight weeks (p<0.001). After two weeks and post postpartum follow-up, >90% and 100% good to excellent overall improvement in the disease condition were noted, respectively. No adverse events in the mother or newborn were noted. This pivotal study underscores the potential of a combination therapy with Euphorbia prostrate 100 mg tablet and cream 1% as a potential solution for managing the distressing burden of hemorrhoids in pregnant women. Furthermore, these observations will empower clinicians in the judicious selection of the most suitable course of action for hemorrhoid management during pregnancy.", "provenance": [ { "field": "n", "quote": "A total of 100 patients (mean age 24.1 years) were included" }, { "field": "population", "quote": "hemorrhoids during pregnancy" }, { "field": "intervention", "quote": "Sitcom® tablet (Euphorbia prostrata 100 mg) once daily and Sitcom® cream (Euphorbia prostrata 1%w/w) for 14 days" }, { "field": "comparator", "quote": "non-randomized, open-label, prospective single-arm interventional multicentric study" }, { "field": "primaryOutcome", "quote": "to assess hemorrhoidal symptoms relief during the follow-up periods" }, { "field": "result", "quote": "The mean pain score at defecation, itching, exudates, and swelling showed a significant reduction of 77.6%, 96.9%, 100%, and 84.5% at eight weeks (p<0.001)." } ] }, { "id": "pmid:38463771", "pmid": "38463771", "doi": "10.1016/j.heliyon.2024.e27215", "nctId": null, "pmcid": "PMC10923721", "title": "The efficacy of topical sodium pentaborate formulation on hemorrhoid disease: A randomized, double-blind, placebo-controlled trial", "firstAuthor": "Şahin", "multipleAuthors": true, "journal": "Heliyon", "year": 2024, "design": "rct", "n": 206, "nField": "reported", "population": "patients with grade 1, 2, and 3 hemorrhoid disease", "intervention": "topical gel containing sodium pentaborate pentahydrate 3%", "comparator": "placebo gel", "primaryOutcome": "hemorrhoid symptom severity (including pain, itching, bleeding) and anoscopy findings", "result": "the sodium pentaborate gel group had less resting pain, less pain during defecation, less itching, less bleeding, and lower hemorrhoid degree than the placebo group", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized placebo-controlled trial with a reasonable number of patients, but it only looked at hemorrhoids specifically and lasted just four weeks.", "directness": "indirect", "limitations": "abstract does not report dropout rates, blinding success, or longer-term follow-up beyond the 4-week treatment period", "followUp": "four weeks", "plainFinding": "Less pain and bleeding with gel.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38463771/", "sourceText": "BACKGROUND: The topical application of boron has been significantly associated with intensifying wound healing. Using 3% boric acid in deep wounds significantly contributes to wound healing and reduces the duration of hospitalization in the intensive care. The objective of this study was to assess the therapeutic impact of a topical gel containing sodium pentaborate pentahydrate on the management of wounds resulting from grade 1 to 3 hemorrhoids. METHODS: In this randomized double-blind placebo-controlled trial, we applied a topical gel consisting of sodium pentaborate pentahydrate 3% on 206 eligible patients with the diagnosis of grade 1, 2, and 3 hemorrhoid diseases. Then patients were randomly allocated to two groups of sodium pentaborate pentahydrate or placebo gel with a ratio of 1:1 and received the allocated gel for four weeks. Patient hemorrhoid symptoms severity, hemorrhoid degree, and anoscopy findings were compared before and after the trial. RESULTS: Before the intervention, symptom severity (p > 0.05) and anoscopy findings (p = 0.815) were similar between the two groups. Subsequent to the intervention, a majority of patients in the intervention group experienced a reduction in anal itching compared to the placebo group [adjusted mean difference (aMD) 95% CI: -1.98 (-2.2 to -1.8), p = 0.007]. Moreover, resting pain [aMD (95% CI): -1.37 (-1.6 to -1.1), p = 0.015], pain during defecation [aMD (95% CI): -2.19 (-2.4 to -2.0), p = 0.005], feeling a lump in the anus (aMD (95% CI): -0.71 (-1.2 to -0.2), p = 0.011), bleeding during defecation (41.7% vs. 66.9%, p = 0.027), and hemorrhoid degree (p < 0.001) in the intervention group was less than the placebo group. CONCLUSION: Our findings indicate the effectiveness of the study gel on hemorrhoid symptoms and anoscopy findings in patients.", "provenance": [ { "field": "n", "quote": "we applied a topical gel consisting of sodium pentaborate pentahydrate 3% on 206 eligible patients" }, { "field": "population", "quote": "patients with the diagnosis of grade 1, 2, and 3 hemorrhoid diseases" }, { "field": "intervention", "quote": "topical gel consisting of sodium pentaborate pentahydrate 3%" }, { "field": "comparator", "quote": "placebo gel" }, { "field": "primaryOutcome", "quote": "Patient hemorrhoid symptoms severity, hemorrhoid degree, and anoscopy findings were compared before and after the trial." }, { "field": "result", "quote": "resting pain [aMD (95% CI): -1.37 (-1.6 to -1.1), p = 0.015], pain during defecation [aMD (95% CI): -2.19 (-2.4 to -2.0), p = 0.005], feeling a lump in the anus (aMD (95% CI): -0.71 (-1.2 to -0.2), p = 0.011), bleeding during defecation (41.7% vs. 66.9%, p = 0.027), and hemorrhoid degree (p < 0.001) in the intervention group was less than the placebo group" } ] }, { "id": "pmid:38357940", "pmid": "38357940", "doi": "10.14309/ctg.0000000000000687", "nctId": null, "pmcid": "PMC11124638", "title": "Clinical Outcomes Before and After Prucalopride Treatment: An Observational Study in Patients With Chronic Idiopathic Constipation in the United States", "firstAuthor": "Lembo", "multipleAuthors": true, "journal": "Clin Transl Gastroenterol", "year": 2024, "design": "retrospective", "n": 690, "nField": "reported", "population": "adults with chronic idiopathic constipation", "intervention": "prucalopride treatment", "comparator": "same patients' symptoms before treatment", "primaryOutcome": "constipation-related symptoms and complications, including anal fissure, hemorrhoids, and rectal bleeding", "result": "decreased proportions of patients with abdominal pain, abdominal distension, nausea, intestinal obstruction, hemorrhoids, and rectal bleeding after starting prucalopride, but no improvement in incomplete defecation", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a before-and-after claims study with no control group, so other reasons for the changes can't be ruled out.", "directness": "indirect", "limitations": "Retrospective design using insurance claims data; no comparator group; relies on diagnosis codes rather than direct symptom reporting.", "followUp": "6 months", "plainFinding": "Fewer hemorrhoids and bleeding with treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38357940/", "sourceText": "INTRODUCTION: This real-world US-based claims study compared constipation-related symptoms and complications 6 months before and after prucalopride initiation in adults with chronic idiopathic constipation (CIC). METHODS: This observational, retrospective cohort analysis used the IBM MarketScan Commercial Claims and Encounters Database and the Medicare Supplemental Database (January 2015-June 2020). Prucalopride-treated patients (≥18 years old) who had ≥1 constipation-related International Classification of Diseases, Tenth Revision, Clinical Modification ( ICD-10-CM ) diagnosis code during the baseline or study period were included. The proportions of patients with constipation-related symptoms (abdominal pain, abdominal distension [gaseous], incomplete defecation, and nausea) and constipation-related complications (anal fissure and fistula, intestinal obstruction, rectal prolapse, hemorrhoids, perianal venous thrombosis, perianal/perirectal abscess, and rectal bleeding) were examined. Constipation-related symptoms and complications were identified using ICD-10-CM , ICD-10 - Procedure Coding System , or Current Procedural Terminology codes. Data were stratified by age (overall, 18-64 years, and ≥65 years). RESULTS: This study included 690 patients: The mean (SD) patient age was 48.0 (14.7) years, and 87.5% were women. The proportions of patients overall with constipation-related symptoms decreased 6 months after prucalopride initiation (abdominal pain [50.4% vs 33.3%, P < 0.001]; abdominal distension [gaseous] [23.9% vs 13.3%, P < 0.001]; and nausea [22.6% vs 17.7%, P < 0.01]; no improvements observed for incomplete defecation). Similarly, the proportions of patients overall with constipation-related complications decreased 6 months after prucalopride initiation (intestinal obstruction [4.9% vs 2.0%, P < 0.001]; hemorrhoids [10.7% vs 7.0%, P < 0.05]; and rectal bleeding [4.1% vs 1.7%, P < 0.05]). DISCUSSION: This study suggests that prucalopride may be associated with improved constipation-related symptoms and complications 6 months after treatment initiation.", "provenance": [ { "field": "population", "quote": "adults with chronic idiopathic constipation (CIC)" }, { "field": "intervention", "quote": "prucalopride initiation" }, { "field": "comparator", "quote": "6 months before and after prucalopride initiation" }, { "field": "primaryOutcome", "quote": "constipation-related symptoms (abdominal pain, abdominal distension [gaseous], incomplete defecation, and nausea) and constipation-related complications (anal fissure and fistula, intestinal obstruction, rectal prolapse, hemorrhoids, perianal venous thrombosis, perianal/perirectal abscess, and rectal bleeding)" }, { "field": "result", "quote": "hemorrhoids [10.7% vs 7.0%, P < 0.05]; and rectal bleeding [4.1% vs 1.7%, P < 0.05]" }, { "field": "n", "quote": "This study included 690 patients" } ] }, { "id": "pmid:38318578", "pmid": "38318578", "doi": "10.7759/cureus.51612", "nctId": null, "pmcid": "PMC10840063", "title": "Prevalence of Hemorrhoids and the Associated Risk Factors Among the General Adult Population in Makkah, Saudi Arabia", "firstAuthor": "Al-Masoudi", "multipleAuthors": true, "journal": "Cureus", "year": 2024, "design": "registry", "n": 400, "nField": "reported", "population": "general adult population in Makkah, Saudi Arabia", "intervention": "not applicable (observational survey on hemorrhoid prevalence and risk factors)", "comparator": "", "primaryOutcome": "prevalence of hemorrhoids and associated symptoms", "result": "16% reported diagnosed hemorrhoids; among those, 76.2% had pain with defecation, 63.5% discomfort, and 55.6% swelling", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a self-reported online survey without clinical confirmation, so it can only suggest associations, not prove causes.", "directness": "direct", "limitations": "Self-reported diagnosis and symptoms via online questionnaire; cross-sectional design cannot establish cause and effect.", "followUp": "", "plainFinding": "Hemorrhoids often cause pain after pooping.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38318578/", "sourceText": "INTRODUCTION: Hemorrhoidal disease is one of the most common benign anorectal conditions. It is described as the symptomatic enlargement and abnormally downward displacement of anal cushions. Its effect on the quality of life of patients is significantly negative and is considered one of the leading causes of lower gastrointestinal bleeding. However, studies that determine the prevalence of and risk factors associated with hemorrhoidal disease are limited. Therefore, this study aimed to evaluate the prevalence of and risk factors for hemorrhoids among the general adult population in the city of Makkah, Saudi Arabia. METHODS: A descriptive cross-sectional study was conducted with a structured, prevalidated questionnaire and was used with some modifications. It was created using Google Forms (Google, Mountain View, CA) and distributed via social media platforms in Arabic along with the English version of each question. All data from the returned survey were encrypted. IBM SPSS Statistics, version 21 (IBM Corp., Armonk, NY) was used to analyze the data. RESULTS: A total of 400 participants completed the study questionnaire. Regarding the prevalence of hemorrhoids among the general population in Makkah, 64 participants (16%) reported that they were diagnosed with hemorrhoid disorder. The most reported symptoms among participants with hemorrhoids were pain with defecation (76.2%), discomfort (63.5%), and swelling (55.6%). CONCLUSION: Hemorrhoids are one of the most common complaints among surgical patients and are more prevalent in men. The risk of hemorrhoids is significantly higher in married women with a history of pregnancy, who are overweight, and who consume low-fiber diets. It is better to practice close follow-up of patients with hemorrhoids to avoid complications, particularly, patients with chronic diseases who are at a high risk.", "provenance": [ { "field": "n", "quote": "A total of 400 participants completed the study questionnaire." }, { "field": "population", "quote": "general adult population in the city of Makkah, Saudi Arabia" }, { "field": "primaryOutcome", "quote": "evaluate the prevalence of and risk factors for hemorrhoids among the general adult population" }, { "field": "result", "quote": "64 participants (16%) reported that they were diagnosed with hemorrhoid disorder. The most reported symptoms among participants with hemorrhoids were pain with defecation (76.2%), discomfort (63.5%), and swelling (55.6%)." }, { "field": "intervention", "quote": "A descriptive cross-sectional study was conducted with a structured, prevalidated questionnaire" } ] }, { "id": "pmid:38316476", "pmid": "38316476", "doi": "10.31128/AJGP/05-23-6843", "nctId": null, "pmcid": null, "title": "Anal fissures: An update on treatment options", "firstAuthor": "Lyle", "multipleAuthors": true, "journal": "Aust J Gen Pract", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal fissures (a tear near the anus)", "intervention": "treatments for anal fissure, including fibre, sitz baths, topical nitrates, calcium channel blockers, botulinum toxin, or surgery", "comparator": "different treatment steps compared to each other (no single control group)", "primaryOutcome": "healing or resolution of the anal fissure and pain with bowel movements", "result": "this is a review describing current treatment options rather than reporting a specific trial result", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a narrative review summarizing guidelines and other studies rather than presenting new controlled data.", "directness": "direct", "limitations": "no original data, patient numbers, or outcome statistics are given; it only describes general management approaches.", "followUp": "", "plainFinding": "Pain is from an anal tear.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38316476/", "sourceText": "BACKGROUND: Anal fissure (AF) is the second most common anorectal complaint in healthcare settings. The presentation might be acute or chronic, characterised by severe pain with defaecation that persists for one to two hours. Non-surgical and surgical interventions are available based on the severity and persistence of the fissure. OBJECTIVE: The aim of this article is to review the pathophysiology, clinical presentation and management of AF under current guidelines. DISCUSSION: The aetiology of AF is unclear, although it is commonly associated with local trauma or associated chronic conditions. Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths. Addition of topical nitrates, topical calcium channel blockers or botulinum toxin injection is indicated with failure of conservative treatment or at medical discretion. Surgical options are considered if AF persists despite treatment. Most present as hypertonic, but special consideration is needed for hypotonic or secondary presentations.", "provenance": [ { "field": "population", "quote": "Anal fissure (AF) is the second most common anorectal complaint in healthcare settings." }, { "field": "intervention", "quote": "Non-surgical and surgical interventions are available based on the severity and persistence of the fissure." }, { "field": "intervention", "quote": "Addition of topical nitrates, topical calcium channel blockers or botulinum toxin injection is indicated with failure of conservative treatment or at medical discretion." }, { "field": "comparator", "quote": "Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths." }, { "field": "primaryOutcome", "quote": "characterised by severe pain with defaecation that persists for one to two hours" }, { "field": "result", "quote": "The aim of this article is to review the pathophysiology, clinical presentation and management of AF under current guidelines." } ] }, { "id": "pmid:38294561", "pmid": "38294561", "doi": "10.1007/s10151-023-02881-4", "nctId": null, "pmcid": "PMC10830612", "title": "Liposomal bupivacaine versus conventional anesthetic or placebo for hemorrhoidectomy: a systematic review and meta-analysis", "firstAuthor": "Solis-Pazmino", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2024, "design": "meta-analysis", "n": 338, "nField": "reported", "population": "adults who had surgery to remove hemorrhoids (hemorrhoidectomy)", "intervention": "a long-acting local anesthetic (liposomal bupivacaine) given after hemorrhoid surgery", "comparator": "regular bupivacaine anesthetic or placebo", "primaryOutcome": "pain levels and pain with bowel movements after hemorrhoid surgery", "result": "patients given the long-acting anesthetic had lower pain scores at 72 hours, needed opioids later, and reported less pain during bowel movements than those given regular anesthetic or placebo", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it pools only three small randomized trials, so the overall evidence is suggestive but not very robust.", "directness": "indirect", "limitations": "Only three trials included, relatively small total sample, and all patients had undergone hemorrhoid surgery rather than having ordinary pain after a bowel movement without surgery.", "followUp": "72 h", "plainFinding": "Less post-surgery pain with special anesthetic.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38294561/", "sourceText": "BACKGROUND: Liposome bupivacaine (LB) is a long-acting anesthetic to enhance postoperative analgesia. Studies evaluating the efficacy of the LB against an active comparator (bupivacaine or placebo) on acute postoperative pain control in hemorrhoidectomy procedures are few and heterogeneous. Therefore, we performed a systematic review and meta-analysis comparing LB's analgesic efficacy and side effects to conventional/placebo anesthetic in hemorrhoidectomy patients. METHODS: We performed a systematic review and meta-analysis of randomised controlled trials investigating the use of LB after haemorrhoidectomy. We searched the literature published from the time of inception of the datasets to August 19, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus. RESULTS: A total of 338 patients who underwent a hemorrhoidectomy procedure enrolled in three randomized clinical trials were included. The overall mean age was 45.84 years (SD ± 11.43), and there was a male predominance (53.55% male). In total 194 patients (52.2%) received LB and 144 (47.8%) received either bupivacaine or placebo. Pain scores at 72 h in the LB (199, 266, and 300 mg) were significantly lower than in the bupivacaine HCl group (p = 0.002). Compared to the bupivacaine/placebo group, the time to first use of opioids in the LB group was significantly longer at LB 199 mg (11 h vs. 9 h), LB 266 mg (19 h vs. 9 h), and LB 300 mg (19 h vs. 8 h) (p < 0.05). Moreover, compared to the bupivacaine/epinephrine group, it was significantly lower in the LB 266 mg group (3.7 vs. 10.2 mg) and at LB 300 mg (13 vs. 33 mg) (p < 0.05). Finally, regarding adverse effects, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups (OR 2.60, 95% CI 1.31-5.16). CONCLUSIONS: Comparing LB to conventional anesthetic/placebo anesthetic for hemorrhoidectomy, we found a statistically significant reduction in pain through 72 h, decreased opioid requirements, and delayed time to first opioid use. Moreover, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups.", "provenance": [ { "field": "n", "quote": "A total of 338 patients who underwent a hemorrhoidectomy procedure enrolled in three randomized clinical trials were included." }, { "field": "population", "quote": "patients who underwent a hemorrhoidectomy procedure" }, { "field": "intervention", "quote": "Liposome bupivacaine (LB) is a long-acting anesthetic to enhance postoperative analgesia." }, { "field": "comparator", "quote": "received either bupivacaine or placebo" }, { "field": "primaryOutcome", "quote": "comparing LB's analgesic efficacy and side effects to conventional/placebo anesthetic in hemorrhoidectomy patients" }, { "field": "result", "quote": "Pain scores at 72 h in the LB (199, 266, and 300 mg) were significantly lower than in the bupivacaine HCl group (p = 0.002)." }, { "field": "result", "quote": "the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups (OR 2.60, 95% CI 1.31-5.16)." } ] }, { "id": "pmid:38157069", "pmid": "38157069", "doi": "10.1007/s00104-023-02010-9", "nctId": null, "pmcid": "PMC11649745", "title": "Comparison between stapled hemorrhoidopexy and harmonic scalpel hemorrhoidectomy in the management of third- and fourth-degree piles: a randomized clinical trial", "firstAuthor": "Nada", "multipleAuthors": true, "journal": "Chirurgie (Heidelb)", "year": 2024, "design": "rct", "n": 70, "nField": "reported", "population": "adults with third- and fourth-degree hemorrhoids (piles) undergoing surgery", "intervention": "harmonic scalpel hemorrhoidectomy (HSH)", "comparator": "stapled hemorrhoidopexy (SH)", "primaryOutcome": "postoperative pain, patient satisfaction, wound infection, bleeding, incontinence and recurrence within 1 year", "result": "HSH took longer initially but had less bleeding, fewer recurrences, and higher satisfaction after 2 weeks, while SH caused less pain in the first 2 weeks but more lingering mild pain, bleeding, and recurrence", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "It was a randomized trial but was single-center, single-blind, and relatively small, which limits confidence in the results.", "directness": "indirect", "limitations": "Single-center, single-blind design with modest sample size and some subjective outcome reporting (e.g., reclassification of incontinence cases).", "followUp": "1 year", "plainFinding": "Harmonic scalpel surgery had fewer recurrences.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38157069/", "sourceText": "BACKGROUND: This study compared the results of stapled hemorrhoidopexy (SH) and harmonic scalpel hemorrhoidectomy (HSH) in the management of grade III and grade IV piles regarding the time of the procedure, postoperative pain, patient satisfaction, wound infection, bleeding, incontinence, and recurrence within 1 year. PATIENTS AND METHODS: This was a single-blind, prospective, randomized, controlled, single-center trial conducted from January to December 2022 that included 50 (68.75%) male and 20 (31.25%) female patients with third- and fourth-degree piles. RESULTS: The patients were divided into two groups of 35 patients each. Group I underwent SH and group II underwent HSH. The mean age of group I was 42.94 years and of group II, 42.20 years. The mean time of the procedure was 24.42 min ± 2.367 for SH and 31.48 min ± 2.21 for HSH. Postoperative pain in group I was lower than in group II during the first 2 weeks, but there was persistent mild pain in most patients in group I at the 2‑week follow-up. In group II there was significant improvement in pain after 2 weeks, with higher patient satisfaction. Wound infection was detected in 3 (5%) patients in group I and no patients in group II (p = 0.077). Postoperative bleeding occurred in 4 (11.4%) patients in group I in the form of spotting after defecation only during the first postoperative month; no bleeding was detected in group II (p = 0.039). There were 3 (15%) cases of flatus incontinence but after taking a detailed history these were found to be cases of urgency to defecate rather than incontinence. There were 7 (20%) cases of recurrence at the 1‑year follow-up in group I and 1 (2.9%) case in group II (p = 0.024). CONCLUSION: Compared with SH, HSH was safer, easier, and associated with a lower incidence of recurrence after 1 year and with higher patient satisfaction.", "provenance": [ { "field": "population", "quote": "included 50 (68.75%) male and 20 (31.25%) female patients with third- and fourth-degree piles" }, { "field": "intervention", "quote": "harmonic scalpel hemorrhoidectomy (HSH)" }, { "field": "comparator", "quote": "stapled hemorrhoidopexy (SH)" }, { "field": "primaryOutcome", "quote": "postoperative pain, patient satisfaction, wound infection, bleeding, incontinence, and recurrence within 1 year" }, { "field": "result", "quote": "Postoperative pain in group I was lower than in group II during the first 2 weeks, but there was persistent mild pain in most patients in group I at the 2‑week follow-up. In group II there was significant improvement in pain after 2 weeks, with higher patient satisfaction." }, { "field": "result", "quote": "There were 7 (20%) cases of recurrence at the 1‑year follow-up in group I and 1 (2.9%) case in group II (p = 0.024)." }, { "field": "n", "quote": "The patients were divided into two groups of 35 patients each." } ] }, { "id": "pmid:38110281", "pmid": "38110281", "doi": "10.3760/cma.j.cn441530-20230720-00008", "nctId": null, "pmcid": null, "title": "[Application of a new-type of defecator in the treatment of rectal fecal impaction]", "firstAuthor": "Yang", "multipleAuthors": true, "journal": "Zhonghua Wei Chang Wai Ke Za Zhi", "year": 2023, "design": "case-series", "n": 42, "nField": "reported", "population": "adults aged 18 to 80 with rectal fecal impaction confirmed by CT scan", "intervention": "a new manual defecator device used to break up and remove impacted stool", "comparator": "none; single-group treatment with no control group", "primaryOutcome": "how well the device cleared the impaction and how much pain and complications occurred during use", "result": "all patients were successfully treated, but nearly half had moderate to severe anal pain and one had anal fissure bleeding", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It's a small retrospective case series with no comparison group, so it can't show whether the device is better or worse than other methods.", "directness": "indirect", "limitations": "Retrospective, single-center, no control group, and focused on a specific procedure for fecal impaction rather than everyday pain after a normal bowel movement.", "followUp": "", "plainFinding": "Procedure often caused anal pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38110281/", "sourceText": "Objective: This study aimed to investigate the viability and safety of a novel defecator in managing rectal fecal impaction. Methods: In a descriptive case series, this new defecator was administered to constipated individuals among the ages of 18 and 80 years who met the diagnostic criteria for rectal fecal impaction and were identified with acute rectal fecal impaction through CT scans. The contraindications for this defecator included: (1) Anal stenosis, acute intestinal obstruction, and intestinal perforation; (2) Concomitant rectal malignant tumors; (3) Coagulation dysfunction, low platelet counts, gastrointestinal bleeding, or other bleeding risks; (4) Patients with severe underlying conditions affecting the heart, brain, lungs, or other systems; (5) Individuals with mental health disorders. Based on these criteria, clinical data from 42 patients with rectal fecal impaction who underwent treatment with the new defecator at Deyang People's Hospital between July 2020 and April 2023 were retrospectively analyzed.The defecator comprises three components: a head, a spiral rod, and a handle, constructed from disposable stainless steel wire. The treatment procedure involves the following steps: The patient assumes a flexed, supine position on their left side with their buttocks slightly protruding from the bed's edge. A transparent sealing bag is affixed to the buttocks, centered around the anus. With gloved hands inserted through the bag's entrance, a cotton ball soaked in liquid paraffin lubricates the anal canal and the head of the defecator's spiral rod. The defecator is then slowly rotated and inserted into the anus, with careful attention to any changes in resistance. Once the spiral rod is fully inserted, the patient is instructed to inhale and defecate while the defecator is slowly withdrawn, carrying the dislodged fecal matter, and depositing it into the sealed bag. This operation is repeated 2 to 3 times, followed by the injection of either 100 ml of 36°C normal saline or 60 ml of liquid paraffin into the rectum. After a 5 to 8-minute wait, the patient assumes a squatting position to expel any remaining feces from the rectum. The study assessed the operation time, single treatment success rate, pain levels during treatment, and the occurrence of complications. Results: All 42 patients successfully underwent treatment with the new defecator device, achieving a single treatment success rate of 100%. The average operation time was 11.0 minutes (range: 9.0 to 13.3 minutes). During treatment, 20 cases (47.6%) reported moderate to severe anal pain, with 1 case (2.4%) experiencing anal fissure bleeding, and 6 cases (14.3%) reporting discomfort such as palpitations and sweating. No serious complications, including rectal perforation, were observed in any case. Conclusion: The new defecator device demonstrates ease of use and safety, making it a feasible option for treating acute rectal fecal impaction.", "provenance": [ { "field": "n", "quote": "clinical data from 42 patients with rectal fecal impaction who underwent treatment with the new defecator at Deyang People's Hospital between July 2020 and April 2023 were retrospectively analyzed." }, { "field": "population", "quote": "constipated individuals among the ages of 18 and 80 years who met the diagnostic criteria for rectal fecal impaction and were identified with acute rectal fecal impaction through CT scans" }, { "field": "intervention", "quote": "this new defecator was administered to constipated individuals" }, { "field": "comparator", "quote": "In a descriptive case series" }, { "field": "primaryOutcome", "quote": "The study assessed the operation time, single treatment success rate, pain levels during treatment, and the occurrence of complications." }, { "field": "result", "quote": "All 42 patients successfully underwent treatment with the new defecator device, achieving a single treatment success rate of 100%." }, { "field": "result", "quote": "During treatment, 20 cases (47.6%) reported moderate to severe anal pain, with 1 case (2.4%) experiencing anal fissure bleeding, and 6 cases (14.3%) reporting discomfort such as palpitations and sweating." } ] }, { "id": "pmid:38104065", "pmid": "38104065", "doi": "10.1186/s12876-023-03062-1", "nctId": null, "pmcid": "PMC10725019", "title": "The comparison of an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) versus circular stapled hemorrhoidopexy (CSH) in patients with grade IV hemorrhoids: a retrospective cohort study", "firstAuthor": "He", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2023, "design": "retrospective", "n": 222, "nField": "reported", "population": "Patients with grade IV hemorrhoids undergoing surgery", "intervention": "C-shaped partial stapled hemorrhoidopexy (C-PSH)", "comparator": "Circular stapled hemorrhoidopexy (CSH)", "primaryOutcome": "Five-year hemorrhoid recurrence rate", "result": "Recurrence rates were similar between groups, but C-PSH patients had less pain and fewer complications after surgery", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This was a retrospective, single-center study without randomization, which limits how confident we can be in its results.", "directness": "indirect", "limitations": "Retrospective design, single center, not randomized", "followUp": "five-year", "plainFinding": "Less pain after first bowel movement", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38104065/", "sourceText": "OBJECTIVES: The objectives of this study were to present an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) in the treatment of grade IV hemorrhoids and to assess long-term outcomes of this technique compared with circular stapled hemorrhoidopexy (CSH). METHODS: Conventional CSH kits combined with an intestinal spatula were used for performing C-PSH. A total of 256 patients with grade IV hemorrhoids referred to Hangzhou Third People's Hospital between January 2016 and June 2017 were obtained: 122 (47.7%) with C-PSH, and 134 (52.3%) with CSH. After propensity score matching, 222 patients (111 in C-PSH group and 111 in CSH group) were ultimately analyzed. The primary outcome was the five-year recurrence rate of hemorrhoids. Secondary outcomes included intraoperative outcomes, postoperative outcomes and complications. RESULTS: The operative time in the C-PSH group was slightly longer than that in the CSH group (p < 0.01). The vertical length of rectal mucosa specimen in the C-PSH group was shorter than that in the CSH group (p < 0.01). Compared with the CSH group, fecal urgency incidence and numeric rating scale (NRS) score at first defecation were lower in the C-PSH group (p < 0.05). Major complication rate in the CSH group was higher than that in the C-PSH group (p = 0.03). Five-year recurrence rate between the C-PSH group and CSH group was comparable (p > 0.05). Multivariate Cox regression analysis revealed that constipation was an independent prognostic factor for hemorrhoidal recurrence. CONCLUSIONS: The accessible C-PSH seems to be a safe and effective technique in managing grade IV hemorrhoids. It has advantages in alleviating postoperative pain at first defecation, fecal urgency and major complications compared with CSH. It could be an alternative technique in the treatment of grade IV hemorrhoids.", "provenance": [ { "field": "n", "quote": "222 patients (111 in C-PSH group and 111 in CSH group) were ultimately analyzed" }, { "field": "population", "quote": "patients with grade IV hemorrhoids" }, { "field": "intervention", "quote": "accessible C-shaped partial stapled hemorrhoidopexy (C-PSH)" }, { "field": "comparator", "quote": "circular stapled hemorrhoidopexy (CSH)" }, { "field": "primaryOutcome", "quote": "The primary outcome was the five-year recurrence rate of hemorrhoids." }, { "field": "result", "quote": "Five-year recurrence rate between the C-PSH group and CSH group was comparable (p > 0.05)." }, { "field": "result", "quote": "fecal urgency incidence and numeric rating scale (NRS) score at first defecation were lower in the C-PSH group (p < 0.05)" }, { "field": "result", "quote": "Major complication rate in the CSH group was higher than that in the C-PSH group (p = 0.03)." } ] }, { "id": "pmid:37927595", "pmid": "37927595", "doi": "10.3389/fphar.2023.1270339", "nctId": null, "pmcid": "PMC10620711", "title": "Traditional Chinese Medicine in the treatment of hemorrhoids-a review of preparations used and their mechanism of action", "firstAuthor": "Zhou", "multipleAuthors": true, "journal": "Front Pharmacol", "year": 2023, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids", "intervention": "Traditional Chinese Medicine preparations", "comparator": "not reported (review discusses surgery and TCM mechanisms generally)", "primaryOutcome": "reducing hemorrhoid symptoms like pain, bleeding, and improving quality of life", "result": "the abstract does not report a quantified outcome; it states TCM has an advantage in reducing pain and symptoms based on reviewed mechanisms", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a narrative review summarizing mechanisms rather than testing treatment effectiveness with data.", "directness": "indirect", "limitations": "No original data, no comparator outcomes, no quantified results, and it covers general hemorrhoid treatment rather than specifically post-defecation anal pain.", "followUp": "", "plainFinding": "Review of TCM mechanisms, no outcome data.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37927595/", "sourceText": "Hemorrhoids are a proctological disease primarily characterized by bleeding, prolapse, edema, and pain, severely affecting the quality of life. Surgery is an effective treatment for hemorrhoids, but the cost is relatively high, and complications such as difficulty in defecation, persistent pain, and heavy bleeding may occur postoperatively. Traditional Chinese Medicine (TCM) has a distinctive advantage in alleviating the clinical symptoms of hemorrhoid patients, reducing pain, and improving the quality of life. However, there are few summary literature about the mechanism of TCM in the prevention and treatment of hemorrhoids. Based on the etiology of hemorrhoids in both traditional Chinese and Western medicine, this paper reviews the recent research on the mechanism of TCM in the treatment of hemorrhoids, hoping to provide a basis for the better application of TCM in clinical and experimental research.", "provenance": [ { "field": "population", "quote": "Hemorrhoids are a proctological disease primarily characterized by bleeding, prolapse, edema, and pain" }, { "field": "intervention", "quote": "Traditional Chinese Medicine (TCM) has a distinctive advantage in alleviating the clinical symptoms of hemorrhoid patients" }, { "field": "comparator", "quote": "Surgery is an effective treatment for hemorrhoids, but the cost is relatively high, and complications such as difficulty in defecation, persistent pain, and heavy bleeding may occur postoperatively" }, { "field": "primaryOutcome", "quote": "reducing pain, and improving the quality of life" }, { "field": "result", "quote": "this paper reviews the recent research on the mechanism of TCM in the treatment of hemorrhoids, hoping to provide a basis for the better application of TCM in clinical and experimental research" } ] }, { "id": "pmid:37885500", "pmid": "37885500", "doi": "10.7759/cureus.45919", "nctId": null, "pmcid": "PMC10599269", "title": "Prevalence of Hemorrhoids and Their Risk Factors Among the Adult Population in Jazan, Saudi Arabia", "firstAuthor": "Oberi", "multipleAuthors": true, "journal": "Cureus", "year": 2023, "design": "retrospective", "n": 361, "nField": "reported", "population": "adults in the Jazan region of Saudi Arabia", "intervention": "no treatment tested; survey of hemorrhoid symptoms and risk factors", "comparator": "no comparison group, cross-sectional survey of the general population", "primaryOutcome": "how common hemorrhoid symptoms were and what risk factors were linked to them", "result": "59% reported at least one hemorrhoid symptom, and lack of exercise, prolonged sitting, high-fat diet, family history and constipation were linked to more symptoms", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This was a self-reported survey without physician confirmation in most cases, so recall and reporting bias are likely.", "directness": "indirect", "limitations": "Self-administered questionnaire, only 34% had an actual physician diagnosis, cross-sectional design cannot show cause and effect.", "followUp": "", "plainFinding": "Hemorrhoid symptoms very common, tied to lifestyle.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37885500/", "sourceText": "BACKGROUND: Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. They can be either internal, external, or internoexternal, according to their position in relation to the dentate line. They can cause significant financial burdens and personal discomfort. However, the typical symptoms of hemorrhoids include bleeding, pain, skin irritation, fecal leakage, prolapse, mucus secretion, and developing a thrombosed hernia. Nonetheless, research has shown that individuals with and without hemorrhoids equally report these symptoms. This study aims to investigate the prevalence of hemorrhoids and their risk factors among adult subjects in Jazan, Saudi Arabia. METHODS: This investigation was a cross-sectional study targeting adults diagnosed with hemorrhoids in the Jazan region. Data collection was performed via a self-administered questionnaire to measure sociodemographic data of the participants, lifestyle factors associated with hemorrhoids, clinical presentations of the disease, and Rome IV criteria for diagnosis of functional constipation. The chi-squared test was used to assess the frequency of hemorrhoid symptoms according to the participants' sociodemographic and lifestyle characteristics. RESULTS: In the current study, which recruited 361 participants, 59% (216 individuals) reported experiencing at least one symptom of hemorrhoids. The majority of the sample were females (60%), Saudis (96%), and living in urban areas (59%) and had a university education (77.3%). The most common risk factors identified were lack of regular physical activity (83%), prolonged sitting during office work (51%), and consuming food with saturated fat (50%). A total of 44% (159 participants) had a family history of hemorrhoids, and 40% reported suffering from constipation three times or more per week. Only 34% (123 participants) had been diagnosed with hemorrhoids by a physician. Interestingly, the majority of participants (57%) preferred using home remedies instead of seeking medical care from a healthcare professional. When assessing factors associated with experiencing a minimum of six hemorrhoid symptoms per month, age, lifestyle factors, family history of hemorrhoids, and defecation practices were found to be significantly correlated with a higher occurrence of symptoms (with a p-value of less than 0.05). CONCLUSION: The current study identified a high prevalence of hemorrhoid symptoms and their risk factors among the adult population in the Jazan region of Saudi Arabia. The findings suggest a need to increase the awareness of the public about hemorrhoids risk factors and the importance of seeking healthcare at an early stage of the disease.", "provenance": [ { "field": "n", "quote": "which recruited 361 participants" }, { "field": "population", "quote": "adult subjects in Jazan, Saudi Arabia" }, { "field": "intervention", "quote": "This study aims to investigate the prevalence of hemorrhoids and their risk factors among adult subjects in Jazan, Saudi Arabia." }, { "field": "comparator", "quote": "This investigation was a cross-sectional study targeting adults diagnosed with hemorrhoids in the Jazan region." }, { "field": "primaryOutcome", "quote": "investigate the prevalence of hemorrhoids and their risk factors among adult subjects in Jazan, Saudi Arabia" }, { "field": "result", "quote": "59% (216 individuals) reported experiencing at least one symptom of hemorrhoids" }, { "field": "result", "quote": "The most common risk factors identified were lack of regular physical activity (83%), prolonged sitting during office work (51%), and consuming food with saturated fat (50%)" } ] }, { "id": "pmid:37848640", "pmid": "37848640", "doi": "10.1007/s10151-023-02863-6", "nctId": null, "pmcid": null, "title": "Mid-term outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids", "firstAuthor": "Tsunoda", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2023, "design": "retrospective", "n": null, "nField": "not-reported", "population": "patients with grade III hemorrhoids", "intervention": "ALTA sclerotherapy combined with rectal mucopexy (AM surgery)", "comparator": "none reported (no comparison group)", "primaryOutcome": "postoperative pain scores, complication rates, success rates, and patient satisfaction", "result": "low pain scores, few complications, high success rates and high satisfaction after treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a retrospective single-center study without a comparison group, so it can't prove the treatment caused the improvement.", "directness": "indirect", "limitations": "retrospective analysis of prospectively collected data, single institution, no control group mentioned", "followUp": "one, three, and five years", "plainFinding": "Low pain, good hemorrhoid treatment success.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37848640/", "sourceText": "BACKGROUND: Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for the treatment of internal hemorrhoids. ALTA therapy with rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study investigated the midterm outcomes of AM surgery in patients with hemorrhoids. METHODS: Patients with grade III hemorrhoids who underwent AM surgery were enrolled in this retrospective analysis of prospectively collected data from a single institution. Cumulative success rates, postoperative symptoms, including pain scores, analgesic requirements, and postoperative complications, and patient satisfaction were assessed. RESULTS: The median number of ALTA injection procedures was 3 (range 1-4), and the median total injection dose was 19 mL (range 7-32 mL). The median number of mucopexy procedures was 2 (range 1-4). The median postoperative pain score (0 = no pain at all, 10 = worst pain imaginable) at rest or during defecation were ≤2. The total dose of analgesics administered during the first two weeks after surgery was 1 (range 0-25). Six patients (5.3%) showed postoperative complications: five showed Clavien-Dindo (C-D) grade I and one showed C-D grade IIIa complications. Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively. Patient satisfaction scores, which were assessed using a 10-point scale, were ≥9 at each postoperative year. CONCLUSIONS: AM surgery is an effective non-excisional surgery with satisfactory mid-term results for grade III hemorrhoids, and is associated with lower complication rates, postoperative analgesic requirements, and higher patient satisfaction.", "provenance": [ { "field": "population", "quote": "Patients with grade III hemorrhoids who underwent AM surgery" }, { "field": "intervention", "quote": "ALTA therapy with rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse" }, { "field": "comparator", "quote": "This study investigated the midterm outcomes of AM surgery in patients with hemorrhoids." }, { "field": "primaryOutcome", "quote": "Cumulative success rates, postoperative symptoms, including pain scores, analgesic requirements, and postoperative complications, and patient satisfaction were assessed." }, { "field": "result", "quote": "The median postoperative pain score (0 = no pain at all, 10 = worst pain imaginable) at rest or during defecation were ≤2." }, { "field": "result", "quote": "Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively." }, { "field": "result", "quote": "Patient satisfaction scores, which were assessed using a 10-point scale, were ≥9 at each postoperative year." }, { "field": "followUp", "quote": "Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively." } ] }, { "id": "pmid:37837466", "pmid": "37837466", "doi": "10.1007/s00423-023-03128-4", "nctId": null, "pmcid": null, "title": "Comparison of ointment-based agents after excisional procedures for hemorrhoidal disease: a network meta-analysis of randomized controlled trials", "firstAuthor": "Perivoliotis", "multipleAuthors": true, "journal": "Langenbecks Arch Surg", "year": 2023, "design": "meta-analysis", "n": 2132, "nField": "reported", "population": "patients who had surgery to remove hemorrhoids", "intervention": "topical ointments or creams applied after hemorrhoid surgery (such as EMLA, aloe vera, metronidazole, lidocaine)", "comparator": "different topical agents compared against each other", "primaryOutcome": "pain after hemorrhoid surgery, including pain during bowel movements", "result": "different creams ranked best at different time points, with no single agent clearly best overall", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it combines many small trials of different creams after surgery, and the authors themselves say the results are inconclusive and limited.", "directness": "indirect", "limitations": "abstract states results were inconclusive and there were several study limitations", "followUp": "14 days", "plainFinding": "No clearly best pain cream found.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37837466/", "sourceText": "INTRODUCTION: Efficient postoperative pain control is important after hemorrhoidal surgery. Although several locally applied medications have been used, current evidence regarding the optimal strategy is still conflicting. This network meta-analysis assessed analgesic efficacy and safety of the various topical medications in patients submitted to excisional procedures for hemorrhoids. METHODS: The present study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The last systematic literature screening was performed at 15 June 2023. Comparisons were based on a random effects multivariate network meta-analysis under a Bayesian framework. RESULTS: Overall, 26 RCTs and 2132 patients were included. Regarding postoperative pain, EMLA cream (surface under the cumulative ranking curve (SUCRA) 80.3%) had the highest ranking at 12-h endpoint, while aloe vera cream (SUCRA 82.36%) scored first at 24 h. Metronidazole ointments had the highest scores at 7 and 14 days postoperatively. Aloe vera had the best analgesic profile (24-h SUCRA 84.8% and 48-h SUCRA 80.6%) during defecation. Lidocaine (SUCRA 87.9%) displayed the best performance regarding overall morbidity rates. CONCLUSIONS: Due to the inconclusive results and several study limitations, further RCTs are required.", "provenance": [ { "field": "n", "quote": "26 RCTs and 2132 patients were included" }, { "field": "population", "quote": "patients submitted to excisional procedures for hemorrhoids" }, { "field": "intervention", "quote": "locally applied medications" }, { "field": "comparator", "quote": "the various topical medications" }, { "field": "primaryOutcome", "quote": "Regarding postoperative pain" }, { "field": "result", "quote": "Metronidazole ointments had the highest scores at 7 and 14 days postoperatively. Aloe vera had the best analgesic profile (24-h SUCRA 84.8% and 48-h SUCRA 80.6%) during defecation." }, { "field": "limitations", "quote": "Due to the inconclusive results and several study limitations, further RCTs are required." } ] }, { "id": "pmid:37741471", "pmid": "37741471", "doi": "10.1016/j.jep.2023.117173", "nctId": null, "pmcid": null, "title": "The beneficial effect of Sanhuang ointment and its active constituents on experimental hemorrhoids in rats", "firstAuthor": "Yu", "multipleAuthors": true, "journal": "J Ethnopharmacol", "year": 2024, "design": "animal", "n": null, "nField": "not-reported", "population": "rats with chemically induced hemorrhoids", "intervention": "Sanhuang ointment applied to the anal area", "comparator": "other hemorrhoid creams (Mayinglong musk ointment and Taining cream) and untreated controls", "primaryOutcome": "inflammation, pain-related markers, and tissue swelling in the anal area", "result": "Sanhuang ointment reduced inflammation, swelling, and abnormal levels of pain and blood vessel growth markers in rat anal tissue", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is an animal study using rats with induced hemorrhoids, so it may not reflect what happens in humans with pain after bowel movements.", "directness": "indirect", "limitations": "Animal study only, not in humans; does not address general post-defecation anal pain unrelated to hemorrhoids.", "followUp": "11 days", "plainFinding": "Herbal ointment reduced hemorrhoid inflammation in rats.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37741471/", "sourceText": "ETHNOPHARMACOLOGICAL RELEVANCE: Sanhuang ointment (SHO) has been widely used in the traditional Chinese medical system for 1500 years and has efficacy in clearing away heat and dampness, reducing swelling, and alleviating pain. Hemorrhoids will damage the normal physiological function of the body, resulting in obstructed defecation, accompanied by massive hemorrhage and necrosis of tissues and cells, which is easy to breed bacteria and cause infection. SHO can promote lesion healing in hemorrhoid rats, but the pharmacological mechanism underlying this effect remains unknown. AIM: To evaluate the effect of SHO on experimental hemorrhoids in rats induced by croton oil and glacial acetic acid. MATERIALS AND METHODS: In this research, the effective components of SHO were analyzed in detail by High performance liquid chromatography (HPLC) and Liquid chromatography/mass spectrometry (LC/MS). Hemorrhoids were induced by 6% balsam and glacial acetic acid respectively in the anorectal region of rats. SHO was administered externally to the anorectal region of rats at doses of 185 mg/g (crude drug/ointment), 370 mg/g (crude drug/ointment) and 740 mg/g (crude drug/ointment) for 11 days. Mayinglong musk hemorrhoids ointment (1 g/kg) and Taining cream (1 g/kg) were used as reference anti hemorrhoids drugs. On the 11th day, hemorrhoids were evaluated by measuring the biochemical parameters of hemorrhoids in rats and the histology of anorectal tissues. RESULTS: Using high performance liquid chromatography liquid chromatography mass spectrometry, 41 compounds, including phenylpropionic acids and alkaloids, were identified. the fingerprints of 18 common peaks were identified. In Hemorrhoids like rats, acetic acid induced inflammation was inhibited in a dose-dependent manner during SHO treatment. In addition, the detailed experimental results show that SHO can effectively improve hemorrhoids by inhibiting the production of inflammatory cytokines in serum, reversing the down-regulation of vanillin subtype 1 (TRPV1), calcitonin gene related peptide (CGRP) and substance P (SP) levels of pain related genes in anal tissues, and the up regulation of Vascular endothelial growth factor (VEGF) levels of vascular growth related genes. CONCLUSION: The results showed that SHO could alleviate the edema caused by the exudation of anorectal tissue fluid in rats by anti-inflammatory effect and reducing the Vascular permeability of rats. The study validates the traditional use of SHO in the treatment of hemorrhoids and demonstrates its anti-hemorrhoidal potential.", "provenance": [ { "field": "population", "quote": "Hemorrhoids were induced by 6% balsam and glacial acetic acid respectively in the anorectal region of rats." }, { "field": "intervention", "quote": "SHO was administered externally to the anorectal region of rats at doses of 185 mg/g (crude drug/ointment), 370 mg/g (crude drug/ointment) and 740 mg/g (crude drug/ointment) for 11 days." }, { "field": "comparator", "quote": "Mayinglong musk hemorrhoids ointment (1 g/kg) and Taining cream (1 g/kg) were used as reference anti hemorrhoids drugs." }, { "field": "primaryOutcome", "quote": "hemorrhoids were evaluated by measuring the biochemical parameters of hemorrhoids in rats and the histology of anorectal tissues" }, { "field": "result", "quote": "SHO can effectively improve hemorrhoids by inhibiting the production of inflammatory cytokines in serum, reversing the down-regulation of vanillin subtype 1 (TRPV1), calcitonin gene related peptide (CGRP) and substance P (SP) levels of pain related genes in anal tissues, and the up regulation of Vascular endothelial growth factor (VEGF) levels of vascular growth related genes." } ] }, { "id": "pmid:37659951", "pmid": "37659951", "doi": "10.1016/j.asjsur.2023.08.194", "nctId": null, "pmcid": null, "title": "A retrospective comparative study of hemorrhoidal artery ligation versus ligasure hemorrhoidectomy for the third degree hemorrhoidal disease", "firstAuthor": "Onder", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2023, "design": "retrospective", "n": 91, "nField": "reported", "population": "patients with hemorrhoidal disease treated surgically at a surgery clinic", "intervention": "Doppler-guided ligation of the hemorrhoidal arteries (ADHL)", "comparator": "Ligasure hemorrhoidectomy (LH)", "primaryOutcome": "operation time, bleeding, hospital stay, and postoperative pain", "result": "ADHL had shorter operative time, shorter hospital stay, quicker resolution of bleeding, and seemed to cause less post-defecation pain than LH, with similar recurrence rates", "resultDirection": "benefit", "quality": "low", "qualityWhy": "It is a retrospective, non-randomized comparison of two surgical techniques in a small group of patients, so the findings are not strong evidence.", "directness": "indirect", "limitations": "Retrospective design without randomization; authors state prospective randomized controlled studies are needed.", "followUp": "", "plainFinding": "Less pain, quicker recovery with artery ligation.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37659951/", "sourceText": "BACKGROUND: Hemorrhoidal disease (HD) is the most common disease of the anorectal region. Excision of pathological hemorrhoidal structures by providing bipolar energy transfer with Ligasure, which is basically an electrosurgical device, is one of the treatment methods Ligasure hemorrhoidectomy (LH). In another method applied for the first time by Morinaga, the vascular plexus is provided by Doppler-guided ligation of the hemorrhoidal arteries (ADHL). In our study, we aimed to compare and evaluate the results of these two minimally invasive treatment methods. MATERIALS AND METHODS: Patients treated with ADHL and LH for HD in our Surgery Clinic were included in the study. Demographic data, complaints, number of hemorrhoidal structures, location, complications, operation time, bleeding during and after the operation, length of hospital stay, postoperative pain scoring, and postoperative results were evaluated from the patient files. RESULTS: The number of patients included in the study was 91. While 54 patients were treated with ADHL (group 1), 37 patients (group 2) were treated with LH. Although the gender distribution between the groups was similar, there was male predominance in both groups. The mean operative time was shorter in group 1. The number of packages was 2.7 in group 1 and 2.4 in group 2. The mean hospital stay was 1.5 days in the ADHL-treated group, compared to. 3.05 days in the LH group. In the postoperative period, bleeding was not observed after an average of 1.4 days in group 1, while this period was 4.9 days in group 2. While recurrence occurred in 4 patients in the ADHL group, recurrence developed in 3 patients who underwent LH. CONCLUSION: ADHL and LH techniques have advantages and disadvantages over each other. Although the ADHL technique seems to be superior to LH in terms of post-defecation pain and shorter hospital stay, prospective randomized controlled studies are needed to determine which method should be chosen in which patient.", "provenance": [ { "field": "n", "quote": "The number of patients included in the study was 91." }, { "field": "population", "quote": "Patients treated with ADHL and LH for HD in our Surgery Clinic were included in the study." }, { "field": "intervention", "quote": "the vascular plexus is provided by Doppler-guided ligation of the hemorrhoidal arteries (ADHL)" }, { "field": "comparator", "quote": "Excision of pathological hemorrhoidal structures by providing bipolar energy transfer with Ligasure, which is basically an electrosurgical device, is one of the treatment methods Ligasure hemorrhoidectomy (LH)." }, { "field": "primaryOutcome", "quote": "operation time, bleeding during and after the operation, length of hospital stay, postoperative pain scoring, and postoperative results were evaluated from the patient files." }, { "field": "result", "quote": "Although the ADHL technique seems to be superior to LH in terms of post-defecation pain and shorter hospital stay" } ] }, { "id": "pmid:37653473", "pmid": "37653473", "doi": "10.1186/s12876-023-02933-x", "nctId": null, "pmcid": "PMC10469794", "title": "Milligan-Morgan hemorrhoidectomy combined with non-doppler hemorrhoidal artery ligation for the treatment of grade III/IV hemorrhoids: a single centre retrospective study", "firstAuthor": "Long", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2023, "design": "retrospective", "n": 115, "nField": "reported", "population": "adults with grade III or IV hemorrhoids needing surgery", "intervention": "combined surgery: Milligan-Morgan hemorrhoidectomy plus non-Doppler hemorrhoidal artery ligation", "comparator": "Milligan-Morgan hemorrhoidectomy alone", "primaryOutcome": "pain after surgery (measured by pain scale) and other surgical complications", "result": "the combined surgery group had lower pain scores, less bleeding, less blood loss, less swelling, and less urinary retention than the standard surgery alone group", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a retrospective, single-center study comparing two surgery types without randomization, so it cannot reliably rule out bias.", "directness": "indirect", "limitations": "retrospective design, single center, not randomized, and focuses on comparing two surgical techniques for hemorrhoids rather than explaining the general cause of pain after bowel movements.", "followUp": "12 months", "plainFinding": "Combined hemorrhoid surgery caused less pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37653473/", "sourceText": "BACKGROUND: Milligan-Morgan hemorrhoidectomy (MMH) is the most widely used surgical procedure because of its precise curative effect, but it has the disadvantages such as obvious postoperative pain and bleeding. To retrospectively evaluate the efficacy and safety of MMH combined with non-Doppler hemorrhoidal artery ligation (MMH + ND-HAL) for the treatment of grade III/IV hemorrhoids. METHODS: We conducted a retrospective analysis of 115 patients with grade III/IV hemorrhoids, 53 patients had received MMH + ND-HAL, and the remaining 62 patients received MMH. We collected and compared demographic and clinical characteristics of both groups, including intraoperative blood loss, postoperative visual analog scale (VAS) for pain, analgesic consumption, postoperative bleeding, perianal incision edema, urinary retention, anal stenosis, anal incontinence incidence, recurrence rate (prolapse or bleeding), and patient satisfaction. RESULTS: The VAS pain score of the first postoperative defecation and at the postoperative 12 h, 1 day, 2 days, 3 days, and 7 days, as well as the total analgesic consumption within 7 days, for the MMH + ND-HAL group were lower than those for the MMH group (P < 0.05). The intraoperative blood loss, the incidence of postoperative bleeding, perianal incision edema, and urinary retention in the MMH + ND-HAL group was lower than that in the MMH group (P < 0.05). No anal stenosis or anal incontinence occurred in either group. At follow-up by telephone or outpatient 12 months after surgery, the recurrence rate (prolapse or bleeding) was lower in the MMH + ND-HAL group than in the MMH group (P < 0.05), and satisfaction was higher in the MMH + ND-HAL group than in the MMH group (P < 0.05). CONCLUSIONS: MMH + ND-HAL was a satisfactory surgical modality for treating III/IV hemorrhoids.", "provenance": [ { "field": "n", "quote": "We conducted a retrospective analysis of 115 patients with grade III/IV hemorrhoids, 53 patients had received MMH + ND-HAL, and the remaining 62 patients received MMH." }, { "field": "population", "quote": "We conducted a retrospective analysis of 115 patients with grade III/IV hemorrhoids" }, { "field": "intervention", "quote": "53 patients had received MMH + ND-HAL" }, { "field": "comparator", "quote": "the remaining 62 patients received MMH" }, { "field": "primaryOutcome", "quote": "postoperative visual analog scale (VAS) for pain, analgesic consumption, postoperative bleeding, perianal incision edema, urinary retention, anal stenosis, anal incontinence incidence, recurrence rate (prolapse or bleeding), and patient satisfaction" }, { "field": "result", "quote": "The VAS pain score of the first postoperative defecation and at the postoperative 12 h, 1 day, 2 days, 3 days, and 7 days, as well as the total analgesic consumption within 7 days, for the MMH + ND-HAL group were lower than those for the MMH group (P < 0.05)." } ] }, { "id": "pmid:37634164", "pmid": "37634164", "doi": "10.1007/s10151-023-02855-6", "nctId": null, "pmcid": null, "title": "Comparison of the efficacy and safety of different surgical procedures for patients with hemorrhoids: a network meta-analysis", "firstAuthor": "Yuan", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2023, "design": "meta-analysis", "n": 3573, "nField": "reported", "population": "patients with hemorrhoids undergoing surgery", "intervention": "different surgical procedures for hemorrhoids (e.g., Ligasure, Milligan-Morgan, Ferguson, Harmonic, PPH, TST, STARR)", "comparator": "the other surgical procedures compared against each other", "primaryOutcome": "operative time, blood loss, hospital stay, time to first bowel movement, recurrence, anal narrowing, and pain after surgery", "result": "different procedures were best for different outcomes; Ferguson had the least pain after 24 hours while PPH had the most pain after 24 hours", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "It pools many randomized trials, but the abstract gives no detail on bias risk or consistency of evidence, so confidence is limited.", "directness": "indirect", "limitations": "The abstract does not describe study quality, heterogeneity, or long-term follow-up, and findings apply only to surgical hemorrhoid patients, not general post-defecation pain.", "followUp": "", "plainFinding": "Pain after hemorrhoid surgery varies by technique.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37634164/", "sourceText": "PURPOSE: This study used a network meta-analysis to evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids. METHODS: PubMed, Embase, Web of science, and Cochrane Library were searched for randomized controlled trials on patients with hemorrhoids treated by different surgical procedures. The search was conducted until January 15, 2023. Two investigators independently screened the resulting literature, extracted information, evaluated the risk of bias of the included studies, and performed a network meta-analysis. RESULT: A total of 23 randomized controlled studies were included and involved 3573 patients and 10 interventions, namely L (Ligasure), M-M (Milligan-Morgan), F (Ferguson), H (Harmonic), OH (open Harmonic), CH (closed Harmonic), PPH (procedure for prolapse and hemorrhoids), TST (tissue selecting technique), T-S (TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection). Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time, F and H have the longest length of hospitalization and T-S has the shortest length of hospitalization, PPH has the most intraoperative blood loss and L has the least intraoperative blood loss, TST has the shortest time to first defecation and M-M has the longest time to first defecation, STARR had the least recurrence and PPH had the most recurrence, PPH had the least anal stenosis and L had the most anal stenosis, and F had the least postoperative pain after 24 h and PPH had the most postoperative pain after 24 h. CONCLUSION: Current evidence suggests that L is best at reducing mean operative time and intraoperative bleeding, T-S is best at reducing mean length of stay, TST has the shortest time to first defecation, STARR is best at reducing recurrence rates, PPH is best at reducing postoperative anal stricture, and F is best at reducing postoperative pain after 24 h.", "provenance": [ { "field": "n", "quote": "involved 3573 patients and 10 interventions" }, { "field": "population", "quote": "patients with hemorrhoids treated by different surgical procedures" }, { "field": "intervention", "quote": "L (Ligasure), M-M (Milligan-Morgan), F (Ferguson), H (Harmonic), OH (open Harmonic), CH (closed Harmonic), PPH (procedure for prolapse and hemorrhoids), TST (tissue selecting technique), T-S (TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection)" }, { "field": "comparator", "quote": "Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time" }, { "field": "primaryOutcome", "quote": "evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids" }, { "field": "result", "quote": "F had the least postoperative pain after 24 h and PPH had the most postoperative pain after 24 h" } ] }, { "id": "pmid:37451888", "pmid": "37451888", "doi": "10.1016/j.asjsur.2023.06.069", "nctId": null, "pmcid": null, "title": "Role of antibiotics in Milligan-Morgan hemorrhoidectomy for Grade III to IV Hemorrhoids: A randomized clinical trial", "firstAuthor": "Liu", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2024, "design": "rct", "n": 150, "nField": "reported", "population": "adults with grade III to IV hemorrhoids having surgery to remove them", "intervention": "antibiotics given through a vein before and/or after hemorrhoid surgery", "comparator": "no antibiotics", "primaryOutcome": "pain scores after surgery, plus wound swelling, bleeding, urinary retention and infection markers", "result": "pain scores were no different between the antibiotic and no-antibiotic groups at any time point measured", "resultDirection": "no-benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial but only in people having hemorrhoid surgery, so it does not tell us about ordinary pain after pooping without surgery.", "directness": "indirect", "limitations": "study only covers patients undergoing a specific surgical procedure for severe hemorrhoids, not general post-defecation pain; single tertiary-hospital setting", "followUp": "1 year", "plainFinding": "Antibiotics didn't reduce post-surgery pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37451888/", "sourceText": "PURPOSE: This study was mainly to compare the safety and long-term clinical efficacy of using intravenous antibiotics in Milligan Morgan hemorrhoidectomy for Grade III to IV Prolapsing Hemorrhoids. METHODS: This was a parallel group, 3-arm, randomized clinical trial to evaluate the efficacy of intravenous prophylactic antibiotics. A total of 150 consecutive patients undergoing Milligan Morgan hemorrhoidectomy (MMH) in a tertiary hospital for grade III/IV hemorrhoids from January 2020 to August 2022 were enrolled. Patients were randomly assigned to three groups using a computer-generated table. Group A did not receive any prophylactic antibiotic, group B received 2 g I/V Cefoxitin Sodium before the induction of anesthesia, and group C received 2 g I/V Cefoxitin Sodium before the induction of anesthesia and 6 h after operation. RESULTS: There was no significant difference in measured VAS values on the 1st day,3rd day and 7th day after surgery (p> 0.05). Compared with VAS values on the 1st day postoperatively, these values got decreased on the 3rd day and 7th day after surgery (p< 0.05). In addition, there was no significant difference among the first defecation time, wound edema, bleeding, urinary retention after surgery (p> 0.05). There was no significant difference in the outcome comparison between all 3 groups' basal and the 3rd day postoperatively no matter in WBC, NUET% or CRP (p> 0.05). However, compared with basal, the WBC, NUET%,CRP(p< 0.05) of group A and group B on the 3rd day postoperatively got rised, the rate of recurrence of hemorrhoids follow-up for 1 year was 1.4%. CONCLUSIONS: Our results suggest that there is no efficacy on intravenous prophylactic antibiotics in Milligan Morgan hemorrhoidectomy.", "provenance": [ { "field": "population", "quote": "A total of 150 consecutive patients undergoing Milligan Morgan hemorrhoidectomy (MMH) in a tertiary hospital for grade III/IV hemorrhoids" }, { "field": "intervention", "quote": "group B received 2 g I/V Cefoxitin Sodium before the induction of anesthesia, and group C received 2 g I/V Cefoxitin Sodium before the induction of anesthesia and 6 h after operation" }, { "field": "comparator", "quote": "Group A did not receive any prophylactic antibiotic" }, { "field": "primaryOutcome", "quote": "There was no significant difference in measured VAS values on the 1st day,3rd day and 7th day after surgery (p> 0.05)" }, { "field": "result", "quote": "there was no significant difference in the outcome comparison between all 3 groups' basal and the 3rd day postoperatively no matter in WBC, NUET% or CRP (p> 0.05)" }, { "field": "n", "quote": "A total of 150 consecutive patients undergoing Milligan Morgan hemorrhoidectomy (MMH)" } ] }, { "id": "pmid:37419805", "pmid": "37419805", "doi": "10.1016/j.asjsur.2023.06.066", "nctId": null, "pmcid": null, "title": "Efficacy and safety of Lingnan surgery for the treatment of multi-quadrant acute incarcerated hemorrhoids: A retrospective study", "firstAuthor": "Liu", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2023, "design": "retrospective", "n": 44, "nField": "reported", "population": "patients with severe, acutely painful hemorrhoids affecting multiple areas around the anus", "intervention": "Lingnan surgery (a surgical procedure for multi-quadrant hemorrhoid crisis)", "comparator": "none (before-and-after comparison, no control group)", "primaryOutcome": "pain levels and complications after surgery", "result": "pain scores dropped from 6.8 before surgery to 1.4 by day 5 after, with no major complications or recurrence over 6 months", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small, retrospective study with no comparison group, so it can't prove the surgery itself caused the improvement.", "directness": "indirect", "limitations": "Retrospective design, no control/comparator group, single center, small sample size.", "followUp": "6-month follow-up", "plainFinding": "Pain and symptoms improved after surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37419805/", "sourceText": "OBJECTIVE: In this study, we introduce a surgical procedure for multiple-quadrant hemorrhoid crisis, namely Lingnan surgery, and discuss its clinical efficacy and safety. METHODS: We performed a retrospective analysis of patients with acute incarcerated hemorrhoids who underwent Lingnan surgery at the Anorectal Department of Yunan County Hospital of Traditional Chinese Medicine of Guangdong Province from 2017 to 2021. The baseline data, preoperative condition, and postoperative condition of each patient were recorded in detail. RESULTS: A total of 44 patients were studied. There were no cases of massive hemorrhage, wound infection, wound nonunion, anal stenosis, abnormal anal defecation, recurrent anal fissure, or mucosal eversion within 30 days after surgery, and no recurrence of hemorrhoids and anal dysfunction occurred during the 6-month follow-up after surgery. The average operation time was 26.5 ± 6.2 min (17-43 min). The average length of hospital stay was 4.0 ± 1.2 days (2-7 days). In terms of postoperative analgesia, 35 patients took oral nimesulide, 6 did not use any analgesics, and 3 required nimesulide plus tramadol by injection. The mean Visual Analog Scale pain score was 6.8 ± 0.8 preoperatively and 2.9 ± 1.2, 2.0 ± 0.7, and 1.4 ± 0.6 at 1, 3, and 5 days postoperatively, respectively. The average basic activities of daily living score was 98.2 ± 2.6 (90-100) at discharge. CONCLUSION: Lingnan surgery is easy to perform and has obvious curative effects, providing an alternative to conventional procedures for acute incarcerated hemorrhoids.", "provenance": [ { "field": "n", "quote": "A total of 44 patients were studied." }, { "field": "population", "quote": "patients with acute incarcerated hemorrhoids" }, { "field": "intervention", "quote": "a surgical procedure for multiple-quadrant hemorrhoid crisis, namely Lingnan surgery" }, { "field": "comparator", "quote": "We performed a retrospective analysis of patients with acute incarcerated hemorrhoids who underwent Lingnan surgery" }, { "field": "primaryOutcome", "quote": "The mean Visual Analog Scale pain score was 6.8 ± 0.8 preoperatively and 2.9 ± 1.2, 2.0 ± 0.7, and 1.4 ± 0.6 at 1, 3, and 5 days postoperatively, respectively." }, { "field": "result", "quote": "no recurrence of hemorrhoids and anal dysfunction occurred during the 6-month follow-up after surgery" }, { "field": "followUp", "quote": "6-month follow-up after surgery" } ] }, { "id": "pmid:37289116", "pmid": "37289116", "doi": null, "nctId": null, "pmcid": null, "title": "[Management of anal fissure]", "firstAuthor": "Higuero", "multipleAuthors": false, "journal": "Rev Prat", "year": 2023, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal fissure", "intervention": "medical treatment (fiber, laxatives, topical medications)", "comparator": "surgery (sphincterotomy or fissurectomy/anoplasty)", "primaryOutcome": "healing and pain control of anal fissure", "result": "Medical treatment can control symptoms but surgery remains most effective long-term; surgery is offered if medical treatment fails", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a narrative review/opinion article without original data, numbers of patients, or study methods described.", "directness": "direct", "limitations": "No study design, patient numbers, or data presented; appears to be expert opinion/narrative summary.", "followUp": "6 to 8 weeks", "plainFinding": "Fiber and topical meds help; surgery most effective long-term.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37289116/", "sourceText": "MANAGEMENT OF ANAL FISSURE. The news in the management of the anal fissure are few but to know. The medical treatment must be well explained to the patient and optimized from the outset. Healthy bowel movements combining a sufficient fiber intake and soft laxatives must be continued for at least 6 months. Pain control is important. Topicals, specific (in case of sphincter hypertonia) or not, must be maintained for 6 to 8 weeks. Calcium channel blockers seem the most interesting with fewer side effects for similar effectiveness. Surgery is proposed (apart a no medically control of the pain or a fistula associated) in the event of failure of well-conducted medical treatment. It remains the most effective long-term treatment. Lateral internal sphincterotomy has its place in the absence of anal continence disorder, in which case fissurectomy and/or cutaneous anoplasty can be proposed.", "provenance": [ { "field": "population", "quote": "MANAGEMENT OF ANAL FISSURE." }, { "field": "intervention", "quote": "Healthy bowel movements combining a sufficient fiber intake and soft laxatives must be continued for at least 6 months." }, { "field": "intervention", "quote": "Topicals, specific (in case of sphincter hypertonia) or not, must be maintained for 6 to 8 weeks." }, { "field": "comparator", "quote": "Surgery is proposed (apart a no medically control of the pain or a fistula associated) in the event of failure of well-conducted medical treatment." }, { "field": "result", "quote": "It remains the most effective long-term treatment." }, { "field": "primaryOutcome", "quote": "Pain control is important." }, { "field": "followUp", "quote": "maintained for 6 to 8 weeks" } ] }, { "id": "pmid:37208893", "pmid": "37208893", "doi": "10.12659/AJCR.939444", "nctId": null, "pmcid": "PMC10208546", "title": "Anal Repair and Diamond Flap in Patient with Moderate Anal Stenosis After Open Hemorrhoidectomy Surgery: A Case Report", "firstAuthor": "Purnama", "multipleAuthors": true, "journal": "Am J Case Rep", "year": 2023, "design": "case-series", "n": 1, "nField": "reported", "population": "57-year-old woman with anal stenosis (narrowing) causing pain and difficulty pooping, 2 years after hemorrhoid surgery", "intervention": "surgical repair with diamond-shaped skin flap graft", "comparator": "none", "primaryOutcome": "healing and complications after surgery", "result": "flap healed well with no complications 10 days after surgery", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether this treatment works in general.", "directness": "indirect", "limitations": "only one patient, very short follow-up, no comparison group, and the stenosis was caused by a prior hemorrhoidectomy rather than ordinary post-bowel-movement anal pain.", "followUp": "10 days", "plainFinding": "Surgery fixed narrowing, no complications.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37208893/", "sourceText": "BACKGROUND Anal stenosis due to anoderm scarring is usually caused by surgical trauma and decreases the patient's quality of life significantly. Even though mild anal stenosis can be treated non-surgically, surgical reconstruction is unavoidable for moderate to severe cases of anal stenosis, especially stenosis that causes severe anal pain and the inability to defecate. In this study, we report the diamond flap method in the treatment of anal stenosis. CASE REPORT A 57-year-old female patient reported difficulty and discomfort in defecation caused by anal stenosis 2 years after a hemorrhoidectomy surgery. On physical examination, a forceful dilatation was needed using the index finger; the size of the anal canal was precisely 6 mm, as measured by a hegar dilator. Laboratory tests results were normal. The patient underwent an anal repair and diamond flap procedure in which the scar tissue at 6 and 9 o'clock was excised and a diamond graft was incised carefully, with attention given to the vascular supply. Finally, the graft was sutured to the anal canal. After 2 days, the patient was discharged without any adverse event. Ten days after surgery, the diamond flap was in good condition and without any complications. The patient was then scheduled for further follow-up at the Digestive Surgery Division. CONCLUSIONS Anal stenosis due to overzealous hemorrhoidectomy is a complication that is preventable when the procedure is performed by an experienced surgeon. The diamond flap was the option used for anal stenosis treatment and had few complications.", "provenance": [ { "field": "n", "quote": "A 57-year-old female patient" }, { "field": "population", "quote": "reported difficulty and discomfort in defecation caused by anal stenosis 2 years after a hemorrhoidectomy surgery" }, { "field": "intervention", "quote": "underwent an anal repair and diamond flap procedure in which the scar tissue at 6 and 9 o'clock was excised and a diamond graft was incised carefully" }, { "field": "comparator", "quote": "The patient underwent an anal repair and diamond flap procedure" }, { "field": "primaryOutcome", "quote": "the diamond flap was in good condition and without any complications" }, { "field": "result", "quote": "Ten days after surgery, the diamond flap was in good condition and without any complications." }, { "field": "followUp", "quote": "Ten days after surgery" } ] }, { "id": "pmid:37199352", "pmid": "37199352", "doi": "10.7417/CT.2023.2522", "nctId": null, "pmcid": null, "title": "Anal Cryptitis: A misdiagnosed condition", "firstAuthor": "Gkegkes", "multipleAuthors": true, "journal": "Clin Ter", "year": 2023, "design": "case-series", "n": 1, "nField": "reported", "population": "a 42-year-old woman with anal pain and itching for a year", "intervention": "surgical opening of the inflamed anal crypt (cryptotomy)", "comparator": "previous conservative treatment for anal fissure", "primaryOutcome": "anal pain and pruritus after defecation", "result": "the abstract reports the procedure was performed but does not state the outcome or whether symptoms improved", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether treatment works in general.", "directness": "direct", "limitations": "only one patient; no outcome data given after treatment; diagnosis delayed for a year with prior misdiagnosis", "followUp": "", "plainFinding": "Misdiagnosed anal crypt infection, cause unclear.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37199352/", "sourceText": "INTRODUCTION: Crypts are small anatomical structures situated between the anal papillae, which do not cause any symptoms unless they become inflamed. Cryptitis is a localized infection of one or more of the anal crypts. CASE PRESENTATION: A 42-year-old woman presented to our practice, complaining intermittently of anal pain and pruritus ani over a span of 1 year. She was referred multiple times to various surgeons, and she was treated conservatively for anal fissure without any evident improvement. The referred symptoms were increased often after defecation. Under general anesthesia, a hooked fistula probe was introduced into the inflamed anal crypt and the whole length of the crypt was layed open. CONCLUSION: Anal cryptitis is a misdiagnosed condition. The un-specific symptomatology of the disease can easily mislead. The clinical suspicion is fundamental for the diagnosis. Patient's history, digital ex-amination, and anoscopy are essential for the diagnosis of anal cryptitis.", "provenance": [ { "field": "n", "quote": "A 42-year-old woman presented to our practice" }, { "field": "population", "quote": "A 42-year-old woman presented to our practice, complaining intermittently of anal pain and pruritus ani over a span of 1 year." }, { "field": "intervention", "quote": "a hooked fistula probe was introduced into the inflamed anal crypt and the whole length of the crypt was layed open" }, { "field": "comparator", "quote": "she was treated conservatively for anal fissure without any evident improvement" }, { "field": "primaryOutcome", "quote": "The referred symptoms were increased often after defecation." }, { "field": "result", "quote": "Under general anesthesia, a hooked fistula probe was introduced into the inflamed anal crypt and the whole length of the crypt was layed open." } ] }, { "id": "pmid:37193430", "pmid": "37193430", "doi": "10.7759/cureus.37531", "nctId": null, "pmcid": "PMC10182782", "title": "A Pilot, Prospective, Randomized-Controlled Study to Evaluate the Efficacy and Safety of Arsha Hita™ in the Treatment of Anal Fissures", "firstAuthor": "B J", "multipleAuthors": true, "journal": "Cureus", "year": 2023, "design": "rct", "n": 53, "nField": "reported", "population": "People with anal fissures", "intervention": "Arsha Hita tablets and ointment (herbal treatment)", "comparator": "Standard treatment: lidocaine-nifedipine cream plus oral fiber (Isabgol)", "primaryOutcome": "Reduction in combined symptom score (pain, bleeding, healing) after six weeks", "result": "More patients on Arsha Hita had a 90% reduction in symptom scores, with better pain relief, less bleeding, and better overall impression than standard treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small pilot study with only 53 participants, so results need confirming in larger trials.", "directness": "direct", "limitations": "Pilot study with small sample size; authors say larger randomized trials are needed to confirm findings.", "followUp": "six weeks", "plainFinding": "Herbal treatment eased fissure pain and bleeding better.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37193430/", "sourceText": "Introduction Anal fissures are tears in the anal canal that cause pain, bleeding, and spasms. They can be treated with non-operative options such as sitz baths, local anesthetics, topical nitrates, oral fiber, and calcium channel blockers, but some patients require surgery. Topical nitrates have side effects such as severe headaches, while topical calcium channel blockers can cause itching. There is a need to explore alternative treatments with fewer side effects. This proof-of-concept pilot study aimed to compare the efficacy and safety of a combination of Arsha Hita™ tablets and ointment (Shree Dhootapapeshwar Limited, Mumbai Maharastra, India) (test treatment) with a combination of lidocaine 1.5% w/w + nifedipine 0.3% w/w cream for local application and Isabgol powder (6 g) orally as an active comparator (standard treatment), which is the standard treatment of anal fissures as per the Association of Colon and Rectal Surgeons of India (ACRSI) guidelines. Methodology This study was a single-center, prospective, randomized-controlled study conducted in Karnataka, India. Participants were screened for anal fissures and randomized to receive either standard treatment (Group A) or test treatment (Group B) for 14 days, and were re-evaluated after two, four, and six weeks. The study assessed signs and symptoms related to anal fissures, such as pain post-defecation on Visual Analog Scale (VAS), bleeding per anus grading, wound healing grade, stool consistency, and stool frequency. Compliance, inter-current illness, and concomitant therapy were noted at each visit. The study used independent sample t-tests to compare variables at baseline and chi-square or Fisher's exact tests to compare the number/proportion of participants achieving primary and secondary endpoints. Mann-Whitney U test was used to compare median composite scores at baseline and Visit 4, and Friedman's two-way analysis of variance was used to compare median composite scores across the four visits (p < 0.05 was considered significant). Descriptive analysis was used to assess VAS, bleeding, and healing grades. Results The study included 53 participants with anal fissures, of which 25 out of 27 allocated in Group A (two drop-outs) received standard treatment, and all 26 allocated in Group B received Arsha Hita treatment. At the end of the study, 11 participants in Group B achieved a 90% reduction in composite scores compared to only three patients in Group A (p<0.05). Both groups showed improvement in pain on defecation, severity of bleeding, healing of anal fissure wound, and participant's and physician's global impression score. Group B had significantly better results in terms of VAS score, resolution of per-anal bleeding, and physician's global impression score (p<0.05). There were no adverse events in either group during the six-week treatment period. Conclusion The pilot study provides evidence that the combination of Arsha Hita tablets and Arsha Hita ointment may be more effective and safer for treating anal fissures than the standard treatment. The test treatment group experienced greater pain relief, complete resolution of per-anal bleeding, and better global impression scores than the standard treatment group. These findings suggest the need for further research through larger, randomized controlled trials to determine the efficacy and safety of Arsha Hita in treating anal fissures.", "provenance": [ { "field": "n", "quote": "The study included 53 participants with anal fissures" }, { "field": "population", "quote": "Participants were screened for anal fissures and randomized" }, { "field": "intervention", "quote": "a combination of Arsha Hita™ tablets and ointment" }, { "field": "comparator", "quote": "a combination of lidocaine 1.5% w/w + nifedipine 0.3% w/w cream for local application and Isabgol powder (6 g) orally as an active comparator" }, { "field": "primaryOutcome", "quote": "compare the number/proportion of participants achieving primary and secondary endpoints" }, { "field": "result", "quote": "11 participants in Group B achieved a 90% reduction in composite scores compared to only three patients in Group A (p<0.05)" }, { "field": "result", "quote": "Group B had significantly better results in terms of VAS score, resolution of per-anal bleeding, and physician's global impression score (p<0.05)" }, { "field": "limitations", "quote": "These findings suggest the need for further research through larger, randomized controlled trials" } ] }, { "id": "pmid:37169574", "pmid": "37169574", "doi": "10.15586/aei.v51i3.738", "nctId": null, "pmcid": null, "title": "Associations between functional constipation and non-IgE-mediated food allergy in infants and children", "firstAuthor": "Sissoko", "multipleAuthors": true, "journal": "Allergol Immunopathol (Madr)", "year": 2023, "design": "retrospective", "n": 305, "nField": "reported", "population": "infants and children with constipation", "intervention": "testing for food allergy (IgG, IgE, skin prick test, food avoidance and reintroduction)", "comparator": "children with constipation without food allergy", "primaryOutcome": "presence of food allergy and related symptoms such as anal fissure and pain during defecation", "result": "15% of children with functional constipation had food allergy, mostly non-IgE-mediated, with symptoms including anal fissure, abdominal pain, and pain during defecation", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a small, uncontrolled study of a selected subgroup, so it can't reliably show cause and effect.", "directness": "indirect", "limitations": "Only a subset of constipated children with 'allergy-related indicators' were tested for food allergy, and there is no control group without constipation.", "followUp": "", "plainFinding": "Food allergy linked to painful defecation", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37169574/", "sourceText": "BACKGROUND: The non-IgE-mediated food allergy (non-IgE-FA) is less prevalent than IgE-mediated food allergy, and their relationship with functional constipation (FC) needs to be clarified. METHODS: A total of 305 infants and children with constipation treated in the Department of Pediatric Gastroenterology, Children's Hospital of Nanjing Medical University, from July 2020 to December 2021 were included in this study. Four cases with organic lesions were excluded. Among 301 diagnosed with FC, according to ROME IV criteria, 81 cases with allergy-related indicators were further evaluated for food allergy by food-specific IgG antibody test, allergen- specific IgE antibody detection, skin prick test, and food avoidance and reintroduction. RESULTS: A total of 45 cases with FC were diagnosed with food allergy, and the incidence rate was 15%. Among the 45 patients, 35 cases (77.8%) had FC with non-IgE-FA. The main clinical symptoms or signs included anal fissure, abdominal pain, and pain during defecation. The most prevalent allergic foods were cow's milk, eggs, fish, and shrimp. Ten (22.2%) cases reported FC with mixed food allergy, including both non-IgE-mediated and IgE-mediated food allergy. This study focused on non-IgE-mediated food allergy-related FC. CONCLUSION: Our results showed that the incidence of food allergy in infants and children with FC was 15%, which was mainly mediated by non-IgE-FA. The main clinical symptoms or signs in these cases included anal fissure, abdominal pain, and pain during defecation, and the main allergens included milk, eggs, fish, and shrimp.", "provenance": [ { "field": "n", "quote": "A total of 305 infants and children with constipation treated in the Department of Pediatric Gastroenterology, Children's Hospital of Nanjing Medical University, from July 2020 to December 2021 were included in this study." }, { "field": "population", "quote": "infants and children with constipation" }, { "field": "intervention", "quote": "evaluated for food allergy by food-specific IgG antibody test, allergen- specific IgE antibody detection, skin prick test, and food avoidance and reintroduction" }, { "field": "comparator", "quote": "81 cases with allergy-related indicators were further evaluated for food allergy" }, { "field": "primaryOutcome", "quote": "The main clinical symptoms or signs included anal fissure, abdominal pain, and pain during defecation." }, { "field": "result", "quote": "A total of 45 cases with FC were diagnosed with food allergy, and the incidence rate was 15%. Among the 45 patients, 35 cases (77.8%) had FC with non-IgE-FA." } ] }, { "id": "pmid:37077600", "pmid": "37077600", "doi": "10.7759/cureus.36304", "nctId": null, "pmcid": "PMC10108892", "title": "A Prospective Study Comparing Stapler and Open Surgical Technique of Hemorrhoidectomy", "firstAuthor": "Kumar", "multipleAuthors": true, "journal": "Cureus", "year": 2023, "design": "rct", "n": 60, "nField": "reported", "population": "patients with grade III and IV hemorrhoids undergoing surgery", "intervention": "stapled hemorrhoidectomy", "comparator": "open hemorrhoidectomy", "primaryOutcome": "postoperative pain, operating time, hospital stay, complications, and recurrence", "result": "stapled hemorrhoidectomy had less postoperative pain, shorter operating time and hospital stay, and no recurrence at three months compared to open surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small study of only 60 patients with short follow-up, so the results may not be reliable for larger populations.", "directness": "indirect", "limitations": "Small sample size of 60 patients; this is about surgical treatment for hemorrhoids, not general post-defecation anal pain.", "followUp": "three months", "plainFinding": "Less pain after stapler surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37077600/", "sourceText": "Introduction Hemorrhoids are basically anal cushions which turn out to be pathological giving rise to bleeding, pain and protrusion outside the anal canal. The chief complaint of patients with hemorrhoids is bleeding from the rectum which is usually painless and associated with episodes of defecation. The study was done to assess postoperative pain, time duration of the procedure, complications in the postoperative period, return to normal work, and recurrence between the stapler and open hemorrhoidectomy for grade III and IV hemorrhoids. Material and methods The present prospective study was conducted among 60 patients in the General Surgery department at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar over the duration of two years presenting with grade III and IV degree hemorrhoids. Thirty patients each were divided into open hemorrhoidectomy and stapled hemorrhoidectomy groups. The study evaluated variables like operative time, stay at the hospital and postoperative complications and compared them between the two techniques. Follow-up of patients was done at regular intervals. Evaluation of postoperative pain was done using visual analogue scale (VAS) with ranges from 0 to 10. We evaluated the data using the chi-square test with a p-value <0.05 as significant. Results Of 60 patients, 47 (78.3%) were males and 13 (21.7%) were females with a male: female ratio being 3.6:1. The operating time and hospital stay were much less in the stapler hemorrhoidectomy group as compared to the open procedure group. Also, postoperative pain (visual analogue scale) was less in the stapler hemorrhoidectomy group with 36.7% of patients presenting with pain at one week, 23.3% at one month and 3.3% at three months in the open hemorrhoidectomy group whereas 13.3% presenting as pain in one week, 10% presenting at one month and none presenting at three months in the stapler hemorrhoidectomy group. There was recurrence seen in 10% of cases at three months in the open hemorrhoidectomy group as compared to the stapler hemorrhoidectomy group where no recurrence was found at three months follow-up. Conclusion Hemorrhoid offers a variety of surgical modalities of treatment. We have come to the conclusion that stapled hemorrhoidectomy has less complications and good patient compliance. It can be an effective option in the treatment of third and fourth-grade hemorrhoids. With proper training and expertise, stapler hemorrhoidectomy is a better and reliable technique for hemorrhoid surgery.", "provenance": [ { "field": "n", "quote": "The present prospective study was conducted among 60 patients" }, { "field": "population", "quote": "presenting with grade III and IV degree hemorrhoids" }, { "field": "intervention", "quote": "stapled hemorrhoidectomy" }, { "field": "comparator", "quote": "open hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "assess postoperative pain, time duration of the procedure, complications in the postoperative period, return to normal work, and recurrence" }, { "field": "result", "quote": "postoperative pain (visual analogue scale) was less in the stapler hemorrhoidectomy group with 36.7% of patients presenting with pain at one week, 23.3% at one month and 3.3% at three months in the open hemorrhoidectomy group whereas 13.3% presenting as pain in one week, 10% presenting at one month and none presenting at three months in the stapler hemorrhoidectomy group" }, { "field": "followUp", "quote": "three months" } ] }, { "id": "pmid:37035554", "pmid": "37035554", "doi": "10.3389/fsurg.2023.1145170", "nctId": null, "pmcid": "PMC10073417", "title": "Safety and efficacy of Levorag emulgel in the treatment of anal fissures using a validated scoring system", "firstAuthor": "Tomasicchio", "multipleAuthors": true, "journal": "Front Surg", "year": 2023, "design": "prospective-cohort", "n": 40, "nField": "reported", "population": "adults with anal fissures (both new and long-lasting)", "intervention": "Levorag emulgel applied topically", "comparator": "before vs after treatment (no control group)", "primaryOutcome": "pain, bleeding, and quality of life measured by the REALISE score", "result": "Pain and other symptom scores dropped significantly over 30 days, with most fissures healed by day 30", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small study with no comparison group, so it can't rule out that symptoms would have improved anyway.", "directness": "direct", "limitations": "Observational study without a control group, single arm, relatively small sample size", "followUp": "30 days", "plainFinding": "Gel reduced fissure pain and healed most cases", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37035554/", "sourceText": "INTRODUCTION: Anal fissure is one of the most common anal disease characterized by intense anal pain, and deterioration of patients quality of life. Treatment is mainly based on the topical administration of calcium antagonist or nitric oxide ointments, and in cases refractory to medical treatment patients can undergo surgery. This study aims to assess the efficacy and safety of Levorag emulgel in the treatment of acute and chronic fissures using of a validated scoring system. MATERIAL AND METHODS: A prospective observational study was carried out on patients with anal fissures between February and May 2022. The efficacy of the treatment was evaluated using the REALISE score, a new validated scoring system that rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL), recorded after 10, 20 and 30 days from the beginning of treatment. RESULTS: Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study. The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days. At the 30-day proctological examination, 22 patients (61%) were pain free (median VAS of 0, IQR 0-1.2, p < 0.05). Pain duration after defecation measured according to the REALISE score, showed a significant decrease after 10 days, from a median value of 2 (IQR 1-4) to 1 (IQR 1-1.2) (p < 0.005). The median value of the REALISE score decreased significantly, from 15 (IQR 11-19.25) at first proctological evaluation to 4 (IQR 4-6, p = 0.139) after 30 days of treatment. At day 30, complete fissure healing was achieved in 30 patients (80%). The healing rate was 82% and 78% in patients with acute and chronic anal fissures, respectively. CONCLUSION: The use of Levorag® Emulgel may represent a safe and effective non-invasive first line treatment in patients affected by acute or chronic anal fissure.", "provenance": [ { "field": "n", "quote": "Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study." }, { "field": "population", "quote": "patients with anal fissures between February and May 2022" }, { "field": "intervention", "quote": "Levorag® Emulgel" }, { "field": "comparator", "quote": "recorded after 10, 20 and 30 days from the beginning of treatment" }, { "field": "primaryOutcome", "quote": "rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL)" }, { "field": "result", "quote": "The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days." }, { "field": "result", "quote": "At day 30, complete fissure healing was achieved in 30 patients (80%)." } ] }, { "id": "pmid:36755770", "pmid": "36755770", "doi": "10.7759/cureus.34734", "nctId": null, "pmcid": "PMC9904392", "title": "Efficacy of Harmonic Scalpel Versus Bipolar Diathermy in Hemorrhoidectomy: A Systematic Review and Meta-Analysis of Nine Randomized Controlled Trials", "firstAuthor": "Albazee", "multipleAuthors": true, "journal": "Cureus", "year": 2023, "design": "meta-analysis", "n": null, "nField": "not-reported", "population": "people having surgery to remove hemorrhoids (third and fourth degree prolapse)", "intervention": "hemorrhoid removal surgery using a harmonic scalpel device", "comparator": "hemorrhoid removal surgery using bipolar diathermy device", "primaryOutcome": "complications during and after surgery, including pain, bleeding, and recovery time", "result": "no significant difference between the two surgical methods in complications including pain, bleeding, urinary retention, anal stenosis, and wound healing", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This pools nine trials but does not report total patient numbers and calls for larger trials to confirm the findings.", "directness": "indirect", "limitations": "Abstract does not report sample size; authors state additional RCTs with larger sample sizes are needed to consolidate the power and quality of the evidence.", "followUp": "", "plainFinding": "No difference between two surgery tools.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36755770/", "sourceText": "Hemorrhoidectomy is one of the most common surgical interventions to remove the third and fourth degrees of prolapse hemorrhoid. We carried out this systematic review and meta-analysis of the randomized controlled trials (RCTs) to comprehensively evaluate the efficacy of harmonic scalpel (HS) versus bipolar diathermy (BD) methods in terms of decreasing intraoperative and postoperative morbidities among patients undergoing hemorrhoidectomy. Suitable citations were found utilizing digital medical sources, including the CENTRAL, Web of Science, PubMed, Scopus, and Google Scholar, from inception until December 2022. Only RCTs that matched the inclusion requirements were selected. We used the updated Cochrane risk of bias (ROB) tool (version 2) to assess the quality of the involved citations. The Review Manager (version 5.4 for Windows) was used to perform the pooled analysis. Data were pooled and reported as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in random-effects models. Overall, there was no significant difference between HS and BD in terms of decreasing intraoperative morbidities like operative time, intraoperative blood loss, mean duration of hospital stay, and mean duration of first bowel movement (P>0.05). Similarly, the rate of postoperative complications like pain, bleeding, urinary retention, anal stenosis, flatus incontinence, and wound edema; was similar in both groups with no significant difference (P>0.05). In conclusion, our pooled analysis revealed there was no substantial difference between HS and BD in terms of intraoperative and postoperative endpoints. Additional RCTs with larger sample sizes are needed to consolidate the power and quality of the presented evidence.", "provenance": [ { "field": "population", "quote": "patients undergoing hemorrhoidectomy" }, { "field": "intervention", "quote": "harmonic scalpel (HS)" }, { "field": "comparator", "quote": "bipolar diathermy (BD) methods" }, { "field": "primaryOutcome", "quote": "efficacy of harmonic scalpel (HS) versus bipolar diathermy (BD) methods in terms of decreasing intraoperative and postoperative morbidities among patients undergoing hemorrhoidectomy" }, { "field": "result", "quote": "there was no substantial difference between HS and BD in terms of intraoperative and postoperative endpoints" }, { "field": "limitations", "quote": "Additional RCTs with larger sample sizes are needed to consolidate the power and quality of the presented evidence." } ] }, { "id": "pmid:36736690", "pmid": "36736690", "doi": "10.1016/j.jvir.2023.01.022", "nctId": null, "pmcid": null, "title": "Embolization of the Superior Rectal Arteries versus Closed Hemorrhoidectomy (Ferguson Technique) in the Treatment of Hemorrhoidal Disease: A Randomized Clinical Trial", "firstAuthor": "Falsarella", "multipleAuthors": true, "journal": "J Vasc Interv Radiol", "year": 2023, "design": "rct", "n": 33, "nField": "reported", "population": "adults with hemorrhoids (grade 2 or 3) needing treatment", "intervention": "artery embolization procedure to shrink the hemorrhoids", "comparator": "surgical hemorrhoid removal (Ferguson technique)", "primaryOutcome": "pain level after bowel movements and need for pain medication in the week after treatment", "result": "pain after the first bowel movement was much lower with embolization (score 0) than with surgery (score ~6), and far fewer pain pills were needed", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a very small randomized trial (fewer than 30 people analyzed), so the results could easily be due to chance or not apply broadly.", "directness": "direct", "limitations": "Small sample size with four patients excluded from analysis; outcomes measured mainly by patient-reported pain scales.", "followUp": "12 months", "plainFinding": "Embolization caused much less pain than surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36736690/", "sourceText": "PURPOSE: To compare short-term and medium-term results of superior rectal artery embolization versus surgical hemorrhoidectomy in the treatment of patients with hemorrhoidal disease. MATERIAL AND METHODS: This study was a prospective randomized clinical trial following 33 patients with symptomatic hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups: the superior rectal artery embolization group (n = 15) and Ferguson closed hemorrhoidectomy surgical group (n = 14). Four patients were excluded from the analysis. Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7 days of the postoperative period. Recurrent symptoms and satisfaction with treatment were also evaluated in the subsequent first, third, sixth, and twelfth months. RESULTS: The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in the embolization group (P = .001). The mean use of pain medication was higher in the surgery group (28.92 doses ± 15.78 vs 2.4 doses ± 5.21; P < .001). In the embolization group, the most prevalent preprocedural symptom was bleeding in 14 patients, with complete improvement in 12 (83.3%) patients. Mucus, skin tag, and pruritus were symptoms that showed little improvement in both groups. The frequency of symptoms (bleeding, pain, prolapse, and pruritus) was similar between the groups at 12 months (P = .691). No severe adverse events were observed in both groups. CONCLUSIONS: Despite no difference in outcomes, embolization of the superior rectal arteries for the treatment of hemorrhoidal disease showed pain levels lower than those observed after surgical treatment.", "provenance": [ { "field": "population", "quote": "33 patients with symptomatic hemorrhoidal disease Grades 2 and 3" }, { "field": "intervention", "quote": "superior rectal artery embolization group" }, { "field": "comparator", "quote": "Ferguson closed hemorrhoidectomy surgical group" }, { "field": "primaryOutcome", "quote": "Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7 days of the postoperative period." }, { "field": "result", "quote": "The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in the embolization group (P = .001)." }, { "field": "n", "quote": "33 patients with symptomatic hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups" } ] }, { "id": "pmid:36619264", "pmid": "36619264", "doi": "10.34172/mejdd.2022.291", "nctId": null, "pmcid": "PMC9489436", "title": "Effectiveness of Local Botulinum Toxin Injection for Perianal Pain after Hemorrhoidectomy", "firstAuthor": "Yaghoobi Notash", "multipleAuthors": true, "journal": "Middle East J Dig Dis", "year": 2022, "design": "rct", "n": 40, "nField": "reported", "population": "patients who had surgery to remove hemorrhoids", "intervention": "botulinum toxin injection near the anal muscle after hemorrhoid surgery", "comparator": "no injection after hemorrhoid surgery", "primaryOutcome": "pain levels after surgery, including pain during bowel movements", "result": "botulinum toxin injection reduced pain scores on days 1, 3, 5, and 7 after surgery and reduced pain during defecation, compared to no treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small trial of only 40 people studying pain after hemorrhoid surgery, not everyday post-poop pain without surgery.", "directness": "indirect", "limitations": "small sample size; authors state further studies are needed to prove clinical value", "followUp": "seven days", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36619264/", "sourceText": "Background: Hemorrhoidectomy is commonly associated with post-operative perianal pain. Local botulinum toxin injection by relaxing the smooth muscles of the perianal sphincter and reducing anal pressure can be effective in decreasing post-operative pain. This study evaluates the effectiveness of local botulinum toxin injection in controlling pain after hemorrhoidectomy. Methods: This study was a double-blind, randomized clinical trial. A total of 40 patients undergoing hemorrhoidectomy who were referred to Shariati Hospital in 2019- 2020 were enrolled as participants and divided into two groups. In one group, injection of botulinum toxin was done in intersphincteric area, and in the other group, there was no intervention after hemorrhoidectomy. SPSS software version 24 was used to analyze the data. Results: Local botulinum toxin injection (MASPORT® 500) significantly reduced post-operative perianal pain on the first, third, fifth, and seventh days after the operation compared with the second group (P<0.05). The mean pain scores in the first, third, fifth, and seventh days in the first and second groups were 7.60 (±0.88) versus 8.25 (±1.16), 40.5 (±0.88) versus 6.05 (±0.99), 2.45 (±0.51) versus 3.05 (±0.68), and 2.05 (±0.39) versus 1.70 (±0.57), respectively. Furthermore, pain during defecation was significantly lower for the experimental group (P<0.05). Conclusion: Local botulinum toxin injection effectively improves post-operative pain after hemorrhoidectomy. Further studies are needed to prove the clinical value of local botulinum toxin injection.", "provenance": [ { "field": "n", "quote": "A total of 40 patients undergoing hemorrhoidectomy" }, { "field": "population", "quote": "patients undergoing hemorrhoidectomy who were referred to Shariati Hospital" }, { "field": "intervention", "quote": "injection of botulinum toxin was done in intersphincteric area" }, { "field": "comparator", "quote": "there was no intervention after hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "Local botulinum toxin injection (MASPORT® 500) significantly reduced post-operative perianal pain" }, { "field": "result", "quote": "significantly reduced post-operative perianal pain on the first, third, fifth, and seventh days after the operation compared with the second group (P<0.05)" }, { "field": "result", "quote": "pain during defecation was significantly lower for the experimental group (P<0.05)" } ] }, { "id": "pmid:36609578", "pmid": "36609578", "doi": "10.1007/s00384-022-04294-5", "nctId": null, "pmcid": null, "title": "Comparing the efficacy and safety of different analgesic strategies after open hemorrhoidectomy: a systematic review and network meta-analysis", "firstAuthor": "Yang", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2023, "design": "meta-analysis", "n": 731, "nField": "reported", "population": "patients with pain after open hemorrhoidectomy (hemorrhoid removal surgery)", "intervention": "different pain-relief treatments applied after hemorrhoid surgery", "comparator": "placebo", "primaryOutcome": "pain scored on a Visual Analogue Scale at various times after surgery", "result": "Diltiazem was the most effective at reducing pain in the week after surgery, with botulinum toxin and sucralfate also helpful, GTN helpful at 24 hours, and electroacupuncture reducing pain specifically during the first bowel movement after surgery", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it combines 13 randomized trials but the abstract notes safety data were limited and calls for more high-quality trials.", "directness": "indirect", "limitations": "The abstract states there is limited evidence on the safety of the interventions, and this concerns pain after surgical hemorrhoid removal, not pain after an ordinary bowel movement.", "followUp": "7 d", "plainFinding": "Certain ointments ease pain after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36609578/", "sourceText": "PURPOSE: To evaluate the clinical efficacy and safety of different analgesic interventions in the treatment of pain after open hemorrhoidectomy by systematic review and network meta-analysis. METHODS: Randomized controlled trials that met the inclusion criteria in PubMed, Cochrane Library, Embase, Web of Science, Scopus, CNKI, WANFANG DATA, and VIP were searched from the date of database construction to June 28, 2022. RESULTS: Among the 13 randomized controlled trials (RCTs), 731 patients were included in the network meta-analysis. Most interventions are more effective than placebo in relieving postoperative pain. 24 h postoperative Visual Analogue Scale (VAS): glyceryl trinitrate (GTN) (mean difference (MD) - 4.20, 95% CI - 5.35, - 3.05), diltiazem (MD - 1.97, 95% CI - 2.44, - 1.51), botulinum toxin (BT) (MD - 1.50, 95% CI - 2.25, - 0.75), sucralfate (MD - 1.01, 95% CI - 1.53, - 0.49), and electroacupuncture (EA) (MD - 0.45, 95% CI - 0.87, - 0.04). 48 h postoperative VAS: diltiazem (MD - 2.45, 95% CI - 2.74, - 2.15), BT (MD - 2.18, 95% CI - 2.52, - 1.84), and sucralfate (MD - 1.41, 95% CI - 1.85, - 0.97). 7 d postoperative VAS: diltiazem (MD - 2.49, 95% CI - 3.20, - 1.78) and sucralfate (MD - 1.42, 95% CI - 2.00, - 0.85). The first postoperative defecation VAS: EA (MD - 0.70, 95% CI - 0.95, - 0.46). There are few data on intervention safety, and additional high-quality RCTs are expected to study this topic in the future. CONCLUSION: Diltiazem ointment may be the most effective medication for pain relief following open hemorrhoidectomy, and it can dramatically reduce pain within one week of surgery. The second and third recommended medications are BT and sucralfate ointment. GTN has a significant advantage in alleviating pain 24 h after open hemorrhoidectomy, but whether it causes headache is debatable; thus, it should be used with caution. EA's analgesic efficacy is still unknown. There was limited evidence on the safety of the intervention in this study, and it was simply presented statistically.", "provenance": [ { "field": "n", "quote": "731 patients were included in the network meta-analysis" }, { "field": "population", "quote": "pain after open hemorrhoidectomy" }, { "field": "intervention", "quote": "glyceryl trinitrate (GTN)" }, { "field": "intervention", "quote": "diltiazem" }, { "field": "intervention", "quote": "botulinum toxin" }, { "field": "intervention", "quote": "sucralfate" }, { "field": "intervention", "quote": "electroacupuncture" }, { "field": "comparator", "quote": "Most interventions are more effective than placebo in relieving postoperative pain." }, { "field": "primaryOutcome", "quote": "24 h postoperative Visual Analogue Scale (VAS)" }, { "field": "result", "quote": "Diltiazem ointment may be the most effective medication for pain relief following open hemorrhoidectomy, and it can dramatically reduce pain within one week of surgery." }, { "field": "followUp", "quote": "7 d postoperative VAS" } ] }, { "id": "pmid:36440295", "pmid": "36440295", "doi": "10.7759/cureus.31812", "nctId": null, "pmcid": "PMC9683847", "title": "Comparative Efficacy of Topical Metronidazole and Glyceryl Trinitrate Versus Topical Glyceryl Trinitrate Alone in the Treatment of Acute Anal Fissure: A Randomized Clinical Trial", "firstAuthor": "Shahid", "multipleAuthors": true, "journal": "Cureus", "year": 2022, "design": "rct", "n": 137, "nField": "reported", "population": "Adults aged 18-70 with acute anal fissures causing pain after bowel movements", "intervention": "Topical metronidazole combined with glyceryl trinitrate (GTN) cream", "comparator": "Topical glyceryl trinitrate (GTN) cream alone", "primaryOutcome": "Healing of the anal fissure, confirmed by finding a scar", "result": "More patients healed faster and had less pain with metronidazole plus GTN than with GTN alone", "resultDirection": "benefit", "quality": "low", "qualityWhy": "It was a single-blinded trial at one hospital with some patients lost to follow-up, so results may not be fully reliable.", "directness": "direct", "limitations": "Single-blinded design, conducted at a single hospital, three patients lost to follow-up", "followUp": "3 weeks", "plainFinding": "Faster healing and less pain with added metronidazole", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36440295/", "sourceText": "Background and objective An anal fissure is a longitudinal, oval lesion in the anal canal. In over 90% of instances, the anal fissures are located posterior to the midline and produce discomfort upon defecation and/or bleeding owing to spasms of the internal anal sphincter that leads to ischemia. This research aimed to determine if topical metronidazole treatment when combined with glyceryl trinitrate 0.2% (GTN), is more successful than GTN alone in reducing the time for an acute anal fissure to heal. Material and methods This study was a single-blinded, randomized controlled trial conducted at the DHQ Hospital Okara from January 2022 to August 2022. Patients of both genders, aged 18 to 70 years, with acute anal fissures, were included. One hundred forty patients who satisfied the inclusion criteria were randomized through the lottery technique and were divided into two groups (70 in each group). Group A contained patients who got metronidazole combination with GTN, while in Group B, patients treated with GTN alone without metronidazole. The primary endpoint was fissure healing, confirmed as finding a scar where the fissure was. While the secondary endpoint was maximum pain on defecation assessed by the Visual Analogue Scale (VAS). Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) v24. Chi-Square and Fisher's Exact tests were done for statistical analysis, and p < 0.05 was considered significant. Results Three patients lost the follow-up. Out of the remaining 137, 70 (51.1%) patients were male. The patient's ages ranged from 22 to 68 years, with a mean age of 39.18 ± 11.52. One hundred twenty six (92%) complained of pain on defecation with a mean VAS of 6.01 ± 2.35. 80 (58.4%) patients complained of perianal itching, while 25 (18.2%) patients complained of bleeding on defecation. On week 1 follow-up, in group A out of 69 patients, 27 (39.1%) had complete healing, 38 (55.1%) had partial healing, while in group B out of 68 patients, one (1.4%) had complete healing, 43 (63.2%) had partial healing (p = < 0.001, significant). On week 3 follow-up, in group A out of 69 patients, 47 (68.1%) had complete healing, and 22 (31.8%) had partial healing, while in group B out of 68 patients, 16 (23.5%) had complete healing, 49 (72%) had partial healing (p = < 0.001, significant). Mean VAS score of group A was 0.61 ± 1.38 while that of group B was 2.57 ± 2.50 (p = < 0.001, significant). Conclusion Using topical metronidazole as an addition to standard therapy may reduce the chronicity of acute anal fissures and prevent surgical treatments with high rates of complications.", "provenance": [ { "field": "n", "quote": "Out of the remaining 137, 70 (51.1%) patients were male." }, { "field": "population", "quote": "Patients of both genders, aged 18 to 70 years, with acute anal fissures, were included." }, { "field": "intervention", "quote": "Group A contained patients who got metronidazole combination with GTN" }, { "field": "comparator", "quote": "in Group B, patients treated with GTN alone without metronidazole" }, { "field": "primaryOutcome", "quote": "The primary endpoint was fissure healing, confirmed as finding a scar where the fissure was." }, { "field": "result", "quote": "On week 3 follow-up, in group A out of 69 patients, 47 (68.1%) had complete healing, and 22 (31.8%) had partial healing, while in group B out of 68 patients, 16 (23.5%) had complete healing, 49 (72%) had partial healing (p = < 0.001, significant)." }, { "field": "result", "quote": "Mean VAS score of group A was 0.61 ± 1.38 while that of group B was 2.57 ± 2.50 (p = < 0.001, significant)." } ] }, { "id": "pmid:36415415", "pmid": "36415415", "doi": "10.7759/cureus.30530", "nctId": null, "pmcid": "PMC9675890", "title": "Lateral Internal Anal Sphincterotomy of Chronic Anal Fissure: An Experience of 165 Cases", "firstAuthor": "Al-Ubaide", "multipleAuthors": true, "journal": "Cureus", "year": 2022, "design": "retrospective", "n": 165, "nField": "reported", "population": "people with chronic anal fissure (longstanding tear near the anus)", "intervention": "surgery cutting part of the anal sphincter muscle (lateral internal anal sphincterotomy)", "comparator": "none (no comparison group, before/after outcomes only)", "primaryOutcome": "complete healing and resolution of pain after surgery", "result": "163 of 165 patients had complete healing with pain resolved by two months after surgery; 5 developed flatus incontinence", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective case series without a comparison group, so it cannot prove the surgery caused the improvement.", "directness": "indirect", "limitations": "Retrospective design, no control group, and the abstract does not describe how pain or healing were measured.", "followUp": "two months postoperatively", "plainFinding": "Surgery resolved fissure pain in most.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36415415/", "sourceText": "BACKGROUND: The anal fissure is frequently seen in surgical practice. It is caused by a longitudinal tear in the anoderm distal to the dentate line. The hallmark feature of the disease is severe pain during defecation. Chronic anal fissure (CAF) causes undue stress that leads to poor quality of life. Different options of treatment, whether medical or surgical, are employed to treat this condition. One of these modalities is lateral internal anal sphincterotomy (LIAS). OBJECTIVES: We aimed to assess the safety and efficacy of the LIAS surgical procedure for the treatment of CAF. MATERIALS AND METHODS: This retrospective study was conducted at the Al-Muqdadiya General Hospital, Diala, Iraq, for a period from January 2016 to March 2021. The medical records of the patients with CAF who were subjected to LIAS under local anesthesia were reviewed. Data regarding the age, gender, smoking habit, body mass index (BMI), healing time, complications, and outcome for each participant were recorded. RESULTS: Of 165 participants, there were 91 men. The majority of the cases were ≤ 35 years (78.19%), were non-smokers (80%), and had no history of DM (98.79%). There was complete healing with a resolution of the pain at two months postoperatively in 163 subjects. The most common complication in our study was flatus incontinence (n = 5). All of them were found in the age group > 35 years and women. There were statistically significant differences between the age groups, gender, BMI, and the occurrence of flatus incontinence (P-value = 0.000, 0.012, and 0.009 respectively). However, there was no such association between smoking habit and a history of DM (P-value > 0.05). Conclusion: LIAS is safe and effective in the treatment of CAF, with an excellent outcome in resolving pain and a low complication rate. Age, female gender, and high BMI might affect the occurrence of flatus incontinence.", "provenance": [ { "field": "n", "quote": "Of 165 participants, there were 91 men." }, { "field": "population", "quote": "patients with CAF who were subjected to LIAS under local anesthesia" }, { "field": "intervention", "quote": "lateral internal anal sphincterotomy (LIAS)" }, { "field": "comparator", "quote": "This retrospective study was conducted at the Al-Muqdadiya General Hospital" }, { "field": "primaryOutcome", "quote": "There was complete healing with a resolution of the pain at two months postoperatively in 163 subjects." }, { "field": "result", "quote": "There was complete healing with a resolution of the pain at two months postoperatively in 163 subjects. The most common complication in our study was flatus incontinence (n = 5)." } ] }, { "id": "pmid:36337820", "pmid": "36337820", "doi": "10.7759/cureus.30847", "nctId": null, "pmcid": "PMC9622030", "title": "The Efficacy of Sitz Baths as Compared to Lateral Internal Sphincterotomy in Patients with Anal Fissures: A Systematic Review", "firstAuthor": "Alnasser", "multipleAuthors": true, "journal": "Cureus", "year": 2022, "design": "systematic-review", "n": 11, "nField": "reported", "population": "people with anal fissures (pain with pooping, sometimes with blood)", "intervention": "sitz baths (warm water soaks)", "comparator": "lateral internal sphincterotomy (surgery cutting the anal sphincter muscle)", "primaryOutcome": "pain relief, healing rate, and side effects", "result": "Sitz baths eased pain and healed about 80% of fissures with no reported side effects, but surgery healed fissures better, though surgery risked incontinence", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It is a systematic review of mixed, mostly older studies without pooled statistics, so the comparison is not very precise.", "directness": "direct", "limitations": "Conflicting evidence on pain relief between studies; review did not statistically combine results; quality of included studies not detailed beyond a basic check.", "followUp": "", "plainFinding": "Sitz baths ease pain, heal most fissures", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36337820/", "sourceText": "An anal fissure is a common condition that affects patients of all ages. Its clinical presentation is a sharp pain on defecation with or without blood. It is treated by conservative or surgical means. This study aims to assess the efficacy of a sitz bath as compared to lateral internal sphincterotomy in the treatment of anal fissures. The search strategy used keywords related to the topic of study. Three databases were used: PubMed, Google Scholar, and Science Direct. A total of 551 articles were screened. A quality assessment check was done on the articles leaving 11 articles. Four aspects of sitz bath outcomes were evaluated in the articles. In terms of analgesia, articles showed conflicting evidence. However, the overall evidence supports the use of sitz baths for their analgesic properties. In terms of healing, most articles had similar recovery rates of around 80%. Much of the research supported the use of sitz baths as the primary treatment to heal acute fissures. When compared to lateral internal sphincterotomy, the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths. However, studies showed incontinence as a side effect of lateral internal sphincterotomy, and no studies reported side effects from the sitz baths. To conclude, the results of the articles support the use of sitz baths to treat anal fissures. Sitz baths have been found to have analgesic properties, as well as a good healing time. But, compared to lateral internal sphincterotomy, there is a significant difference in the healing rate at the end stage of treatment, lateral internal sphincterotomy is found to be superior. With regards to the side effects, none have been reported from using a sitz bath.", "provenance": [ { "field": "population", "quote": "An anal fissure is a common condition that affects patients of all ages. Its clinical presentation is a sharp pain on defecation with or without blood." }, { "field": "intervention", "quote": "the efficacy of a sitz bath" }, { "field": "comparator", "quote": "as compared to lateral internal sphincterotomy" }, { "field": "primaryOutcome", "quote": "Four aspects of sitz bath outcomes were evaluated in the articles." }, { "field": "result", "quote": "In terms of healing, most articles had similar recovery rates of around 80%." }, { "field": "result", "quote": "When compared to lateral internal sphincterotomy, the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths." }, { "field": "result", "quote": "studies showed incontinence as a side effect of lateral internal sphincterotomy, and no studies reported side effects from the sitz baths" }, { "field": "n", "quote": "A quality assessment check was done on the articles leaving 11 articles." } ] }, { "id": "pmid:36048469", "pmid": "36048469", "doi": "10.1080/00365521.2022.2116292", "nctId": null, "pmcid": null, "title": "Utility of botulinum toxin injection for post-operative pain management after conventional hemorrhoidectomy: a systematic review and meta-analysis of clinical trials", "firstAuthor": "Lie", "multipleAuthors": true, "journal": "Scand J Gastroenterol", "year": 2023, "design": "meta-analysis", "n": 260, "nField": "reported", "population": "patients who had surgery to remove hemorrhoids", "intervention": "botulinum toxin injection into the anal sphincter muscle", "comparator": "placebo injection", "primaryOutcome": "pain level 24 hours after surgery", "result": "botulinum toxin reduced pain at 24 hours and shortened time to return to work, but did not change time to first bowel movement, incontinence or urinary retention", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Only five small trials with 260 patients total were pooled, so the results are not very reliable.", "directness": "indirect", "limitations": "Small number of trials and patients; authors say further randomized trials are needed to confirm results.", "followUp": "", "plainFinding": "Less pain after hemorrhoid surgery, not plain pooping pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36048469/", "sourceText": "BACKGROUND: Botulinum Toxin (BTX) has been found to have anti-spasm and analgesic effects. The utility of BTX after conventional hemorrhoidectomy remains unclear. Thus, a systematic review and meta-analysis are required to find out its utility after conventional hemorrhoidectomy. METHODS: Using specific keywords, we comprehensively go through the potential articles on PubMed, ClinicalTrials.gov, and Europe PMC sources until March 27th, 2022. All published studies on botulinum toxin anal sphincter injection after conventional hemorrhoidectomy were collected. We were using Review Manager 5.4 software to conduct statistical analysis. RESULTS: Five clinical trial studies with a total of 260 patients undergoing hemorrhoidectomy were included in the analysis Our pooled analysis revealed that BTX injection after hemorrhoidectomy was associated with lower VAS at 24 h post-operative [Mean Difference -1.35 (95% CI -1.90, -0.80), p < 0.00001, I2 = 0%] and shorter time to return work [Mean Difference -8.94 days (95% CI -12.57, -5.30), p < 0.00001, I2 = 0%]. However, BTX injection did not differ significantly from placebo in terms of time to first defecation (p = 0.22), fecal incontinence (p = 0.91) and urinary retention incidence (p = 0.18). CONCLUSION: BTX sphincter injection may offer some benefit after conventional hemorrhoidectomy in reducing pain from the first day after the procedure and promoting wound healing without complication. Further randomized clinical trials are still needed to confirm the results of our study.", "provenance": [ { "field": "n", "quote": "Five clinical trial studies with a total of 260 patients undergoing hemorrhoidectomy were included in the analysis" }, { "field": "population", "quote": "patients undergoing hemorrhoidectomy" }, { "field": "intervention", "quote": "botulinum toxin anal sphincter injection after conventional hemorrhoidectomy" }, { "field": "comparator", "quote": "BTX injection did not differ significantly from placebo" }, { "field": "primaryOutcome", "quote": "lower VAS at 24 h post-operative" }, { "field": "result", "quote": "BTX injection after hemorrhoidectomy was associated with lower VAS at 24 h post-operative [Mean Difference -1.35 (95% CI -1.90, -0.80), p < 0.00001, I2 = 0%] and shorter time to return work [Mean Difference -8.94 days (95% CI -12.57, -5.30), p < 0.00001, I2 = 0%]. However, BTX injection did not differ significantly from placebo in terms of time to first defecation (p = 0.22), fecal incontinence (p = 0.91) and urinary retention incidence (p = 0.18)." } ] }, { "id": "pmid:35979271", "pmid": "35979271", "doi": "10.23922/jarc.2021-069", "nctId": null, "pmcid": "PMC9328796", "title": "Treatment Result of the Mucopexy-Recto Anal Lifting Method for Hemorrhoids in Comparison with Ligation and Excision, and Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy", "firstAuthor": "Sameshima", "multipleAuthors": true, "journal": "J Anus Rectum Colon", "year": 2022, "design": "retrospective", "n": 2338, "nField": "reported", "population": "patients with hemorrhoids who had surgery", "intervention": "Mucopexy-Recto Anal Lifting (MuRAL) surgery", "comparator": "ligation and excision (LE) surgery, and aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy", "primaryOutcome": "operative time, hospital stay, pain after surgery, complications, and recurrence of hemorrhoids", "result": "MuRAL caused less pain than LE and had a lower recurrence rate than ALTA, but LE was the most curative overall", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it is a retrospective comparison of surgical groups without randomization, so differences could be due to patient selection rather than treatment.", "directness": "indirect", "limitations": "retrospective design, no randomization mentioned, and focuses on surgical hemorrhoid treatment rather than general post-defecation anal pain", "followUp": "3-year follow-up", "plainFinding": "New hemorrhoid surgery, less pain, lower recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35979271/", "sourceText": "The outcomes of Mucopexy-Recto Anal Lifting (MuRAL) in hemorrhoid surgery were compared with ligation and excision (LE), and aluminum potassium sulfate and tannic acid sclerotherapy (ALTA). In this study, we conducted a 3-year follow-up study of MuRAL (380 cases) and compared it with LE (1417 cases) and ALTA (541 cases) performed at the same period. Operative time, mean hospital stay, postoperative pain, postoperative complications, and recurrence were compared and examined retrospectively. The mean operative time was the longest for MuRAL, followed by LE, and then ALTA at 29.1, 21.5, and 12.4 minutes, and the mean length of hospital stay was 6.2, 10.6, and 1.3, days, respectively. Based on the frequency of injectable analgesic use, postoperative pain was clearly milder in MuRAL and ALTA than in LE. The recurrence rates were 3.2% with MuRAL, 1.1% with LE, and 12.4% with ALTA. Early postoperative low-grade fever and bowel movement urgency were observed in all surgeries, but these were minor and did not pose a safety problem. LE is painful and requires prolonged hospitalization but is the most curative; ALTA is simple and can be performed as a day surgery but has a high recurrence rate. MuRAL was less painful than LE and had a lower recurrence rate than ALTA. In recent years, there have been various innovations in the surgical treatment of hemorrhoids, and choosing a technique that is appropriate for the condition of the hemorrhoid and patient's needs is necessary. MuRAL can be one of the options for hemorrhoid treatment as a \"cure without cutting\" method.", "provenance": [ { "field": "n", "quote": "MuRAL (380 cases)" }, { "field": "n", "quote": "LE (1417 cases)" }, { "field": "n", "quote": "ALTA (541 cases)" }, { "field": "population", "quote": "hemorrhoid surgery" }, { "field": "intervention", "quote": "Mucopexy-Recto Anal Lifting (MuRAL)" }, { "field": "comparator", "quote": "ligation and excision (LE), and aluminum potassium sulfate and tannic acid sclerotherapy" }, { "field": "primaryOutcome", "quote": "Operative time, mean hospital stay, postoperative pain, postoperative complications, and recurrence were compared and examined retrospectively." }, { "field": "result", "quote": "postoperative pain was clearly milder in MuRAL and ALTA than in LE" }, { "field": "result", "quote": "The recurrence rates were 3.2% with MuRAL, 1.1% with LE, and 12.4% with ALTA." }, { "field": "followUp", "quote": "3-year follow-up study" } ] }, { "id": "pmid:35979270", "pmid": "35979270", "doi": "10.23922/jarc.2021-052", "nctId": null, "pmcid": "PMC9328793", "title": "Pain at the First Post-hemorrhoidectomy Defecation Is Associated with Stool Form", "firstAuthor": "Yano", "multipleAuthors": true, "journal": "J Anus Rectum Colon", "year": 2022, "design": "prospective-cohort", "n": 179, "nField": "reported", "population": "people who had hemorrhoid surgery", "intervention": "softer stool consistency", "comparator": "harder stool consistency", "primaryOutcome": "pain intensity during first bowel movement after surgery", "result": "softer stool was linked to less pain during the first bowel movement after surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was an observational study in post-surgery patients, not people with ordinary post-bowel-movement pain, so it only weakly applies to the general question.", "directness": "indirect", "limitations": "Observational design without randomization; limited to patients who had hemorrhoid surgery, so may not generalize to people without surgery.", "followUp": "", "plainFinding": "Softer stool, less pain after pooping.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35979270/", "sourceText": "OBJECTIVES: Post-hemorrhoidectomy defecation pain is problematic, and pain associated with the first defecation is particularly important for patients. The present study aimed to investigate whether stool form consistency affected defecation pain after hemorrhoidectomy. METHODS: A prospective, cohort, observational study where patients scheduled for hemorrhoidal surgery were analyzed. This study used two patient-reported scales to study parameters based on the first postoperative defecation. The Bristol Stool Form Scale (BSFS) and visual analog scale (VAS) assessed stool consistency and defecation pain. The association between stool consistency and defecation pain intensity was assessed using multiple linear regression analysis. Where there was evidence of non-linearity, we applied a restricted cubic spline with three knots to explore the non-linear association. We performed a non-linear regression analysis to estimate the association. RESULTS: A total of 179 patients were analyzed. The regression model results demonstrated that these scales negatively correlated with statistical significance (p = 0.003). CONCLUSIONS: This study showed that the softer the stool, the less painful the defecation. Surgeons should attempt to induce a patient to avoid hard stool after surgery. TRIAL REGISTRATION: The Ethics Review Committee of the Japan Medical Association approved the study. The study was registered with the Japan Registry of Clinical Trials (jRCT1030190224, https://jrct.niph.go.jp/latest-detail/jRCT1030190224).", "provenance": [ { "field": "population", "quote": "patients scheduled for hemorrhoidal surgery" }, { "field": "n", "quote": "A total of 179 patients were analyzed." }, { "field": "intervention", "quote": "stool form consistency" }, { "field": "comparator", "quote": "hard stool" }, { "field": "primaryOutcome", "quote": "pain associated with the first defecation" }, { "field": "result", "quote": "the softer the stool, the less painful the defecation" } ] }, { "id": "pmid:35761383", "pmid": "35761383", "doi": "10.1186/s13063-022-06107-0", "nctId": null, "pmcid": "PMC9235219", "title": "Preemptive analgesia for hemorrhoidectomy: study protocol for a prospective, randomized, double-blind trial", "firstAuthor": "Kazachenko", "multipleAuthors": true, "journal": "Trials", "year": 2022, "design": "registered-trial-no-results", "n": 144, "nField": "reported", "population": "patients with grade III-IV hemorrhoids undergoing surgical removal", "intervention": "ketoprofen painkiller pill given before surgery (preemptive analgesia)", "comparator": "placebo starch pill before surgery", "primaryOutcome": "pain levels and opioid painkiller use after surgery", "result": "this is a study protocol; no results are reported yet", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is only a trial protocol describing planned methods, with no actual outcome data reported yet.", "directness": "indirect", "limitations": "no results are available; this describes planned methodology only, and concerns surgical hemorrhoidectomy pain rather than typical pain after a normal bowel movement", "followUp": "", "plainFinding": "No results yet; trial planned.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35761383/", "sourceText": "BACKGROUND: Hemorrhoidectomy is associated with intense postoperative pain that requires multimodal analgesia. It includes nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics to reach adequate pain control. There are data in literature preemptive analgesia could decrease postoperative pain after hemorrhoidectomy. The aim of this study is to assess the efficacy of preemptive analgesia with ketoprofen 100 mg 2 h before procedure per os with spinal anesthesia to decrease postoperative pain according to visual analog scale and to reduce the opioids and other analgesics consumption. METHODS: Patients of our clinic who meet the following inclusion criteria are included: hemorrhoids grade III-IV and the planned Milligan-Morgan hemorrhoidectomy. After signing the consent all participants are randomly divided into 2 groups: the first one gets a tablet with 100 mg ketoprofen, the second one gets a tablet containing starch per os 2 h before surgery (72 participants per arm). Patients of both arms receive spinal anesthesia and undergo open hemorrhoidectomy. Following the procedure the primary and secondary outcomes are evaluated: opioid administration intake, the pain at rest and during defecation, duration, and frequency of other analgesics intake, readmission rate, overall quality of life, time from the procedure to returning to work, and the complications rate. DISCUSSION: Multimodality pain management has been shown to improve pain control and decrease opioid intake in patients after hemorrhoidectomy in several studies. Gabapentin can be considered as an alternative approach to pain control as NSAIDs have limitative adverse effects. Systemic admission of ketorolac with local anesthetics also showed significant efficacy in patients undergoing anorectal surgery. We hope to prove the efficacy of multimodal analgesia including preemptive one for patients undergoing excisional hemorrhoidectomy that will help to hold postoperative pain levels no more than 3-4 points on VAS with minimal consumption of opioid analgesics. TRIAL REGISTRATION: ClinicalTrial.gov NCT04361695 . Registered on April 24, 2020, version 1.0.", "provenance": [ { "field": "n", "quote": "72 participants per arm" }, { "field": "population", "quote": "hemorrhoids grade III-IV and the planned Milligan-Morgan hemorrhoidectomy" }, { "field": "intervention", "quote": "the first one gets a tablet with 100 mg ketoprofen" }, { "field": "comparator", "quote": "the second one gets a tablet containing starch per os 2 h before surgery" }, { "field": "primaryOutcome", "quote": "the pain at rest and during defecation, duration, and frequency of other analgesics intake" }, { "field": "result", "quote": "We hope to prove the efficacy of multimodal analgesia including preemptive one for patients undergoing excisional hemorrhoidectomy" } ] }, { "id": "pmid:35729398", "pmid": "35729398", "doi": "10.1007/s00423-022-02587-5", "nctId": null, "pmcid": null, "title": "The necessity of preoperative enema preparation for hemorrhoidal surgery: a single-center comparative study", "firstAuthor": "Lin", "multipleAuthors": true, "journal": "Langenbecks Arch Surg", "year": 2022, "design": "retrospective", "n": 270, "nField": "reported", "population": "patients having surgery for severe hemorrhoids", "intervention": "enema given before hemorrhoid surgery", "comparator": "no enema before hemorrhoid surgery", "primaryOutcome": "pain after surgery and need for pain medicine", "result": "The group that got an enema before surgery had higher pain scores on days 0, 1, and 2 after surgery, with no difference in other recovery measures or complications", "resultDirection": "harm", "quality": "low", "qualityWhy": "This was a retrospective comparison of medical records, not a randomized trial, so differences between groups could be due to other factors.", "directness": "indirect", "limitations": "Retrospective design using medical record and questionnaire data, not randomized, so groups may differ in unmeasured ways.", "followUp": "", "plainFinding": "Enema before surgery increased pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35729398/", "sourceText": "BACKGROUND: Hemorrhoidal surgery is a common treatment for high-grade hemorrhoids. The necessity of preoperative enema preparation (PEP) in hemorrhoidal surgery is inconclusive. This study aims to evaluate the benefit and safety of PEP in hemorrhoidal surgery. METHODS: This comparative study analyzed data from electronic medical record database and outpatient questionnaire archive. Data of patients who underwent hemorrhoidal surgery from March 2020 to February 2021 were obtained. Patients were allocated to either the PEP or non-PEP group. Primary outcome measurements were postoperative pain and oral analgesic use. Secondary outcomes were the number of days until first defecation, length of hospital stay, time to return to work, incidence of urinary retention, delayed bleeding, and local infection. RESULTS: Data of 270 consecutive patients, with 130 and 140 in the PEP and non-PEP groups, respectively, who underwent hemorrhoidal surgery were analyzed. Most patients underwent stapled hemorrhoidopexy, with 106 (81.54%) in PEP group and 113 (80.71%) in non-PEP group. The mean pain score was significantly higher in PEP than in non-PEP group at day 0 (6.21 ± 3.23 vs 5.31 ± 3.14), day 1 (5.79 ± 2.89 vs 4.68 ± 3.02), and day 2 (5.35 ± 2.86 vs 4.42 ± 2.76). No significant differences in postoperative recovery or complications rate were noted between groups. CONCLUSION: Our findings revealed that performing PEP before hemorrhoidal surgery produced no benefit when compared with not performing PEP. Typically, the procedure of PEP is inconvenient and discomforting for patients. Therefore, we suggest that it can be omitted in hemorrhoidal surgery.", "provenance": [ { "field": "n", "quote": "Data of 270 consecutive patients, with 130 and 140 in the PEP and non-PEP groups" }, { "field": "population", "quote": "Hemorrhoidal surgery is a common treatment for high-grade hemorrhoids." }, { "field": "intervention", "quote": "preoperative enema preparation (PEP)" }, { "field": "comparator", "quote": "Patients were allocated to either the PEP or non-PEP group." }, { "field": "primaryOutcome", "quote": "Primary outcome measurements were postoperative pain and oral analgesic use." }, { "field": "result", "quote": "The mean pain score was significantly higher in PEP than in non-PEP group at day 0 (6.21 ± 3.23 vs 5.31 ± 3.14), day 1 (5.79 ± 2.89 vs 4.68 ± 3.02), and day 2 (5.35 ± 2.86 vs 4.42 ± 2.76). No significant differences in postoperative recovery or complications rate were noted between groups." } ] }, { "id": "pmid:35714359", "pmid": "35714359", "doi": "10.1097/DCR.0000000000002250", "nctId": null, "pmcid": null, "title": "Infiltration of Bupivacaine and Triamcinolone in Surgical Wounds of Milligan-Morgan Hemorrhoidectomy for Postoperative Pain Control: A Double-Blind Randomized Controlled Trial", "firstAuthor": "Medina-Gallardo", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2022, "design": "rct", "n": 128, "nField": "reported", "population": "patients who had surgery to remove grade III-IV hemorrhoids", "intervention": "injection of bupivacaine and triamcinolone into the surgical wound", "comparator": "no injection (standard care)", "primaryOutcome": "worst pain level in the 48 hours after surgery", "result": "pain scores were lower with the injection (3 vs 6 points), but pain during pooping was not different between groups", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "it was a randomized trial but had no placebo injection in the control group, which could bias how pain was reported.", "directness": "indirect", "limitations": "no placebo used in control group; 48-hour pain and complication data were pooled as medians rather than reported individually", "followUp": "48 hours", "plainFinding": "Less overall pain, no change during pooping", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35714359/", "sourceText": "BACKGROUND: Pain management after hemorrhoidectomy continues to be challenging. OBJECTIVE: The aim of this study was to evaluate the effectiveness of infiltration of bupivacaine hydrochloride and triamcinolone acetonide in surgical wounds of Milligan-Morgan hemorrhoidectomy for postoperative pain relief. DESIGN: A double-blind randomized controlled clinical trial was conducted between May 2015 and June 2019. SETTINGS: This study was carried out in a secondary referral hospital center in Spain. PATIENTS: Patients who underwent an elective Milligan-Morgan hemorrhoidectomy for grade III-IV hemorrhoids were included. INTERVENTIONS: Patients allocated in the intervention group received a single infiltration of bupivacaine and triamcinolone and patients allocated in the control group did not receive any intervention. MAIN OUTCOMES MEASURES: The primary end point was the median of maximum pain by visual analog scale during the 48 hours of hospital stay. Secondary end points were pain at follow-up, pain during defecation, analgesic requirements, wound healing rate, and complications. RESULTS: A total of 128 patients were randomly assigned (64 in each group). The median of maximum pain score at 48 hours was 3 points in the intervention group and 6 points in the control group, which was significantly different ( p < 0.05). No differences were observed regarding pain during defecation. Morphine requirements were significant lower in the intervention group (6.3% vs 21.9% patients; p = 0.01; 5 vs 23 cumulative doses; p = 0.01). Wound healing and complication rates were similar in both groups. LIMITATIONS: Use of placebo was not considered in the control group (\"intervention group\" vs \"control group\" clinical trial). Data regarding pain or other complications at 48 hours postoperatively were pooled and expressed as median of values. CONCLUSIONS: Infiltration of surgical wounds with bupivacaine and triamcinolone decreases postoperative pain and reduces morphine requirements in Milligan-Morgan hemorrhoidectomies. See Video Abstract at http://links.lww.com/DCR/B867 .Clinical trial registration: European Registry of Clinical Trials. EUDRACT 2014- 003043-35. INFILTRACIN DE BUPIVACANA Y TRIAMCINOLONA EN HERIDAS QUIRRGICAS DE HEMORROIDECTOMA DE MILLIGANMORGAN PARA EL CONTROL DEL DOLOR POSOPERATORIO ENSAYO CLNICO DOBLE CIEGO, ALEATORIZADO Y CONTROLADO: ANTECEDENTES:El manejo del dolor posterior a una hemorroidectomía sigue siendo un desafío.OBJETIVO:El objetivo de este estudio fue evaluar la efectividad de la infiltración de bupivacaína y triamcinolona en heridas quirúrgicas de hemorroidectomía de Milligan-Morgan para el alivio del dolor posoperatorio.DISEÑO:Se realizó un ensayo clínico controlado, aleatorizado, doble ciego entre mayo del 2015 y junio del 2019.ENTORNO CLINICO:Este estudio se llevó a cabo en un centro hospitalario de referencia secundaria en España.PACIENTES:Se incluyeron pacientes que se sometieron a una hemorroidectomía de Milligan-Morgan electiva por hemorroides de grado III-IV.INTERVENCIONES:Los pacientes asignados al grupo de intervención recibieron una única infiltración de bupivacaína y triamcinolona y los pacientes asignados al grupo de control no recibieron ninguna intervención.PRINCIPALES RESULTADOS RESULTADOS:El factor de valoración principal fue la mediana del dolor máximo según la escala análoga visual durante las 48 horas de estancia hospitalaria. Las variables secundarias fueron dolor durante el seguimiento, dolor durante la defecación, requerimientos de analgésicos, tasa de cicatrización de heridas y complicaciones.RESULTADOS:Se asignó aleatoriamente a un total de 128 pacientes (64 en cada grupo). La mediana de puntuación máxima de dolor a las 48 horas fue de 3 puntos en el grupo de intervención y de 6 puntos en el grupo de control con diferencias significativas (p < 0,05). No se observaron diferencias en cuanto al dolor durante la defecación. Las necesidades de morfina fueron significativamente menores en el grupo de intervención (6,3% versus 21,9% de los pacientes; p = 0,01; 5 versus 23 dosis acumuladas; p = 0,01). Las tasas de curación de heridas y complicaciones fueron similares en ambos grupos.LIMITACIONES:No se consideró el uso de placebo en el grupo de control (ensayo clínico: \"grupo de intervención\" versus \"grupo control\"). Los datos con respecto al dolor u otras complicaciones después de 48 horas postoperatorias se agruparon y expresaron como mediana de los valores.CONCLUSIONES:La infiltración de heridas quirúrgicas con bupivacaína y triamcinolona disminuye el dolor posoperatorio y reduce los requerimientos de morfina en la hemorroidectomía de Milligan-Morgan. Consulte Video Resumen en http://links.lww.com/DCR/B867 . (Traducción- Dr. Francisco M. Abarca-Rendon).Registro de ensayos clínicos: Registro europeo de ensayos clínicos. EUDRACT 2014- 003043-35.", "provenance": [ { "field": "n", "quote": "A total of 128 patients were randomly assigned (64 in each group)." }, { "field": "population", "quote": "Patients who underwent an elective Milligan-Morgan hemorrhoidectomy for grade III-IV hemorrhoids were included." }, { "field": "intervention", "quote": "Patients allocated in the intervention group received a single infiltration of bupivacaine and triamcinolone" }, { "field": "comparator", "quote": "patients allocated in the control group did not receive any intervention." }, { "field": "primaryOutcome", "quote": "The primary end point was the median of maximum pain by visual analog scale during the 48 hours of hospital stay." }, { "field": "result", "quote": "The median of maximum pain score at 48 hours was 3 points in the intervention group and 6 points in the control group, which was significantly different ( p < 0.05). No differences were observed regarding pain during defecation." } ] }, { "id": "pmid:35584917", "pmid": "35584917", "doi": "10.3393/ac.2022.00164.0023", "nctId": null, "pmcid": "PMC10915529", "title": "Laser hemorrhoidoplasty in the treatment of symptomatic hemorrhoids: a pilot Australian study", "firstAuthor": "Jain", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2024, "design": "prospective-cohort", "n": 30, "nField": "reported", "population": "adults with symptomatic hemorrhoids who had not improved with non-surgical treatment", "intervention": "laser hemorrhoidoplasty (a laser-based procedure for hemorrhoids)", "comparator": "traditional hemorrhoid removal surgery (Milligan-Morgan hemorrhoidectomy) in a historical group of past patients", "primaryOutcome": "pain after surgery, time to return to normal activity, and quality of life", "result": "the laser procedure group had lower pain scores, especially pain with bowel movements, used less opioid pain medication, and returned to normal function and work faster than those who had traditional surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small pilot study comparing new patients to a historical (not simultaneous or randomized) group of only 43 people, which makes the comparison less reliable.", "directness": "indirect", "limitations": "Pilot study with a small sample, non-randomized design, and comparison to a historical rather than concurrent control group.", "followUp": "12 months", "plainFinding": "Less pain after laser hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35584917/", "sourceText": "PURPOSE: Traditional therapeutic approaches to the surgical management of hemorrhoid disease such as hemorrhoidectomies are plagued with severe postoperative pain and protracted recovery. Our pilot study aims to the laser hemorrhoidoplasty (LH) patients with symptomatic hemorrhoid disease that have failed conservative management for the first time in an Australian population. METHODS: Thirty patients were prospectively enrolled to undergo LH. Postoperative pain, time to return to function, and quality of life (QoL) were determined through the Hemorrhoid Disease Symptom Score and Short Health Scale adapted for hemorrhoidal disease and compared to a historical group of 43 patients who underwent a Milligan-Morgan hemorrhoidectomy by the same surgeon at 3, 6, and 12 months. RESULTS: The LH group had significantly lower mean predicted pain scores on days 1 and 2 and lower defecation pain scores and lower opioid analgesia use on days 1, 2, 3, and 4. The median time to return to normal function was significantly lower in the LH group (2 days vs. 9 days, P<0.001). Similarly, the median days to return to the workplace was significantly lower in the LH group (6 days vs. 13 days, P=0.007). During long-term follow-up (12 months), hemorrhoid symptoms and all QoL measures were significantly improved, especially among those with grade II to III disease. CONCLUSION: This pilot study demonstrates low pain scores with this revivified procedure in an Australian population, indicating possible expansion of the therapeutic options available for this common condition. Further head-to-head studies comparing LH to other hemorrhoid therapies are required to further determine the most efficacious therapeutic approach.", "provenance": [ { "field": "population", "quote": "patients with symptomatic hemorrhoid disease that have failed conservative management" }, { "field": "intervention", "quote": "laser hemorrhoidoplasty (LH)" }, { "field": "comparator", "quote": "a historical group of 43 patients who underwent a Milligan-Morgan hemorrhoidectomy by the same surgeon" }, { "field": "primaryOutcome", "quote": "Postoperative pain, time to return to function, and quality of life (QoL) were determined" }, { "field": "result", "quote": "The LH group had significantly lower mean predicted pain scores on days 1 and 2 and lower defecation pain scores and lower opioid analgesia use on days 1, 2, 3, and 4." }, { "field": "result", "quote": "The median time to return to normal function was significantly lower in the LH group (2 days vs. 9 days, P<0.001)." }, { "field": "n", "quote": "Thirty patients were prospectively enrolled to undergo LH." } ] }, { "id": "pmid:35419404", "pmid": "35419404", "doi": "10.3389/fsurg.2022.815618", "nctId": null, "pmcid": "PMC8995644", "title": "The Role of Acupuncture in Relieving Post-Hemorrhoidectomy Pain: A Systematic Review of Randomized Controlled Trials", "firstAuthor": "Chen", "multipleAuthors": true, "journal": "Front Surg", "year": 2022, "design": "systematic-review", "n": 275, "nField": "reported", "population": "patients who had hemorrhoidectomy surgery and experienced pain afterward", "intervention": "acupuncture (electro-acupuncture or manual acupuncture)", "comparator": "sham acupuncture, local anesthetics, or active medications", "primaryOutcome": "pain level after hemorrhoidectomy, including pain during defecation", "result": "electro-acupuncture reduced pain compared to sham or local anesthetics at some time points, but manual acupuncture showed inconsistent results versus medications", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Only four small trials with variable quality and inconsistent results were combined without statistical pooling.", "directness": "indirect", "limitations": "Variability was found in the quality of included studies; evidence was not conclusive.", "followUp": "7 days after surgery", "plainFinding": "Mixed evidence for acupuncture after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35419404/", "sourceText": "BACKGROUND: Post-hemorrhoidectomy pain (PHP) remains one of the complications of hemorrhoidectomy and can delay patient's recovery. Current clinical guideline on PHP remains skeptical on the effectiveness of acupuncture, which has been applied for PHP in practice with inconsistent evidence. OBJECTIVES: This systematic review aimed to evaluate the effectiveness of acupuncture on PHP by reviewing existing evidence. METHODS: Nine databases such as PubMed and Embase were searched for randomized controlled trials (RCTs) from inception to 30th September 2021. The outcome measures on pain level after hemorrhoidectomy, dose of rescue analgesic drug used, quality of life, adverse events, etc., were extracted and analyzed in a narrative approach. RESULTS: Four RCTs involving 275 patients were included in the analysis. One study showed that the visual analog scale (VAS) score was significantly lower in the electro-acupuncture (EA) group compared to that in the sham acupuncture (SA) group at 6, 24 h after surgery and during the first defecation (p < 0.05). Similar trends were found in the verbal rating scale (VRS) and Wong-Baker Faces scale (WBS) score but at different time points. Another study also found EA was effective on relieving pain during defecation up to 7 days after surgery when compared with local anesthetics (p < 0.05). However, two studies evaluating manual acupuncture (MA) compared with active medications for PHP showed inconsistent results on effectiveness. Variability was found in the quality of included studies. CONCLUSIONS: Although benefit of acupuncture on PHP, especially EA on defecation after surgery, was observed at some time points, evidence on effectiveness of acupuncture on PHP was not conclusive. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/, PROSPERO, identifier: CRD42018099961.", "provenance": [ { "field": "n", "quote": "Four RCTs involving 275 patients were included in the analysis." }, { "field": "population", "quote": "Post-hemorrhoidectomy pain (PHP) remains one of the complications of hemorrhoidectomy" }, { "field": "intervention", "quote": "the visual analog scale (VAS) score was significantly lower in the electro-acupuncture (EA) group compared to that in the sham acupuncture (SA) group" }, { "field": "comparator", "quote": "two studies evaluating manual acupuncture (MA) compared with active medications for PHP showed inconsistent results on effectiveness" }, { "field": "primaryOutcome", "quote": "The outcome measures on pain level after hemorrhoidectomy, dose of rescue analgesic drug used, quality of life, adverse events, etc., were extracted and analyzed" }, { "field": "result", "quote": "Although benefit of acupuncture on PHP, especially EA on defecation after surgery, was observed at some time points, evidence on effectiveness of acupuncture on PHP was not conclusive." } ] }, { "id": "pmid:35334538", "pmid": "35334538", "doi": "10.3390/medicina58030362", "nctId": null, "pmcid": "PMC8954788", "title": "New Techniques in Hemorrhoidal Disease but the Same Old Problem: Anal Stenosis", "firstAuthor": "Leventoglu", "multipleAuthors": true, "journal": "Medicina (Kaunas)", "year": 2022, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal stenosis (narrowing of the anal canal), usually after hemorrhoid surgery", "intervention": "surgical reconstruction with skin flaps", "comparator": "non-surgical treatment and lateral internal sphincterotomy", "primaryOutcome": "functional and surgical outcomes of anal stenosis treatment", "result": "the abstract does not report quantitative outcomes; it states sphincterotomy does not give satisfactory results and flap surgery is used to rebuild anal width and flexibility", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a narrative summary of surgical techniques without original data, patient numbers, or comparative results.", "directness": "indirect", "limitations": "no original patient data, outcomes, or statistics are given; it is a general review of surgical methods, not a study of normal post-defecation pain", "followUp": "", "plainFinding": "Reviews surgery for anal narrowing, not routine pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35334538/", "sourceText": "Anal stenosis, which develops as a result of aggressive excisional hemorrhoidectomy, especially with the stoutly use of advanced technologies (LigaSure®, ultrasonic dissector, laser, etc.), has become common, causing significant deterioration in the patient's quality of life. Although non-surgical treatment is effective for mild anal stenosis, surgical reconstruction is unavoidable for moderate to severe anal stenosis that causes distressing, severe anal pain, and inability to defecate. The problem in anal stenosis, unlike anal fissure, is that the skin does not stretch as a result of chronic fibrosis due to surgery. Therefore, the application of lateral internal sphincterotomy does not provide satisfactory results in the treatment of anal stenosis. Surgical treatment methods are based on the use of flaps of different shapes and sizes to reconstruct the anal caliber and flexibility. This article aims to summarize most-used surgical techniques for anal stenosis regarding functional and surgical outcomes.", "provenance": [ { "field": "population", "quote": "Anal stenosis, which develops as a result of aggressive excisional hemorrhoidectomy" }, { "field": "intervention", "quote": "Surgical treatment methods are based on the use of flaps of different shapes and sizes to reconstruct the anal caliber and flexibility." }, { "field": "comparator", "quote": "Although non-surgical treatment is effective for mild anal stenosis, surgical reconstruction is unavoidable for moderate to severe anal stenosis" }, { "field": "primaryOutcome", "quote": "This article aims to summarize most-used surgical techniques for anal stenosis regarding functional and surgical outcomes." }, { "field": "result", "quote": "the application of lateral internal sphincterotomy does not provide satisfactory results in the treatment of anal stenosis" } ] }, { "id": "pmid:35135658", "pmid": "35135658", "doi": "10.1016/j.gtc.2021.10.008", "nctId": null, "pmcid": null, "title": "A Pain in the Butt: Hemorrhoids, Fissures, Fistulas, and Other Anorectal Syndromes", "firstAuthor": "Lunsford", "multipleAuthors": true, "journal": "Gastroenterol Clin North Am", "year": 2022, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with painful anorectal conditions", "intervention": "", "comparator": "", "primaryOutcome": "", "result": "The abstract discusses diagnostic and management challenges without reporting a specific outcome result", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general narrative review discussing challenges in diagnosis and management, not a study testing a specific treatment or reporting outcome data.", "directness": "indirect", "limitations": "No specific population, intervention, or outcome data reported; general discussion of diagnostic/therapeutic challenges only.", "followUp": "", "plainFinding": "No specific finding reported.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35135658/", "sourceText": "Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities.", "provenance": [ { "field": "population", "quote": "Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians" }, { "field": "result", "quote": "improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities" } ] }, { "id": "pmid:35038820", "pmid": "35038820", "doi": "10.3393/ac.2021.00675.0096", "nctId": null, "pmcid": "PMC10169549", "title": "The importance of topical metronidazole in the treatment of acute anal fissure: a double-blind study controlled for prospective randomization", "firstAuthor": "Mert", "multipleAuthors": false, "journal": "Ann Coloproctol", "year": 2023, "design": "rct", "n": 200, "nField": "reported", "population": "adults with anal fissure lasting less than 8 weeks", "intervention": "topical diltiazem plus metronidazole cream", "comparator": "topical diltiazem cream alone", "primaryOutcome": "pain level and fissure healing", "result": "pain was lower and healing was faster with added metronidazole starting from week 1", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized double-blind trial with a reasonable number of patients, but details on blinding success and dropout were limited.", "directness": "direct", "limitations": "short follow-up of only 6 weeks and no mention of long-term recurrence or dropout rates", "followUp": "6 weeks", "plainFinding": "Faster healing, less pain with metronidazole added.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35038820/", "sourceText": "PURPOSE: Acute anal fissure, a disease characterized by severe pain in the anorectal area, reduces quality of life and becomes chronic absent appropriate treatment. More recently, anaerobic infections have been noted as contributive to etiopathogenesis. This study investigates topical metronidazole's effect in the treatment of acute anal fissure. METHODS: Our prospective randomized controlled double-blind study included 2 groups of 100 patients older than 18 years from our General Surgery Clinic with anal fissure complaints for less than 8 weeks. Topical diltiazem treatment was started in group 1, and topical diltiazem and metronidazole treatment in group 2. Pain levels were evaluated by the visual analogue scale (VAS) score, and recovery status was evaluated by physical examination findings ab initio and at the 1st, 4th, and 6th weeks. VAS score levels, demographic, clinical, and recovery status were then compared. RESULTS: There was no difference between the groups as to age, sex, pain on defecation, bleeding, constipation, and duration of pain, bleeding and constipation (P>0.05). From week 1, fissure epithelialization and healing rates were higher in group 2 (P<0.001); group 2 VAS score levels were lower than in group 1 (P<0.001) and achieved by group 1 only in week 4 (P=0.073). CONCLUSION: Adding topical metronidazole to treatment reduces the duration and severity of pain, shortens healing time, and increases the healing rate.", "provenance": [ { "field": "population", "quote": "patients older than 18 years from our General Surgery Clinic with anal fissure complaints for less than 8 weeks" }, { "field": "intervention", "quote": "topical diltiazem and metronidazole treatment in group 2" }, { "field": "comparator", "quote": "Topical diltiazem treatment was started in group 1" }, { "field": "primaryOutcome", "quote": "Pain levels were evaluated by the visual analogue scale (VAS) score, and recovery status was evaluated by physical examination findings" }, { "field": "result", "quote": "fissure epithelialization and healing rates were higher in group 2 (P<0.001); group 2 VAS score levels were lower than in group 1 (P<0.001)" }, { "field": "n", "quote": "2 groups of 100 patients older than 18 years" } ] }, { "id": "pmid:35028135", "pmid": "35028135", "doi": "10.1016/j.amsu.2021.103203", "nctId": null, "pmcid": "PMC8715064", "title": "Combination of simple advancement flap and fistulectomy to treat complex anal fistula as a complication of hemorrhoidectomy: Case report", "firstAuthor": "Sofii", "multipleAuthors": true, "journal": "Ann Med Surg (Lond)", "year": 2022, "design": "case-series", "n": 1, "nField": "reported", "population": "50-year-old woman with severe anal narrowing and a fistula after hemorrhoid surgery", "intervention": "surgery combining fistula removal and skin advancement flap", "comparator": "none", "primaryOutcome": "complications and return of symptoms after surgery", "result": "no complications and no symptoms returned at 1 and 2 week follow-up", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, which cannot show whether this treatment works in general", "directness": "indirect", "limitations": "only one patient, very short follow-up of two weeks, and this describes anal stenosis and fistula after hemorrhoid surgery rather than typical pain after bowel movements", "followUp": "first and second weeks", "plainFinding": "Surgery fixed fistula after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35028135/", "sourceText": "INTRODUCTION: After hemorrhoidectomy, anal stenosis occurs, which is an uncommon but severe consequence. The majority of severe cases require advancement flap anoplasty. PRESENTATION OF CASE: A 50-year-old female patient with a history of hemorrhoidectomy 10 months prior to admission complained of difficulty defecating, pain, and incomplete evacuation sensation, as well as a hole on the right side of the anal canal through which feces unintentionally passed. On the physical examination, we found that the anal lumen was partially obstructed, which did not allow the insertion of a finger. There was an impression of a perineal fistula at 5 and 7 o'clock, which was connected to the anal canal 3 cm from the edge of the anus. The patient was diagnosed with severe anal stenosis with perianal fistula. The patient underwent fistulectomy and advancement flap with perianal skin. In the outpatient follow-up clinic in the first and second weeks, the patient showed no complications, and no recurrence of her complaints was found. DISCUSSION: Several corrective surgical techniques have been applied to restore a healthy lining to the constricted portion of the anal canal. We performed a combination of simple cutaneous advancement flap and fistulectomy to manage the patient with severe anal stenosis following hemorrhoidectomy with concurrent anal fistula. CONCLUSION: A combination of fistulectomy and simple cutaneous advancement flap anoplasty is a simple, safe, and effective surgical option for the management of severe anal stenosis with concomitant anal fistula.", "provenance": [ { "field": "population", "quote": "A 50-year-old female patient with a history of hemorrhoidectomy 10 months prior to admission complained of difficulty defecating, pain, and incomplete evacuation sensation" }, { "field": "intervention", "quote": "The patient underwent fistulectomy and advancement flap with perianal skin" }, { "field": "comparator", "quote": "We performed a combination of simple cutaneous advancement flap and fistulectomy to manage the patient with severe anal stenosis following hemorrhoidectomy with concurrent anal fistula." }, { "field": "primaryOutcome", "quote": "In the outpatient follow-up clinic in the first and second weeks, the patient showed no complications, and no recurrence of her complaints was found." }, { "field": "result", "quote": "the patient showed no complications, and no recurrence of her complaints was found" }, { "field": "n", "quote": "A 50-year-old female patient" } ] }, { "id": "pmid:34877311", "pmid": "34877311", "doi": "10.12998/wjcc.v9.i32.9722", "nctId": null, "pmcid": "PMC8610929", "title": "Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study", "firstAuthor": "D'Orazio", "multipleAuthors": true, "journal": "World J Clin Cases", "year": 2021, "design": "case-control", "n": 30, "nField": "reported", "population": "men with chronic anal fissure and a tight anal sphincter muscle", "intervention": "surgery (fissurectomy and tissue flap) plus a botulinum toxin injection into the sphincter muscle", "comparator": "the same surgery without botulinum toxin injection", "primaryOutcome": "how much post-pooping pain decreased and how fast the wound healed", "result": "pain after bowel movements decreased more, and wounds healed fully in all patients with the toxin injection versus only 80% without it", "resultDirection": "benefit", "quality": "low", "qualityWhy": "it is a small study of only 30 men comparing two surgical approaches rather than testing a cure for everyday post-pooping pain, so it says little about typical causes.", "directness": "indirect", "limitations": "small sample of 30 male patients; not randomized; findings apply only to surgical patients with a specific tight-sphincter type of chronic fissure", "followUp": "at least 2 years", "plainFinding": "Adding Botox to fissure surgery eased pain faster", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34877311/", "sourceText": "BACKGROUND: Lateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy. AIM: To evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone. METHODS: We conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters. RESULTS: The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of \"de novo\" FI. Manometry parameters reverted to the normal range earlier for group II patients. CONCLUSION: The injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.", "provenance": [ { "field": "population", "quote": "30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement" }, { "field": "intervention", "quote": "those in group II underwent surgery and a botulinum toxin injection directly into the IAS" }, { "field": "comparator", "quote": "those in group I underwent surgery alone" }, { "field": "primaryOutcome", "quote": "The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation" }, { "field": "result", "quote": "Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032)" }, { "field": "n", "quote": "involving 30 male patients affected by CAF with hypertonic IAS" }, { "field": "followUp", "quote": "They were followed up for at least 2 years." } ] }, { "id": "pmid:34804743", "pmid": "34804743", "doi": "10.7759/cureus.19497", "nctId": null, "pmcid": "PMC8595952", "title": "The Laser Therapy for Hemorrhoidal Disease: A Prospective Study", "firstAuthor": "Harvitkar", "multipleAuthors": true, "journal": "Cureus", "year": 2021, "design": "case-series", "n": 100, "nField": "reported", "population": "patients with grade 2 or 3 hemorrhoids and mild rectal prolapse", "intervention": "hemorrhoidal laser procedure (HeLP)", "comparator": "none (single-arm study, no comparison group)", "primaryOutcome": "postoperative pain, complications, and hemorrhoid resolution/recurrence", "result": "pain was minimal or absent in most patients, symptoms like pain, bleeding, and itching dropped by 75-80%, and 7% of patients had recurrence within 12 months", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small single-group study with no comparison treatment, so it can't prove the laser caused the improvement.", "directness": "indirect", "limitations": "No control group, only 9-month median follow-up, and results may not generalize beyond mild-to-moderate hemorrhoids.", "followUp": "nine months", "plainFinding": "Laser hemorrhoid treatment reduced pain, low recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34804743/", "sourceText": "AIM: This prospective study aimed to determine the outcomes and postoperative complications of hemorrhoid disease (HD) treated by hemorrhoidal laser procedure (HeLP). BACKGROUND: We, herein report the results of 18 months of methodical use of mini-invasive laser procedures in 100 patients with grades 2 and 3 hemorrhoids and minimum to a mild degree of rectal prolapse. The surgical technique is called HeLP. METHODS: Data were collected on the duration of the procedure, intraoperative complications, postoperative pain, the declivity of hemorrhoids, persistency or complete resolution, and recurrence of hemorrhoids were collected prospectively. RESULTS: No evidence of intraoperative complications occurred. The median follow-up was nine months. Postoperative pain was not significant or null in most patients. There was no rectal tenesmus or alteration of defecation habits. Plateau of hemorrhoid symptoms and downgrading of hemorrhoid size reached approximately three to seven months post-procedure. The frequency of pain, bleeding, pruritus ani, and acute hemorrhoidal syndrome decreased by 75-80%. There was a significant reduction in hemorrhoids with the rate of recurrence being 7% over 12 months of follow-up. CONCLUSION: Our study evaluated and demonstrated that HeLP is an effective, safe, and non-painful procedure for the management of patients with the symptomatic second or third degree of hemorrhoid with mild to the minimum degree of rectal mucosal prolapse. It is a suitable ambulatory treatment.", "provenance": [ { "field": "n", "quote": "100 patients with grades 2 and 3 hemorrhoids" }, { "field": "population", "quote": "100 patients with grades 2 and 3 hemorrhoids and minimum to a mild degree of rectal prolapse" }, { "field": "intervention", "quote": "hemorrhoidal laser procedure (HeLP)" }, { "field": "comparator", "quote": "Data were collected on the duration of the procedure, intraoperative complications, postoperative pain" }, { "field": "primaryOutcome", "quote": "postoperative pain, the declivity of hemorrhoids, persistency or complete resolution, and recurrence of hemorrhoids" }, { "field": "result", "quote": "The frequency of pain, bleeding, pruritus ani, and acute hemorrhoidal syndrome decreased by 75-80%. There was a significant reduction in hemorrhoids with the rate of recurrence being 7% over 12 months of follow-up." } ] }, { "id": "pmid:34729061", "pmid": "34729061", "doi": "10.4103/jrms.JRMS_612_18", "nctId": null, "pmcid": "PMC8506240", "title": "Postoperative outcomes of intrasphincteric botox injection during hemorrhoidectomy: A double-blind clinical trial", "firstAuthor": "Alvandipour", "multipleAuthors": true, "journal": "J Res Med Sci", "year": 2021, "design": "rct", "n": 67, "nField": "reported", "population": "patients with grade 3 or 4 hemorrhoids having surgical hemorrhoid removal", "intervention": "Botox injection into the anal sphincter muscle during hemorrhoid surgery", "comparator": "saline (salt water) injection during hemorrhoid surgery", "primaryOutcome": "pain after surgery and during bowel movements, and wound healing", "result": "Botox group had less pain at rest and during defecation, used fewer painkillers, and healed faster at one follow-up point", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized double-blind trial but small and only in surgical hemorrhoidectomy patients, not people with ordinary post-bowel-movement pain.", "directness": "indirect", "limitations": "Small sample size (67 patients); applies only to patients undergoing surgical hemorrhoidectomy, not to general anal pain after defecation; operation time was longer in the Botox group.", "followUp": "14 days", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34729061/", "sourceText": "BACKGROUND: Pain is the most common postoperative complication of hemorrhoidectomy. We evaluated the effectiveness of intrasphincteric Botox injection on posthemorrhoidectomy complications including pain reduction and wound healing. MATERIALS AND METHODS: In this randomized, double-blind clinical trial, patients with Grades 3 or 4 symptomatic hemorrhoids who underwent open (Milligan-Morgan) hemorrhoidectomy were enrolled. The experimental group received intrasphincteric Botox injection during hemorrhoidectomy, while the controls received normal saline injection. Hemorrhoid grades, constipation status, history of hemorrhoidectomy, duration of operation, pain at rest and after defecation in six follow-up periods (6, 12, 24, and 48 h and 7 and 14 days after operation), wound healing (during follow-up after discharge with a 2-week period), analgesic use, and Botox side effects were evaluated and compared in the two experimental and control groups. RESULTS: In this trial, 34 and 33 patients were randomly allocated in the experimental and control groups, respectively. Operation time was significantly higher in Botox group (P = 0.009). Mean dose of analgesics use in Botox was significantly lower (P < 0.001). Rate of wound healing during follow-ups was significantly higher in Botox group in the fifth follow-up (P = 0.009). Frequency of urinary retention (P = 0.02) and moderate itching (P = 0.01) was significantly higher in placebo than Botox group. Mean of postoperative pain at rest in Botox group was significantly lower at 12th, 24th, and 48th h and 7th and 14th days after operation (P < 0.01). Mean of postoperative pain in Botox group was significantly lower at 3rd to 5th defecation (P < 0.01). CONCLUSION: Our findings indicated that a single-dose injection of Botox during Milligan-Morgan hemorrhoidectomy is associated with less postsurgical pain at rest and during defecation and improved wound healing. It is suggested that it is a safe and effective procedure during hemorrhoidectomy regarding the procedure-related complications.", "provenance": [ { "field": "population", "quote": "patients with Grades 3 or 4 symptomatic hemorrhoids who underwent open (Milligan-Morgan) hemorrhoidectomy" }, { "field": "intervention", "quote": "The experimental group received intrasphincteric Botox injection during hemorrhoidectomy" }, { "field": "comparator", "quote": "the controls received normal saline injection" }, { "field": "primaryOutcome", "quote": "pain at rest and after defecation in six follow-up periods" }, { "field": "result", "quote": "Mean of postoperative pain at rest in Botox group was significantly lower at 12th, 24th, and 48th h and 7th and 14th days after operation (P < 0.01). Mean of postoperative pain in Botox group was significantly lower at 3rd to 5th defecation (P < 0.01)." }, { "field": "n", "quote": "34 and 33 patients were randomly allocated in the experimental and control groups, respectively" } ] }, { "id": "pmid:34724727", "pmid": "34724727", "doi": "10.3393/ac.2020.00920.0131", "nctId": null, "pmcid": "PMC9441537", "title": "Early postoperative outcomes of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids", "firstAuthor": "Takada", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2022, "design": "retrospective", "n": 54, "nField": "reported", "population": "patients with grade III (prolapsing) hemorrhoids", "intervention": "ALTA (aluminum potassium sulfate and tannic acid) sclerotherapy combined with rectal mucopexy surgery", "comparator": "Doppler-guided transanal hemorrhoidal dearterialization with mucopexy surgery", "primaryOutcome": "pain during bowel movements and painkiller use after surgery", "result": "Pain scores during defecation were lower starting 4 days after surgery, and patients used fewer painkillers over 2 weeks (3.5 tablets vs 7.6 tablets) with the ALTA-mucopexy approach compared to the Doppler-guided surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was not a randomized comparison but compared one group of patients to a separate group from an earlier trial, so differences between groups could explain the results.", "directness": "indirect", "limitations": "Compared to a historical cohort from a previous study rather than a concurrent randomized group; not described as blinded; small patient numbers.", "followUp": "12 months", "plainFinding": "Less pain after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34724727/", "sourceText": "PURPOSE: Aluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids. METHODS: AM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial. RESULTS: The pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6-5.5] vs. 7.6 tablets [range 3.3-11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery. CONCLUSION: AM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.", "provenance": [ { "field": "population", "quote": "patients with grade III hemorrhoids" }, { "field": "intervention", "quote": "ALTA therapy with a rectal mucopexy (AM)" }, { "field": "comparator", "quote": "Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM)" }, { "field": "n", "quote": "AM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery" }, { "field": "primaryOutcome", "quote": "The pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery." }, { "field": "result", "quote": "The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6-5.5] vs. 7.6 tablets [range 3.3-11.9], P=0.04)." }, { "field": "followUp", "quote": "During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery." } ] }, { "id": "pmid:34539803", "pmid": "34539803", "doi": "10.1155/2021/6473754", "nctId": null, "pmcid": "PMC8443359", "title": "Effect of Kangfuxin Solution Fumigation Bath on Postoperative Patients with Hemorrhoid PPH and Influence on the Postoperative Complications", "firstAuthor": "Zeng", "multipleAuthors": true, "journal": "Evid Based Complement Alternat Med", "year": 2021, "design": "rct", "n": 106, "nField": "reported", "population": "adults who had surgery (PPH) for hemorrhoids", "intervention": "Kangfuxin solution fumigation bath after surgery", "comparator": "warm water sitz bath after surgery", "primaryOutcome": "postoperative pain, bleeding, swelling, wound healing and anal function", "result": "the herbal bath group had less pain, bleeding and swelling, faster wound healing, shorter hospital stay, and better anal pressure measurements than the warm water group", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this paper has been formally retracted, and it studied people recovering from hemorrhoid surgery rather than people with ordinary pain after a bowel movement.", "directness": "indirect", "limitations": "The publication is marked as a 'Retracted Publication,' and the population is specifically post-surgical hemorrhoid patients, not people with general anal pain after defecation.", "followUp": "", "plainFinding": "Herbal soak eased pain after hemorrhoid surgery.", "retracted": true, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34539803/", "sourceText": "Surgery is now the main clinical treatment for hemorrhoids, and the procedure for prolapse and hemorrhoids (PPH) is the commonly used procedure. The key to evaluating the efficacy of surgery includes the quality of postoperative wound healing and the occurrence of complications, so it is especially important to enhance the postoperative rehabilitation of hemorrhoids. This study investigates the method of postoperative treatment with Kangfuxin solution fumigation bath to explore the role of this method in the efficacy of patients after hemorrhoid PHH surgery and its effect on postoperative complications. It will accumulate some relevant information to improve the efficacy of hemorrhoid surgery and postoperative complications and open new ideas for further postoperative rehabilitation of other diseases in the anal area. A total of 106 patients with hemorrhoids were included in this study, all of whom were treated with PHH surgery. After surgery, they were randomly divided into a control group treated with warm water sitz bath and an observation group treated with Kangfuxin solution fumigation bath, with 53 cases in each group. We observed all patients' postoperative pain, bleeding, and perianal edema on a daily basis after surgery; we recorded the time of wound healing and hospital stay. The maximum anal squeeze pressure (MASP), anal defecation diastole pressure (ADDP), anal resting pressure (ARP), and the length of the high-pressure zone (HPZ) were used as observation indicators to evaluate the anal function of the patients before and after treatment. The results of the evaluation of the efficacy of patients after the treatment period showed that the total effective rate of treatment in the observation group (92.45%) was significantly higher than that of the control group (77.36%). The postoperative recovery showed that the wound healing time, hospitalization time, pain, bleeding, and edema scores at 3 and 5 days after surgery were lower in the observation group than in the control group; MASP and ARP increased in both groups after treatment compared to before treatment, with more increase in the observation group. The results suggest that patients with hemorrhoids after PPH should pay attention to postoperative care and rehabilitation. It also reveals that the application of Kangfuxin solution fumigation treatment has a significant effect, which can effectively reduce the patient's wound healing and hospital stay, while improving the patient's anal function and reducing postoperative complications, and is worthy of clinical promotion and application.", "provenance": [ { "field": "population", "quote": "A total of 106 patients with hemorrhoids were included in this study, all of whom were treated with PHH surgery." }, { "field": "n", "quote": "A total of 106 patients with hemorrhoids were included in this study" }, { "field": "intervention", "quote": "observation group treated with Kangfuxin solution fumigation bath" }, { "field": "comparator", "quote": "a control group treated with warm water sitz bath" }, { "field": "primaryOutcome", "quote": "We observed all patients' postoperative pain, bleeding, and perianal edema on a daily basis after surgery; we recorded the time of wound healing and hospital stay." }, { "field": "result", "quote": "the wound healing time, hospitalization time, pain, bleeding, and edema scores at 3 and 5 days after surgery were lower in the observation group than in the control group; MASP and ARP increased in both groups after treatment compared to before treatment, with more increase in the observation group." } ] }, { "id": "pmid:34527696", "pmid": "34527696", "doi": "10.3389/fsurg.2021.711958", "nctId": null, "pmcid": "PMC8435737", "title": "Self-Mechanical Anal Dilatation: A Simple Trick to Minimize Postoperative Pain and Stenosis Following Hemorrhoidectomy With Radiofrequency", "firstAuthor": "Eberspacher", "multipleAuthors": true, "journal": "Front Surg", "year": 2021, "design": "retrospective", "n": 78, "nField": "reported", "population": "patients with hemorrhoidal disease who had radiofrequency hemorrhoidectomy and developed sphincter spasms with painful defecation at 3 weeks after surgery", "intervention": "self-mechanical anal dilation after hemorrhoidectomy", "comparator": "historical cohort of matched patients who did not receive self-mechanical anal dilation", "primaryOutcome": "pain levels after surgery", "result": "pain scores were lower and satisfaction higher with self-mechanical anal dilation compared to the historical cohort, with fewer cases of anal stenosis", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a retrospective study comparing a small group to a historical group rather than a randomized trial, so bias cannot be ruled out.", "directness": "indirect", "limitations": "retrospective design, matched to a historical cohort rather than randomized, and the population is specifically post-surgical hemorrhoidectomy patients with sphincter spasm, not general people with pain after normal bowel movements", "followUp": "14 days to end of application (duration not specified in days)", "plainFinding": "Less post-surgery anal pain with dilation.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34527696/", "sourceText": "Aim: Hemorrhoidectomy is still the most effective surgical treatment for hemorrhoidal disease, but it is, however, associated with complications such as pain and stenosis. We proposed to break the \"vicious circle\" of \"pain-sphincteric spasm-stenosis-pain\" with the postoperative use of self-mechanical anal dilation. Methods: We retrospectively analyzed patients with hemorrhoidal disease presenting with a minimum of piles of three quadrants, treated with radiofrequency hemorrhoidectomy between January 2018 and December 2019. All the patients that at 3 weeks presented sphincteric spasms with painful defecation, were considered. Thirty-nine patients performed the cycle of self-mechanical anal dilation (Group A). This group was 1:1 matched with homogeneous patients from our historical cohort of patients (Group B). The primary endpoint was the pain evaluation, secondary endpoints: WCS, overall satisfaction of the patient, anal sphincter spasm, scarring, and the incidence of postoperative stenosis. Results: In Group A mean VAS was 3.25 after 14 days of application and 1.15 at the end of the application. In Group B mean VAS was persistently higher, with a mean VAS of 5 (p = 0.000002) and 3.38 (p = 0.0000000000009). In Group A we observed an improvement of symptoms at the end, with a good overall satisfaction (Group A 7.4 vs. Group B 5.9; p = 0.0000007) and a better mean WCS (Group A WCS 2.8 vs. Group B WCS 4.18; p = 0.0001). Stenosis was observed in 3/39 patients of Group B (7.7%). Conclusions: Self-mechanical anal dilation improves the pain in the late postoperative course, minimizing the risk of anal stenosis.", "provenance": [ { "field": "n", "quote": "Thirty-nine patients performed the cycle of self-mechanical anal dilation (Group A)." }, { "field": "population", "quote": "All the patients that at 3 weeks presented sphincteric spasms with painful defecation, were considered." }, { "field": "intervention", "quote": "postoperative use of self-mechanical anal dilation" }, { "field": "comparator", "quote": "This group was 1:1 matched with homogeneous patients from our historical cohort of patients (Group B)." }, { "field": "primaryOutcome", "quote": "The primary endpoint was the pain evaluation" }, { "field": "result", "quote": "In Group A mean VAS was 3.25 after 14 days of application and 1.15 at the end of the application. In Group B mean VAS was persistently higher, with a mean VAS of 5 (p = 0.000002) and 3.38 (p = 0.0000000000009)." } ] }, { "id": "pmid:34414451", "pmid": "34414451", "doi": "10.3892/mmr.2021.12376", "nctId": null, "pmcid": "PMC8404094", "title": "Polyherbal formulation Anoac‑H suppresses the expression of RANTES and VEGF for the management of bleeding hemorrhoids and fistula", "firstAuthor": "Porwal", "multipleAuthors": true, "journal": "Mol Med Rep", "year": 2021, "design": "lab", "n": null, "nField": "not-reported", "population": "human hemorrhoid and fistula tissue samples and fibroblast/macrophage cell lines in the lab", "intervention": "Anoac-H polyherbal formulation", "comparator": "untreated cells and tissue samples", "primaryOutcome": "levels of inflammation markers RANTES and VEGF, and cell migration", "result": "Anoac-H reduced migration of fibroblast and immune cells and lowered RANTES and VEGF levels, and treated tissue samples showed less inflammation and lower RANTES/VEGF than untreated samples", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is lab and tissue-sample work without patient numbers, symptom outcomes, or a controlled clinical trial, so it cannot show whether people actually feel less pain.", "directness": "indirect", "limitations": "No sample size given, no clinical trial design, no report of pain or symptom outcomes in patients, findings are from cells and tissue samples rather than treated patients followed over time.", "followUp": "", "plainFinding": "Herbal mix reduced hemorrhoid inflammation markers (lab study).", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34414451/", "sourceText": "Hemorrhoids and fistula are considered the most common anorectal conditions in the general population. These conditions affect the quality of a patient's life by causing pain and bleeding during defecation or even in the resting state. Lower grades of hemorrhoids may be controlled by traditional measures. However, surgery is an effective treatment option in recurrent‑lower and higher‑grade hemorrhoids. Surgical procedures are associated with various complications, including pain and delayed wound healing. Recurrence of hemorrhoids is also a major concern in the post‑operative period. An anal fistula is the connection between the anus and the skin and causes severe pain, swelling, as well as blood and pus discharge. Fistula has serious social and economic consequences. Hence, it is important to understand the pathophysiology and molecular pathology of hemorrhoids and fistula, to identify the molecular targets and to develop pharmacological‑interventions. In a previous study by our group, the polyherbal formulation Anoac‑H was developed for the treatment of different stages of hemorrhoids and fistula, and it was demonstrated that Anoac‑H is an effective formulation for treating hemorrhoids. However, the molecular mode of action of Anoac‑H on hemorrhoids and fistula had remained elusive. In the present study, it was determined that this formulation reduces the migration of mesenchymal (fibroblasts) and immune (RAW 264.7) cells without affecting their viability. It was also observed that Anoac‑H suppresses the expression of regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF in fibroblasts and macrophages. Inflammation and elevated expression of RANTES and VEGF were observed in hemorrhoids and fistula. However, inflammation, as well as the expression of RANTES and VEGF, were significantly reduced in treated human hemorrhoid and fistula tissues as compared to untreated ones, confirming the in vitro results.", "provenance": [ { "field": "population", "quote": "treated human hemorrhoid and fistula tissues as compared to untreated ones" }, { "field": "intervention", "quote": "polyherbal formulation Anoac‑H" }, { "field": "comparator", "quote": "as compared to untreated ones" }, { "field": "primaryOutcome", "quote": "Anoac‑H suppresses the expression of regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF in fibroblasts and macrophages" }, { "field": "result", "quote": "inflammation, as well as the expression of RANTES and VEGF, were significantly reduced in treated human hemorrhoid and fistula tissues as compared to untreated ones, confirming the in vitro results" } ] }, { "id": "pmid:34306842", "pmid": "34306842", "doi": "10.7759/cureus.15630", "nctId": null, "pmcid": "PMC8277982", "title": "The Role of Lateral Internal Sphincterotomy in Haemorrhoidectomy: A Study in a Tertiary Care Center", "firstAuthor": "Vijayaraghavalu", "multipleAuthors": true, "journal": "Cureus", "year": 2021, "design": "rct", "n": 200, "nField": "reported", "population": "patients with grade 3 and grade 4 hemorrhoids having surgery", "intervention": "hemorrhoid surgery plus a small cut in the anal muscle (lateral internal sphincterotomy)", "comparator": "standard hemorrhoid surgery alone (Milligan and Morgan technique)", "primaryOutcome": "pain after surgery, anal problems, and urine retention", "result": "adding the muscle cut reduced pain, bleeding, and urine retention after surgery, and lowered long-term anal narrowing and anal tears, but caused more temporary gas leakage", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial with a reasonable number of patients, but it studied surgical hemorrhoid patients, not ordinary post-bowel-movement anal pain.", "directness": "indirect", "limitations": "study focused on surgical hemorrhoidectomy patients with grade 3-4 hemorrhoids, not general post-defecation anal pain; gas incontinence was increased with the added procedure", "followUp": "24 months", "plainFinding": "Less pain with added muscle-cutting step", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34306842/", "sourceText": "Background Hemorrhoids are a common condition that presents with bleeding per rectum, pain at rest and defecation, mucosal discharge, and prolapse. Surgical hemorrhoidectomy is the treatment method of choice for Grade 3 and Grade 4 hemorrhoids. Hemorrhoidectomy is associated with postoperative pain and no single surgical technique has been proved to significantly reduce the pain. We analyzed in our study the effect of lateral internal sphincterotomy with hemorrhoidectomy on postoperative pain, anorectal function, and retention of urine after the Milligan and Morgan technique. Methods This randomized, prospective, and comparative study included 200 Grade 3 and Grade 4 hemorrhoids patients who were scheduled for surgical management. The patients were classified randomly into two groups with an equal number of participants: Group A underwent Milligan & Morgan open hemorrhoidectomy and Group B underwent lateral internal sphincterotomy (LIS) in addition to Milligan and Morgan open hemorrhoidectomy. Postoperative pain was recorded using the Visual Analog Scale (VAS) score for up to 48 hours. Postoperative bleeding, urinary retention, and bowel and gas incontinence were noted. Long-term follow-up at six and 24 months for anal stenosis, anal fissure, incontinence, and recurrence was also noted. Results Patients who underwent LIS showed a significant reduction in postoperative pain at 12 hours (p=0.0008*), 24 hours (p=0.000*), and 48 hours (p=0.003*); the time taken to request rescue analgesia was similar between the two groups (p=0.07). Side effects, such as postoperative bleeding and urinary retention, were significantly lower after LIS (p=0.001* and p=0.01*, respectively), and gas incontinence was significantly higher after LIS (p=0.002*). The long-term outcomes of anal fissure were significantly higher without LIS at six months (p=0.02*) and 24 months (p=0.04*) and those of anal stenosis were significantly higher without LIS at six months (p=0.04*). Conclusions From our study, we conclude that postoperative pain, bleeding, and urinary retention were significantly lower after LIS, and gas incontinence was transient. The long-term outcomes, which included anal stenosis and anal fissure, were significantly lower after LIS. However, bowel and gas incontinence and recurrence were not altered. Therefore, we conclude that the addition of LIS to hemorrhoidectomy improves patient outcomes in terms of postoperative pain and anorectal function.", "provenance": [ { "field": "n", "quote": "This randomized, prospective, and comparative study included 200 Grade 3 and Grade 4 hemorrhoids patients" }, { "field": "population", "quote": "200 Grade 3 and Grade 4 hemorrhoids patients who were scheduled for surgical management" }, { "field": "intervention", "quote": "Group B underwent lateral internal sphincterotomy (LIS) in addition to Milligan and Morgan open hemorrhoidectomy" }, { "field": "comparator", "quote": "Group A underwent Milligan & Morgan open hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "the effect of lateral internal sphincterotomy with hemorrhoidectomy on postoperative pain, anorectal function, and retention of urine" }, { "field": "result", "quote": "postoperative pain, bleeding, and urinary retention were significantly lower after LIS, and gas incontinence was transient. The long-term outcomes, which included anal stenosis and anal fissure, were significantly lower after LIS." } ] }, { "id": "pmid:33987779", "pmid": "33987779", "doi": "10.1007/s10151-021-02459-y", "nctId": null, "pmcid": "PMC8289784", "title": "The REALISE score: a new statistically validated scoring system to assess the severity of anal fissures", "firstAuthor": "Picciariello", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2021, "design": "case-control", "n": 150, "nField": "reported", "population": "patients with anal fissures compared to a control group with hemorrhoids, anal fistula, or obstructed defecation", "intervention": "a new symptom scoring questionnaire (REALISE score) covering pain, quality of life, duration of pain, painkiller use, and bleeding", "comparator": "control group of patients with other anorectal conditions (haemorrhoids, anal fistula, or obstructed defecation syndrome)", "primaryOutcome": "reliability, inter-/intraobserver agreement, and repeatability of the new scoring system", "result": "the REALISE score was significantly higher in anal fissure patients than controls, with high correlation between repeated assessments and good repeatability", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a small single-center tool-validation study that does not test any treatment or explain the cause of pain, so it offers little direct evidence about why pooping hurts.", "directness": "indirect", "limitations": "abstract does not describe blinding details, does not address treatment outcomes, and is limited to one tertiary coloproctology centre over a short recruitment window", "followUp": "", "plainFinding": "New fissure pain scoring tool validated.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33987779/", "sourceText": "BACKGROUND: Anal fissure (AF) is a common, painful disease that strongly affects patients' quality of life, however, no scoring system to assess the severity of AF is available in the literature. The aim of this study was to set up and validate a reliable scoring system to quantify the severity of AF, to be used in prospective trials comparing the efficacy and the outcomes of surgical or medical treatments. METHODS: The study was conducted on patients with acute or chronic AF and a control group in a tertiary centre for coloproctology in June 2020-September 2020. Two researchers independently carried out a structured interviewer-led questionnaire at two different time points (T1/T2). The questionnaire consisted of five items selected according to the most commonly reported symptoms for AF: the item pain, was scored from 0 to 10 using a visual analogue scale, and quality of life, duration of pain, use of painkillers, and bleeding were scored from 1 to 5 using Likert-scale questions. The scoRing systEm for AnaL fIsSurE (REALISE) score was the sum of the points. Patients with AF and a control group of patients with haemorrhoids, anal fistula, or obstructed defecation syndrome entered the study. Main outcome measures were reliability, inter-/intraobserver agreement, and repeatability. RESULTS: One hundred and fifty well-matched patients (75 with AF and 75 controls) were enrolled. A significant difference was found between the mean REALISE score for patients with AF and controls (p < 0.001). The two REALISE scores were highly correlated (r = 0.99). The coefficient of repeatability was 1.45 in T1 and 1.18 in T2. CONCLUSIONS: The REALISE score may have an important role in the assessment and management of AF, in grading the severity of AF and comparing results of different treatments.", "provenance": [ { "field": "n", "quote": "One hundred and fifty well-matched patients (75 with AF and 75 controls) were enrolled." }, { "field": "population", "quote": "patients with acute or chronic AF and a control group" }, { "field": "intervention", "quote": "The scoRing systEm for AnaL fIsSurE (REALISE) score was the sum of the points." }, { "field": "comparator", "quote": "Patients with AF and a control group of patients with haemorrhoids, anal fistula, or obstructed defecation syndrome entered the study." }, { "field": "primaryOutcome", "quote": "Main outcome measures were reliability, inter-/intraobserver agreement, and repeatability." }, { "field": "result", "quote": "A significant difference was found between the mean REALISE score for patients with AF and controls (p < 0.001). The two REALISE scores were highly correlated (r = 0.99)." } ] }, { "id": "pmid:33958029", "pmid": "33958029", "doi": "10.1071/SH20104", "nctId": null, "pmcid": null, "title": "Self-reported anal symptoms and their association with anal pathology among gay and bisexual men: a cross-sectional observational analysis", "firstAuthor": "Goddard", "multipleAuthors": true, "journal": "Sex Health", "year": 2021, "design": "prospective-cohort", "n": 616, "nField": "reported", "population": "gay and bisexual men aged 35 and older recruited from community settings", "intervention": "self-reported anal symptoms such as pain when pooping, itching, discharge, lumps, bleeding, sores, tearing, and tenesmus", "comparator": "anal pathology found on physical examination (high-resolution anoscopy) such as fissures, fistulae, ulcers, warts, haemorrhoids and skin conditions", "primaryOutcome": "whether reported anal symptoms matched up with actual anal pathology found on examination", "result": "most men with anal problems like fissures, fistulae, haemorrhoids or skin conditions had no symptoms, and symptoms were not useful markers of most anal pathology", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "this is a one-time self-report survey compared to exam findings in a specific group of men, so recall and selection issues limit how much it tells us about pooping pain in general.", "directness": "indirect", "limitations": "cross-sectional design limits ability to show cause and effect; relies on self-reported symptoms which may be inaccurate; studied only gay and bisexual men, a specific population with higher STI risk", "followUp": "", "plainFinding": "Pain often doesn't match actual anal problems", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33958029/", "sourceText": "UNLABELLED: Background Anal symptoms may indicate serious pathology. Receptive anal intercourse (RAI) and sexually transmissible infections (STIs) may contribute to a higher prevalence of symptoms among gay and bisexual men (GBM). This study investigated associations with anal symptoms among GBM. METHODS: The Study of the Prevention of Anal Cancer was a longitudinal study of anal human papillomavirus and related lesions in Sydney, Australia. GBM aged ≥35 years were recruited from community settings between September 2010 and August 2015. Information about anal symptoms (discharge, itch, pain defecating, lump, bleeding, 'sores', tearing, tenesmus), STIs and sexual behaviours was collected. High-resolution anoscopy (HRA) and STI testing were performed. Logistic regression analyses on baseline data were performed to assess associations with each symptom. RESULTS: Among 616 participants (median age 49 years, 35.9% HIV positive), 35.3% reported at least one anal symptom within the past week and 65.3% were diagnosed with fistula, fissure, ulcer, warts, haemorrhoids and/or perianal dermatoses at HRA. Anal symptoms were not associated with anal chlamydia, gonorrhoea, warts or syphilis. Self-reported 'sores' were associated with previous anal herpes simplex virus (HSV; P < 0.001). 'Sores' (P < 0.001), itch (P = 0.019), discharge (P = 0.032) and lump (P = 0.028) were independently associated with ulceration. Among participants diagnosed with fissure, fistulae, haemorrhoids and perianal dermatoses, 61.9%, 100%, 62.0% and 63.9% respectively were asymptomatic. Only self-reported anal tear was independently associated with recent RAI. CONCLUSIONS: Previous anal HSV was the only STI associated with any symptom. Anal pathology was highly prevalent, but often asymptomatic. Anal symptoms do not appear to be useful markers of most anal pathology in GBM.", "provenance": [ { "field": "n", "quote": "Among 616 participants (median age 49 years, 35.9% HIV positive)" }, { "field": "population", "quote": "GBM aged ≥35 years were recruited from community settings between September 2010 and August 2015" }, { "field": "intervention", "quote": "Information about anal symptoms (discharge, itch, pain defecating, lump, bleeding, 'sores', tearing, tenesmus), STIs and sexual behaviours was collected." }, { "field": "comparator", "quote": "High-resolution anoscopy (HRA) and STI testing were performed." }, { "field": "primaryOutcome", "quote": "Logistic regression analyses on baseline data were performed to assess associations with each symptom." }, { "field": "result", "quote": "Among participants diagnosed with fissure, fistulae, haemorrhoids and perianal dermatoses, 61.9%, 100%, 62.0% and 63.9% respectively were asymptomatic." }, { "field": "result", "quote": "Anal symptoms do not appear to be useful markers of most anal pathology in GBM." } ] }, { "id": "pmid:33825411", "pmid": "33825411", "doi": null, "nctId": null, "pmcid": null, "title": "Efficacy and safety of Hemoheal cream in patients with hemorrhoids: a randomized double-blind placebo controlled clinical trial", "firstAuthor": "Mehdi", "multipleAuthors": true, "journal": "J Tradit Chin Med", "year": 2021, "design": "rct", "n": 52, "nField": "reported", "population": "patients with symptomatic hemorrhoids", "intervention": "Hemoheal herbal cream (plant extract preparation)", "comparator": "placebo cream", "primaryOutcome": "severity of anal irritation, bleeding, itching, pain, defecation discomfort, swelling, and overall improvement", "result": "significant improvement in anal irritation, bleeding, pain and swelling sense with Hemoheal vs placebo, but no significant difference in itching or defecation discomfort; overall subjective improvement was significantly better with Hemoheal", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Small trial of only 52 patients with short 3-week follow-up limits confidence in the findings.", "directness": "indirect", "limitations": "Small sample size; short treatment duration; studies hemorrhoids rather than general post-defecation anal pain.", "followUp": "3 weeks", "plainFinding": "Herbal cream eased some hemorrhoid pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33825411/", "sourceText": "OBJECTIVE: To evaluate the efficacy and safety of Hemoheal cream, an anti-hemorrhoid herbal preparation, (inspired by Persian medicine literatures in a double-blind, randomized placebo-controlled trial. METHODS: Hemoheal cream consists of aqueous extract of Allium ampeloprasum L., Commiphora mukul (Hook. Ex Stocks) Engl and the oil of Sesamum indicum L. Fifty-two patients with symptomatic hemorrhoids were randomized to receive hemoheal cream or placebo for 3 weeks. The patients were evaluated before and after the intervention in terms of the severity of anal irritation, bleeding, anal itching, pain, defecation discomfort and swelling sense, and overall subjective improvement (%), as well as any reported adverse events. RESULTS: The results showed that after 3 weeks of treatment, distribution of anal irritation, bleeding, pain as well as swelling sense were significantly different (P < 0.05), while the analysis showed no significant differences between two groups for anal itching and defecation discomfort (P > 0.05). Furthermore, a significant difference was observed between the overall subjective improvement of Hemoheal cream and placebo groups (P = 0.012). One patient in the treatment group complained of rashes on the application site. CONCLUSION: The present study showed a positive effect of Hemoheal cream in improving clinical signs and symptoms in patients with hemorrhoids.", "provenance": [ { "field": "n", "quote": "Fifty-two patients with symptomatic hemorrhoids were randomized" }, { "field": "population", "quote": "patients with symptomatic hemorrhoids" }, { "field": "intervention", "quote": "Hemoheal cream consists of aqueous extract of Allium ampeloprasum L., Commiphora mukul (Hook. Ex Stocks) Engl and the oil of Sesamum indicum L." }, { "field": "comparator", "quote": "receive hemoheal cream or placebo for 3 weeks" }, { "field": "primaryOutcome", "quote": "severity of anal irritation, bleeding, anal itching, pain, defecation discomfort and swelling sense, and overall subjective improvement (%)" }, { "field": "result", "quote": "distribution of anal irritation, bleeding, pain as well as swelling sense were significantly different (P < 0.05), while the analysis showed no significant differences between two groups for anal itching and defecation discomfort (P > 0.05)" }, { "field": "followUp", "quote": "after 3 weeks of treatment" } ] }, { "id": "pmid:33778381", "pmid": "33778381", "doi": "10.47717/turkjsurg.2020.4492", "nctId": null, "pmcid": "PMC7963312", "title": "Comparison of the effectiveness of two treatment modalities for chronic anal fissure: Botox versus sphincterotomy", "firstAuthor": "Cakir", "multipleAuthors": true, "journal": "Turk J Surg", "year": 2020, "design": "retrospective", "n": 135, "nField": "reported", "population": "patients with chronic anal fissure", "intervention": "botulinum toxin (Botox) injection into the anal sphincter", "comparator": "lateral internal sphincterotomy (surgical cutting of the anal sphincter muscle)", "primaryOutcome": "post-defecation pain, symptom remission, relapse, and treatment satisfaction", "result": "Surgery group had longer symptom duration, hospital stay, and time to remission, while the Botox group had more anal itching and more relapses; satisfaction and complication rates were similar between groups.", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a retrospective, non-randomized study comparing two treatments without a placebo group, so differences could be due to patient selection rather than the treatments themselves.", "directness": "direct", "limitations": "Retrospective design, multi-center data pooling, reliance on hospital records and patient recall, and no randomization between treatment groups.", "followUp": "", "plainFinding": "Botox and surgery gave similar relief.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33778381/", "sourceText": "OBJECTIVES: Anal fissure is a common health problem that affects the quality of life of young patients. The aim of our study was to benchmark results of lateral internal sphincterotomy (LIS) and botulinum toxin injection in the treatment of chronic anal fissure. MATERIAL AND METHODS: This multi-center, retrospective study used data from 135 chronic anal fissure patients. Patients' demographic features, clinical findings, fissure characteristics, post-defecation pain score, rectal bleeding or pruritus, and treatment satisfaction scores were recorded. Patients' data were collected from the hospital records and patients with all of this data available were called and invited to the hospital for examination. RESULTS: Seventy-four LIS and 61 botulinum toxin applied patients were included. Symptom duration, hospitalization period, and duration of remission of complaints after the treatment were significantly higher in the LIS group (p<0.001). However, pruritus in anus and relapses were found to be higher in the botulinum toxin group (p=¬ 0.04 and p= 0.043, respectively). Abscess and fistula were observed in one patient's perianal region in the LIS group, and an abscess was observed in one patient in the botulinum toxin group. There was no significant difference in treatment satisfaction rates and postoperative complications. CONCLUSION: Botulinum toxin yields satisfying results that are comparable to LIS. Patient selection may help mitigate this disease and allow it to be considered a good alternative option to surgery.", "provenance": [ { "field": "n", "quote": "This multi-center, retrospective study used data from 135 chronic anal fissure patients." }, { "field": "population", "quote": "chronic anal fissure patients" }, { "field": "intervention", "quote": "botulinum toxin injection in the treatment of chronic anal fissure" }, { "field": "comparator", "quote": "lateral internal sphincterotomy (LIS)" }, { "field": "primaryOutcome", "quote": "post-defecation pain score, rectal bleeding or pruritus, and treatment satisfaction scores were recorded" }, { "field": "result", "quote": "Symptom duration, hospitalization period, and duration of remission of complaints after the treatment were significantly higher in the LIS group (p<0.001). However, pruritus in anus and relapses were found to be higher in the botulinum toxin group (p=¬ 0.04 and p= 0.043, respectively)." }, { "field": "result", "quote": "There was no significant difference in treatment satisfaction rates and postoperative complications." } ] }, { "id": "pmid:33549027", "pmid": "33549027", "doi": "10.21037/apm-20-2109", "nctId": null, "pmcid": null, "title": "Efficacy and safety of pudendal nerve block for postoperative analgesia of hemorrhoids: a systematic review of 7 randomized controlled trials", "firstAuthor": "Li", "multipleAuthors": true, "journal": "Ann Palliat Med", "year": 2021, "design": "meta-analysis", "n": 560, "nField": "reported", "population": "patients having hemorrhoid surgery", "intervention": "pudendal nerve block for pain control after hemorrhoid surgery", "comparator": "standard care without pudendal nerve block", "primaryOutcome": "pain scores and need for painkillers after hemorrhoid surgery", "result": "pudendal nerve block lowered pain scores, reduced need for analgesics and reduced side effects, with no difference in bleeding", "resultDirection": "benefit", "quality": "low", "qualityWhy": "The review pooled only 7 small trials with likely differences between them, and the authors say bigger, better studies are still needed.", "directness": "indirect", "limitations": "Small number of trials and participants; authors state results need confirmation by high-quality, multi-center studies.", "followUp": "", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33549027/", "sourceText": "Pudendal nerve block (PNB) is one of the common anesthesia methods, which has been widely applied in postoperative analgesia of hemorrhoids in recent years. To analyze the effectiveness and safety of PNB on postoperative analgesia of hemorrhoids, we conducted a systematic review of 7 randomized controlled trials (RCT) searched from PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), the China Network Knowledge Infrastructure (CNKI), the Wan Fang Database and Chinese Biomedicine (CBM), which were published before 7th September, 2020, and involved a total of 560 participants. We evaluated the function of PNB in improving outcomes of postoperative analgesia of hemorrhoids. Visual analogue scale (VAS) scores on postoperative 6, 12, 24, 48 h and the first time of defecation were enhanced by the application of PNB. The incidence of urinary retention, the need for analgesics [odds ratio (OR), 0.11; 95% CI, 0.04-0.37; P=0.0003] and the incidence of side effects (OR, 0.12; 95% CI, 0.04-0.39; P=0.004) in patients receiving PNB were lower than those of controls. In addition, there was no significant difference in the incidence of bleeding between groups. PNB could effectively relieve postoperative pain of hemorrhoids and reduce complications without increasing the incidence of side effects. Our results still need to be confirmed by high-quality, multi-center clinical studies.", "provenance": [ { "field": "n", "quote": "involved a total of 560 participants" }, { "field": "population", "quote": "postoperative analgesia of hemorrhoids" }, { "field": "intervention", "quote": "Pudendal nerve block (PNB) is one of the common anesthesia methods, which has been widely applied in postoperative analgesia of hemorrhoids" }, { "field": "comparator", "quote": "lower than those of controls" }, { "field": "primaryOutcome", "quote": "Visual analogue scale (VAS) scores on postoperative 6, 12, 24, 48 h and the first time of defecation were enhanced by the application of PNB." }, { "field": "result", "quote": "The incidence of urinary retention, the need for analgesics [odds ratio (OR), 0.11; 95% CI, 0.04-0.37; P=0.0003] and the incidence of side effects (OR, 0.12; 95% CI, 0.04-0.39; P=0.004) in patients receiving PNB were lower than those of controls." }, { "field": "result", "quote": "there was no significant difference in the incidence of bleeding between groups" }, { "field": "limitations", "quote": "Our results still need to be confirmed by high-quality, multi-center clinical studies." } ] }, { "id": "pmid:33532889", "pmid": "33532889", "doi": "10.1007/s00431-021-03965-9", "nctId": null, "pmcid": "PMC8105195", "title": "Perianal streptococcal disease in childhood: systematic literature review", "firstAuthor": "Gualtieri", "multipleAuthors": true, "journal": "Eur J Pediatr", "year": 2021, "design": "systematic-review", "n": null, "nField": "not-reported", "population": "children, mostly boys 7 years old or younger", "intervention": "no treatment tested; review describes diagnosis and clinical features of perianal strep infection", "comparator": "none - descriptive review, not a treatment comparison", "primaryOutcome": "clinical features, recurrence rate, and accuracy of rapid strep tests for perianal infection", "result": "perianal pain, itch, bleeding or fissure with sharply demarcated redness were typical; diagnosis often took 3+ weeks; infection recurred in about 20% of cases; rapid strep tests had 80% positive and 96% negative predictive value", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a descriptive review of case reports and small studies without statistical pooling, so it describes patterns but cannot prove cause and effect strongly.", "directness": "indirect", "limitations": "findings come from pooled case literature on a specific childhood condition, not a general study of anal pain after bowel movements in all ages.", "followUp": "3½ months", "plainFinding": "Strep bacteria cause childhood anal pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33532889/", "sourceText": "Group A Streptococcus has been associated with a perianal infection. We conducted a systematic review of the literature on childhood streptococcal perianitis in three databases: Excerpta Medica, National Library of Medicine, and Web of Science. The main purposes were to document the clinical features, the tendency to recur, the association with an asymptomatic streptococcal throat carriage, the accuracy of rapid streptococcal tests, and the mechanism possibly underlying the acquisition of this infection. More than 80% of cases are boys ≤7.0 years of age with defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness. Perianitis is associated with a streptococcal tonsillopharyngitis in about every fifth case. The time to diagnosis is ≥3 weeks in 65% of cases. Recurrences occur within 3½ months in about 20% of cases. An asymptomatic group A streptococcal throat carriage occurs in 63% of cases. As compared with perianal Streptococcus A culture, the rapid streptococcal tests have a positive predictive value of 80% and a negative predictive value of 96%. It is hypothesized that digital inoculation from nasopharynx to anus underlies perianitis. Many cases are likely caused directly by children, who are throat and nasal carriers of Streptococcus A. Some cases might occur in children, who have their bottoms wiped by caregivers with streptococcal tonsillopharyngitis or carriage of Streptococcus.Conclusion: Perianitis is an infection with a distinctive presentation and a rather long time to diagnosis. There is a need for a wider awareness of this condition among healthcare professionals. What is Known: • Group A Streptococcus may cause perianitis in childhood. • Systemic antimicrobials (penicillin V, amoxycillin, or cefuroxime) are superior to topical treatment. What is New: • The clinical presentation is distinctive (defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness). • The time to diagnosis is usually ≥3 weeks. Recurrences occur in about 20% of cases.", "provenance": [ { "field": "population", "quote": "More than 80% of cases are boys ≤7.0 years of age with defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness." }, { "field": "primaryOutcome", "quote": "The main purposes were to document the clinical features, the tendency to recur, the association with an asymptomatic streptococcal throat carriage, the accuracy of rapid streptococcal tests, and the mechanism possibly underlying the acquisition of this infection." }, { "field": "result", "quote": "The time to diagnosis is ≥3 weeks in 65% of cases. Recurrences occur within 3½ months in about 20% of cases." }, { "field": "result", "quote": "As compared with perianal Streptococcus A culture, the rapid streptococcal tests have a positive predictive value of 80% and a negative predictive value of 96%." }, { "field": "intervention", "quote": "Systemic antimicrobials (penicillin V, amoxycillin, or cefuroxime) are superior to topical treatment." }, { "field": "comparator", "quote": "Systemic antimicrobials (penicillin V, amoxycillin, or cefuroxime) are superior to topical treatment." } ] }, { "id": "pmid:33439376", "pmid": "33439376", "doi": "10.1007/s10103-021-03249-6", "nctId": null, "pmcid": null, "title": "Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis", "firstAuthor": "Crea", "multipleAuthors": true, "journal": "Lasers Med Sci", "year": 2022, "design": "case-series", "n": 189, "nField": "reported", "population": "Patients with second- to third-degree hemorrhoids with mild-to-moderate prolapse", "intervention": "Hemorrhoid laser procedure (HeLP)", "comparator": "None (no comparison group)", "primaryOutcome": "Pain after surgery, hemorrhoid grade improvement, and recurrence of hemorrhoid disease", "result": "Pain after surgery was absent in 94% of patients, with symptom improvement in about 90% over follow-up", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was an uncontrolled case series without a comparison group, so it can't prove the laser caused the improvement.", "directness": "indirect", "limitations": "No control group, single intervention tracked, relies on patient-reported improvement scale", "followUp": "42 months", "plainFinding": "Laser hemorrhoid treatment reduced pain long-term", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33439376/", "sourceText": "We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a \"plateau\" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.", "provenance": [ { "field": "n", "quote": "A total of 189 patients were treated between April 2012 and October 2017." }, { "field": "population", "quote": "patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse" }, { "field": "intervention", "quote": "5-year consecutive use of the hemorrhoidal laser procedure (HeLP)" }, { "field": "comparator", "quote": "We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD)." }, { "field": "primaryOutcome", "quote": "postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD)" }, { "field": "result", "quote": "Pain after surgery was absent in 94% of patients." }, { "field": "result", "quote": "The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up." }, { "field": "followUp", "quote": "The median follow-up was 42 months (range 6-62 months)." } ] }, { "id": "pmid:33415419", "pmid": "33415419", "doi": "10.1007/s00464-020-08248-2", "nctId": null, "pmcid": null, "title": "Doppler-guided hemorrhoidal dearterialization with laser (HeLP): indications and clinical outcome in the long-term. Results of a multicenter trial", "firstAuthor": "Giamundo", "multipleAuthors": true, "journal": "Surg Endosc", "year": 2022, "design": "case-series", "n": 284, "nField": "reported", "population": "Adults with hemorrhoids (183 men, 101 women, average age 47.5) having pain, bleeding, or other symptoms", "intervention": "Doppler-guided laser treatment to close the blood vessels feeding hemorrhoids (HeLP procedure)", "comparator": "None – all patients received the same treatment, no control group", "primaryOutcome": "Whether hemorrhoid-related symptoms (bleeding, pain, frequency of flare-ups) went away", "result": "89.9% of patients had their symptoms resolve after 2 years, with significant improvement in quality of life, pain, and bleeding", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a single-arm study with no comparison group, so it can't prove the laser procedure itself caused the improvement.", "directness": "indirect", "limitations": "No control group for comparison; some patients lost to follow-up; failure rates were higher in patients with constipation or more severe hemorrhoids.", "followUp": "2-year follow-up", "plainFinding": "Laser hemorrhoid treatment reduced pain long-term.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33415419/", "sourceText": "BACKGROUND: Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure. METHODS: Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis. RESULTS: Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation. CONCLUSIONS: The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed.", "provenance": [ { "field": "n", "quote": "Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial" }, { "field": "population", "quote": "Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial" }, { "field": "intervention", "quote": "Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy." }, { "field": "comparator", "quote": "Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up." }, { "field": "primaryOutcome", "quote": "Primary endpoint was resolution of symptoms" }, { "field": "result", "quote": "Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients." } ] }, { "id": "pmid:33371715", "pmid": "33371715", "doi": "10.1177/0003134820981683", "nctId": null, "pmcid": null, "title": "The Effect of Perianal Tramadol Infiltration on Postoperative Pain Following Hemorrhoidectomy", "firstAuthor": "Hatami", "multipleAuthors": true, "journal": "Am Surg", "year": 2022, "design": "rct", "n": 90, "nField": "reported", "population": "patients with grade 3 and 4 hemorrhoids undergoing surgery to remove them", "intervention": "local injection of tramadol around the anus before surgery", "comparator": "local injection of bupivacaine or saline (placebo) before surgery", "primaryOutcome": "pain severity after hemorrhoid surgery, including pain during first bowel movement", "result": "tramadol group had significantly different (lower) pain scores at all times after surgery, including at first bowel movement, compared to the other groups", "resultDirection": "benefit", "quality": "low", "qualityWhy": "small trial of surgical patients, not people with ordinary post-bowel-movement anal pain, so it doesn't directly answer why pooping hurts in general.", "directness": "indirect", "limitations": "Small sample size (90 patients across 3 groups); population is specifically post-hemorrhoidectomy surgical patients, not general anal pain after defecation.", "followUp": "", "plainFinding": "Less pain after hemorrhoid surgery with tramadol.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33371715/", "sourceText": "INTRODUCTION: The present study was attempted to evaluate the effect of perianal infiltration of tramadol on postoperative pain in patients undergoing hemorrhoidectomy. METHOD: This double-blind clinical trial study was carried out on 90 patients with grade 3 and 4 hemorrhoids undergoing hemorrhoidectomy. Patients were randomly assigned into 3 groups of control or bupivacaine or tramadol. Before the surgery, perianal infiltration of .25% bupivacaine or tramadol or normal saline was prescribed to each group, respectively. Data on pain severity (based on the visual analog scale (VAS), the duration of surgery, sedation score, pain at the first defecation, first request time for additional analgesia, nausea and vomiting, and analgesic intakes) were evaluated and analyzed. RESULTS: Duration of surgery was almost similar in all 3 groups (P = .974). The results showed a significant difference in pain score between 3 groups (P ≤.05) at all times after the surgery. In addition, the means of sedation scores (P = .03), pain score at the first defecation (P = .001), the time to first analgesic request (P = .001), and ketorolac administration times (P = .01) were significantly different between 3 groups. Finally, no complication was reported regarding postoperative nausea and vomiting. CONCLUSION: Given the notable efficacy of tramadol in reducing pain after hemorrhoidectomy and its minor side effects, this medication is suggested as an effective topical anesthetic to decrease pain after hemorrhoidectomy.", "provenance": [ { "field": "n", "quote": "90 patients with grade 3 and 4 hemorrhoids undergoing hemorrhoidectomy" }, { "field": "population", "quote": "patients with grade 3 and 4 hemorrhoids undergoing hemorrhoidectomy" }, { "field": "intervention", "quote": "perianal infiltration of tramadol on postoperative pain in patients undergoing hemorrhoidectomy" }, { "field": "comparator", "quote": "Patients were randomly assigned into 3 groups of control or bupivacaine or tramadol." }, { "field": "primaryOutcome", "quote": "Data on pain severity (based on the visual analog scale (VAS), the duration of surgery, sedation score, pain at the first defecation, first request time for additional analgesia, nausea and vomiting, and analgesic intakes) were evaluated and analyzed." }, { "field": "result", "quote": "The results showed a significant difference in pain score between 3 groups (P ≤.05) at all times after the surgery. In addition, the means of sedation scores (P = .03), pain score at the first defecation (P = .001)" } ] }, { "id": "pmid:33092570", "pmid": "33092570", "doi": "10.1186/s12893-020-00914-5", "nctId": null, "pmcid": "PMC7583301", "title": "Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR)", "firstAuthor": "Gallo", "multipleAuthors": true, "journal": "BMC Surg", "year": 2020, "design": "retrospective", "n": 398, "nField": "reported", "population": "patients who had surgery to remove severe hemorrhoids", "intervention": "mesoglycan medication after hemorrhoid removal surgery", "comparator": "no mesoglycan (standard post-surgical care)", "primaryOutcome": "pain levels after bowel movements and other times, plus clot formation and healing after surgery", "result": "mesoglycan group had less pain, less clotting, and recovered independence faster", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a retrospective observational study without random assignment, so differences between groups could be due to other factors.", "directness": "indirect", "limitations": "retrospective design (not randomized), and it studies pain after hemorrhoid surgery specifically, not general pain after normal bowel movements", "followUp": "6 weeks", "plainFinding": "Less pain after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": true, "url": "https://pubmed.ncbi.nlm.nih.gov/33092570/", "sourceText": "BACKGROUND: Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). METHODS: This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. RESULTS: In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). CONCLUSIONS: The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698-Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1.", "provenance": [ { "field": "n", "quote": "Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled." }, { "field": "population", "quote": "patients who underwent open excisional diathermy haemorrhoidectomy (OEH)" }, { "field": "intervention", "quote": "The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain" }, { "field": "comparator", "quote": "There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding." }, { "field": "primaryOutcome", "quote": "VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated." }, { "field": "result", "quote": "all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003)" }, { "field": "design", "quote": "This was a retrospective multicentre observational study." }, { "field": "followUp", "quote": "after 1 week (T2), 3 weeks (T3) and 6 weeks (T4)" } ] }, { "id": "pmid:32972107", "pmid": "32972107", "doi": "10.3393/ac.2020.08.10", "nctId": null, "pmcid": "PMC8566150", "title": "Is There a Relationship Between Stool Consistency and Pain at First Defecation After Limited Half Hemorrhoidectomy? A Pilot Study", "firstAuthor": "Yano", "multipleAuthors": false, "journal": "Ann Coloproctol", "year": 2021, "design": "prospective-cohort", "n": 61, "nField": "reported", "population": "patients who had surgery for severe hemorrhoids (grade III or IV)", "intervention": "soft or hard stool consistency at first bowel movement after surgery", "comparator": "normal stool consistency", "primaryOutcome": "pain intensity during first bowel movement after surgery", "result": "no significant difference in pain across stool consistency groups", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "small pilot study with self-reported pain scores and no control for other factors affecting pain", "directness": "indirect", "limitations": "small pilot study, self-recorded measures, only examined first defecation after hemorrhoidectomy surgery", "followUp": "", "plainFinding": "Stool softness didn't affect pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32972107/", "sourceText": "PURPOSE: While the first defecation pain is a problem following hemorrhoidectomy, it is unknown whether the stool consistency has an influence on pain. This pilot study aimed to investigate whether the intensity of defecation pain varied according to stool consistency. METHODS: This prospective cohort study evaluated patients who underwent hemorrhoidectomy in combination with injection sclerotherapy for grade III or IV hemorrhoids. The pain intensity and stool form during the first postoperative defecation were self-recorded by the patients using a visual analogue scale (score of 0-10) and Bristol Stool Form Scale, respectively. The patients were classified into 3 groups according to stool consistency, and the intensity of defecation pain was compared among the groups using analysis of variance. RESULTS: A total of 61 patients were eligible for this study and were classified into the hard stool (n=15), normal stool (n=21), and soft stool groups (n=25). No significant intergroup differences were identified in the intensity of pain at defecation (P=0.29). CONCLUSION: This pilot study demonstrated that there were no clear differences in pain intensity during the first defecation after surgery among the 3 groups with different levels of stool consistency.", "provenance": [ { "field": "n", "quote": "A total of 61 patients were eligible for this study and were classified into the hard stool (n=15), normal stool (n=21), and soft stool groups (n=25)." }, { "field": "population", "quote": "evaluated patients who underwent hemorrhoidectomy in combination with injection sclerotherapy for grade III or IV hemorrhoids" }, { "field": "intervention", "quote": "The patients were classified into 3 groups according to stool consistency" }, { "field": "comparator", "quote": "normal stool" }, { "field": "primaryOutcome", "quote": "The pain intensity and stool form during the first postoperative defecation were self-recorded by the patients using a visual analogue scale (score of 0-10)" }, { "field": "result", "quote": "No significant intergroup differences were identified in the intensity of pain at defecation (P=0.29)." } ] }, { "id": "pmid:32904150", "pmid": "32904150", "doi": "10.1016/j.amsu.2020.08.010", "nctId": null, "pmcid": "PMC7452092", "title": "Safety and efficacy of the treatment of chronic anal fissure by lateral internal sphincterotomy: A retrospective cohort study", "firstAuthor": "Al-Thoubaity", "multipleAuthors": false, "journal": "Ann Med Surg (Lond)", "year": 2020, "design": "retrospective", "n": 691, "nField": "reported", "population": "women with chronic anal fissure (tear near the anus) causing pain during bowel movements", "intervention": "lateral internal sphincterotomy, a surgery that cuts part of the anal sphincter muscle", "comparator": "none - all patients received the surgery, no comparison group", "primaryOutcome": "safety and how well symptoms improved, including recurrence and incontinence rates", "result": "very few fissures came back (0.3%) and few patients had minor gas incontinence (0.4%), which went away over time, with major improvement in pain", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a retrospective study of one surgery with no comparison group, all patients from a single surgeon and all female, so it can't show how much better this is than other options.", "directness": "direct", "limitations": "retrospective design, no control group, single surgeon, all-female patient population limits how broadly results apply", "followUp": "", "plainFinding": "Surgery relieved fissure pain safely.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32904150/", "sourceText": "BACKGROUND: An anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate line. It causes severe pain during defecation, and the resulting emotional stress leads to a reduction in the overall quality of life of a person. There are several medical and surgical treatment procedures that are employed to treat anal fissures. In the present retrospective study, we aimed to evaluate the safety and efficacy of lateral internal sphincterotomy (LIS) surgical procedure for the treatment of chronic anal fissure. Additionally, we also analyzed the complications arising after the surgery and the factors affecting the complications. METHODS: The present study is a retrospective study that included 691 patients treated for chronic anal fissure in a private sector setting, by a single Saudi female surgeon, starting from April 2004 to April 2020. RESULTS: Out of the 691 patients included in the study, all the patients were female, with an average age of 45.77 years (ranging from 17 to 82 years). Major complaints of the patients were as follows: pain, bleeding, constipation, pruritus, perianal discharge. Recurrence was reported in 2 patients (0.3%) while, 3 patients (0.4%) developed gas incontinence.The complaints of all patients with gas incontinence regressed over a period of time. CONCLUSION: This study reports that lateral internal sphincterotomy (LIS) is a safe surgical treatment for chronic anal fissure, leading to a reduction in recurrence, incontinence rate and substantially improves symptoms, especially pain.", "provenance": [ { "field": "population", "quote": "all the patients were female, with an average age of 45.77 years (ranging from 17 to 82 years)" }, { "field": "population", "quote": "patients treated for chronic anal fissure" }, { "field": "intervention", "quote": "lateral internal sphincterotomy (LIS) surgical procedure for the treatment of chronic anal fissure" }, { "field": "comparator", "quote": "691 patients included in the study, all the patients were female" }, { "field": "primaryOutcome", "quote": "we aimed to evaluate the safety and efficacy of lateral internal sphincterotomy (LIS) surgical procedure" }, { "field": "n", "quote": "included 691 patients treated for chronic anal fissure" }, { "field": "result", "quote": "Recurrence was reported in 2 patients (0.3%) while, 3 patients (0.4%) developed gas incontinence.The complaints of all patients with gas incontinence regressed over a period of time." }, { "field": "result", "quote": "leading to a reduction in recurrence, incontinence rate and substantially improves symptoms, especially pain" } ] }, { "id": "pmid:32798197", "pmid": "32798197", "doi": "10.1016/j.joim.2020.08.001", "nctId": null, "pmcid": null, "title": "Effects of the pestle needle therapy, a type of acupoint stimulation, on post-hemorrhoidectomy pain: A randomized controlled trial", "firstAuthor": "Wang", "multipleAuthors": true, "journal": "J Integr Med", "year": 2020, "design": "rct", "n": 154, "nField": "reported", "population": "patients receiving Milligan hemorrhoidectomy surgery", "intervention": "pestle needle therapy, a type of acupoint stimulation given after hemorrhoid surgery", "comparator": "sham treatment with very light pressure at the same points", "primaryOutcome": "pain level measured with a visual analogue scale 12 hours after surgery", "result": "the treatment group had lower pain scores, needed less pain medicine, had less anxiety, and had their first bowel movement sooner than the sham group", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "It was a single-center randomized trial with blinded assessors but only a sham-pressure control, so some bias and limited generalizability remain.", "directness": "indirect", "limitations": "Single-center design; patients (not just assessors) may have noticed which treatment felt different despite blinding attempts; no mention of long-term follow-up beyond 48 hours.", "followUp": "48 h", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32798197/", "sourceText": "BACKGROUND: Hemorrhoids 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. OBJECTIVE: This study evaluates the clinical efficacy of the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: This 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 MEASURES: The 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. RESULTS: The 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). CONCLUSION: The pestle needle therapy was effective for relieving pain, reducing anxiety and improving bowel function after hemorrhoidectomy, and it is worthy of clinical application.", "provenance": [ { "field": "population", "quote": "154 patients receiving Milligan hemorrhoidectomy surgery" }, { "field": "intervention", "quote": "the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain" }, { "field": "comparator", "quote": "the control group received a sham treatment with very light pressure" }, { "field": "primaryOutcome", "quote": "The primary outcome was post-operative pain measured with the visual analogue scale (VAS) at 12 h after surgery" }, { "field": "result", "quote": "The 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." }, { "field": "n", "quote": "154 patients receiving Milligan hemorrhoidectomy surgery" }, { "field": "followUp", "quote": "the VAS scores measured at 0.5, 2, 4, 6, 8, 24 and 48 h after surgery" } ] }, { "id": "pmid:32750730", "pmid": "32750730", "doi": "10.1111/codi.15291", "nctId": null, "pmcid": null, "title": "Efficacy of postoperative oral metronidazole for haemorrhoidectomy pain: a randomized double-blind, placebo-controlled trial", "firstAuthor": "Wilkie", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2021, "design": "rct", "n": 40, "nField": "reported", "population": "patients recovering from haemorrhoidectomy surgery", "intervention": "oral metronidazole plus standard care after haemorrhoid surgery", "comparator": "placebo plus standard care", "primaryOutcome": "pain scores after surgery measured over 21 days", "result": "no significant difference in pain scores between metronidazole and placebo groups", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "it was a small trial of only 40 patients and the small pain trend seen did not hold up after correcting for multiple comparisons", "directness": "indirect", "limitations": "small sample size of 40 patients; apparent trend toward benefit lost significance after Bonferroni correction", "followUp": "21 days", "plainFinding": "No pain relief after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32750730/", "sourceText": "AIM: The aim of this work was to examine the efficacy of oral metronidazole in reducing posthaemorrhoidectomy pain versus placebo. METHOD: 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 21 days, measured on a 10-point Likert scale. RESULTS: 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). CONCLUSION: 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.", "provenance": [ { "field": "n", "quote": "Forty patients were randomized to either metronidazole and standard care or placebo and standard care (21 metronidazole, 19 placebo)" }, { "field": "population", "quote": "posthaemorrhoidectomy pain" }, { "field": "intervention", "quote": "metronidazole and standard care" }, { "field": "comparator", "quote": "placebo and standard care" }, { "field": "primaryOutcome", "quote": "posthaemorrhoidectomy pain scores over 21 days, measured on a 10-point Likert scale" }, { "field": "result", "quote": "treatment allocation (placebo versus metronidazole) did not significantly affect the improvement in patients' reported pain (P = 0.8837)" }, { "field": "result", "quote": "Our data do not support the hypothesis that postoperative metronidazole has a clinically meaningful effect on posthaemorrhoidectomy pain." } ] }, { "id": "pmid:32609161", "pmid": "32609161", "doi": "10.1590/S0004-2803.202000000-36", "nctId": null, "pmcid": null, "title": "PREVALENCE AND FACTORS ASSOCIATED WITH CONSTIPATION IN PREMENOPAUSAL WOMEN: A COMMUNITY-BASED STUDY", "firstAuthor": "Dantas", "multipleAuthors": true, "journal": "Arq Gastroenterol", "year": 2020, "design": "retrospective", "n": 195, "nField": "reported", "population": "premenopausal women in northeastern Brazil", "intervention": "having constipation (Rome III criteria)", "comparator": "not having constipation", "primaryOutcome": "factors associated with constipation, including pain and burning sensation on bowel movement", "result": "pain and burning sensation during bowel movements, along with hemorrhoids and sexual dysfunction, were linked to constipation", "resultDirection": "harm", "quality": "low", "qualityWhy": "This is a cross-sectional study that can show links but cannot prove constipation causes the pain, and it relies on self-reported symptoms.", "directness": "indirect", "limitations": "Cross-sectional design cannot establish cause and effect; based on self-report; specific population (premenopausal women, one region) may not generalize.", "followUp": "", "plainFinding": "Constipation linked to painful, burning bowel movements.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32609161/", "sourceText": "BACKGROUND: Intestinal constipation is characterized by problems related to evacuation, and presents high prevalence in the female gender. This condition has demonstrated negative effects on the development of daily activities, causing damage to the physical and emotional well-being of individuals who are diagnosed with it. Studies that investigate what health impairments intestinal constipation can cause are scarce in the literature. OBJECTIVE: This study aimed to verify the prevalence and factors associated with intestinal constipation in premenopausal women living in Northeastern Brazil. METHODS: It is a cross-sectional study. This was carried out in the northeast of Brazil. Participated 195 women, adult and middle age. Social conditions, habits and lifestyle, clinical aspects and obstetric history were investigated. Constipation was diagnosed using the Rome III Criteria. Multivariate analysis was conducted using Poisson Regression with robust variance to analyze the relationship between intestinal constipation and independent variables. A statistical significance level of P<0.05 was considered. RESULTS: Most of the women were between 25 and 39 years old (49.2%) and had an income of up to one minimum wage (79.5%). The intestinal constipation prevalence was 35.4%. In the final multivariate regression model, hemorrhoid clinical aspects (P=0.01), pain (P=0.001) and a burning sensation (P=0.01) on bowel movement, and sexual dysfunction (P=0.03) remained associated with constipation. CONCLUSION: The present study found a significant prevalence of constipation among premenopausal women and clinical factors such as hemorrhoids, pain and a burning sensation, and sexual dysfunction were associated with intestinal constipation.", "provenance": [ { "field": "n", "quote": "Participated 195 women, adult and middle age." }, { "field": "population", "quote": "premenopausal women living in Northeastern Brazil" }, { "field": "intervention", "quote": "Constipation was diagnosed using the Rome III Criteria." }, { "field": "comparator", "quote": "Constipation was diagnosed using the Rome III Criteria." }, { "field": "primaryOutcome", "quote": "verify the prevalence and factors associated with intestinal constipation" }, { "field": "result", "quote": "hemorrhoid clinical aspects (P=0.01), pain (P=0.001) and a burning sensation (P=0.01) on bowel movement, and sexual dysfunction (P=0.03) remained associated with constipation" } ] }, { "id": "pmid:32509650", "pmid": "32509650", "doi": "10.4103/jfmpc.jfmpc_944_19", "nctId": null, "pmcid": "PMC7266196", "title": "Therapeutic properties of botulinum toxin on chronic anal fissure treatment and the patient factors role", "firstAuthor": "Soltany", "multipleAuthors": true, "journal": "J Family Med Prim Care", "year": 2020, "design": "case-series", "n": 106, "nField": "reported", "population": "patients with chronic anal fissure", "intervention": "botulinum toxin injection (30 units)", "comparator": "none (single-arm, no control group)", "primaryOutcome": "healing of the anal fissure", "result": "84.9% of patients healed, with mean healing time of 4.68 weeks", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small study with no comparison group, so it can't prove the treatment caused the improvement.", "directness": "indirect", "limitations": "No control group; heterogeneity among prior studies noted; case-series design without randomization", "followUp": "8 weeks", "plainFinding": "Most fissures healed with injection.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32509650/", "sourceText": "BACKGROUND: One of the most frequent distressing diseases which causes anal pain and bleeding after defecation is anal fissure. Despite a poorly understood pathogenesis, the internal anal sphincter spasm has been identified to play a central role in pathogenesis. Recently, botulinum toxin is being used increasingly for the treatment of chronic anal fissure to achieve chemical sphincterotomy and reduce internal sphincter tonicity. Based on the heterogeneity among the published studies, we aimed this study to evaluate its healing rate and for recognizing the factors of patients which may affect the outcome. SUBJECTS AND METHODS: In a prospective case series medical research, 106 patients who suffer from chronic anal fissure were treated by botulinum toxin injections. All patients received 30 units of botulinum toxin and were physically examined every week for 2 months. They were evaluated for bleeding, pain, hematoma, thrombosis, infection, incontinence, and healing of the fissure. At the end of the follow-up period, the fissure healing rate and its relation to age, gender, prior topical therapy, duration of symptoms, and the position of the fissure were assessed. RESULTS: At the end of the study (8 weeks), the healing rate was 84.9% (90 patients responded to injections). Healing rate was higher in females and in patients who experienced a shorter duration of symptoms before injection. The mean healing time was 4.68 weeks. In addition, patients with one fissure (anterior or posterior) demonstrated higher healing rate and shorter healing time compared to patients with two fissures (anterior and posterior). CONCLUSION: This study demonstrated that botulinum toxin injection is safe and effective for the treatment of chronic anal fissures, with a low complication rate. In addition, the healing rate was higher in females, patients with shorter duration of symptoms, and those with one fissure.", "provenance": [ { "field": "population", "quote": "106 patients who suffer from chronic anal fissure" }, { "field": "intervention", "quote": "All patients received 30 units of botulinum toxin" }, { "field": "comparator", "quote": "prospective case series medical research" }, { "field": "primaryOutcome", "quote": "fissure healing rate" }, { "field": "result", "quote": "the healing rate was 84.9% (90 patients responded to injections)" }, { "field": "n", "quote": "106 patients who suffer from chronic anal fissure were treated by botulinum toxin injections" }, { "field": "followUp", "quote": "At the end of the study (8 weeks)" } ] }, { "id": "pmid:32412899", "pmid": "32412899", "doi": "10.5152/tjg.2020.19183", "nctId": null, "pmcid": "PMC7236649", "title": "Recovery from hemorrhoids and anal fissure without surgery", "firstAuthor": "Şişik", "multipleAuthors": true, "journal": "Turk J Gastroenterol", "year": 2020, "design": "case-control", "n": 180, "nField": "reported", "population": "adults with hemorrhoids or anal fissure compared to healthy people", "intervention": "having hard stools, straining, spending more than 5 minutes on the toilet, spicy food, and anxiety", "comparator": "healthy individuals without hemorrhoids or anal fissure", "primaryOutcome": "whether toilet habits, diet, and anxiety are linked to hemorrhoids and anal fissure", "result": "hard stools, long toilet time, straining, and (for fissures) anxiety were more common in patients with these conditions than in healthy people", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a small questionnaire-based study comparing groups after the fact, so it can show links but not prove what causes the pain.", "directness": "direct", "limitations": "relies on patient-reported survey answers and compares groups after diagnosis rather than following people over time", "followUp": "", "plainFinding": "Straining and hard stools linked to pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32412899/", "sourceText": "BACKGROUND/AIMS: An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF. MATERIALS AND METHODS: A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors. RESULTS: Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05). CONCLUSION: Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.", "provenance": [ { "field": "n", "quote": "patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals" }, { "field": "population", "quote": "patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals" }, { "field": "intervention", "quote": "Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD" }, { "field": "comparator", "quote": "compared with the control group (n=60) of healthy individuals" }, { "field": "primaryOutcome", "quote": "The survey was designed to assess the participants' toilet and dietary habits and anxiety risk." }, { "field": "result", "quote": "hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05)" } ] }, { "id": "pmid:32246662", "pmid": "32246662", "doi": "10.4103/njcp.njcp_383_19", "nctId": null, "pmcid": null, "title": "Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure", "firstAuthor": "Acar", "multipleAuthors": true, "journal": "Niger J Clin Pract", "year": 2020, "design": "rct", "n": 550, "nField": "reported", "population": "people with chronic anal fissure (a tear in the skin near the anus)", "intervention": "topical ointments (nitroglycerin or diltiazem) or surgical lateral internal sphincterotomy", "comparator": "the four treatment groups were compared against each other", "primaryOutcome": "pain relief and healing of the fissure after treatment", "result": "Surgery (lateral internal sphincterotomy) gave the best pain relief and healing, while many patients on topical ointments still had pain and no healing by two months and needed surgery", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "It was a large randomized trial, but the abstract gives few details on how groups were assigned or blinded, so some bias is possible.", "directness": "indirect", "limitations": "The abstract does not describe blinding, dropout rates, or long-term follow-up after surgery.", "followUp": "", "plainFinding": "Surgery relieves fissure pain best.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32246662/", "sourceText": "BACKGROUND: Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. AIMS: In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. METHOD: This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. RESULTS: In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. CONCLUSION: LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.", "provenance": [ { "field": "population", "quote": "patients who were treated for chronic anal fissure" }, { "field": "intervention", "quote": "topical ointment with medical treatment and surgical lateral internal sphincterotomy" }, { "field": "comparator", "quote": "Patients were randomly divided into 4 groups according to the treatment type they received." }, { "field": "primaryOutcome", "quote": "Both pain relief and healing of the fissure, which are the components of response to treatment" }, { "field": "result", "quote": "had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month" }, { "field": "result", "quote": "The best response to treatment was also obtained in lateral internal sphincterotomy group." }, { "field": "n", "quote": "a randomized clinical trial of 550 patients who were treated for chronic anal fissure" } ] }, { "id": "pmid:31937070", "pmid": "31937070", "doi": "10.3393/ac.2018.09.18", "nctId": null, "pmcid": "PMC6968720", "title": "Role of a Micronized Purified Flavonoid Fraction as an Adjuvant Treatment to Rubber Band Ligation for the Treatment of Patients With Hemorrhoidal Disease: A Longitudinal Cohort Study", "firstAuthor": "Caetano", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2019, "design": "prospective-cohort", "n": 44, "nField": "reported", "population": "patients with hemorrhoidal disease treated at a gastroenterology outpatient clinic", "intervention": "combination of rubber band ligation plus a micronized purified flavonoid fraction (MPFF)", "comparator": "rubber band ligation (RBL) alone", "primaryOutcome": "severity of hemorrhoid symptoms including bleeding, itching, pain at rest, pain during defecation and prolapse", "result": "the combined treatment reduced bleeding and itching more than RBL alone, with only a non‑significant trend toward improvement in pain during defecation", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small, non‑randomized comparison of two treatment groups, so differences could be due to chance or other factors rather than the treatment itself.", "directness": "indirect", "limitations": "Small sample size (19 vs 25 patients), non-randomized design, and only a 'trend' rather than significant difference for pain outcomes.", "followUp": "28 days", "plainFinding": "Less bleeding, no clear pain relief", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31937070/", "sourceText": "PURPOSE: Nonsurgical treatment of hemorrhoidal disease (HD) includes medical and instrumental techniques. We aimed to compare the efficacy of the most frequently used nonsurgical strategies, either alone or in combination, applied in an ambulatory setting. METHODS: Patients who received nonsurgical treatment for HD by proctology appointment at the Gastroenterology Department of Braga Hospital were evaluated. Isolated rubber band ligation (RBL) and a combination of RBL with a micronized purified flavonoid fraction (MPFF) were the 2 most frequently used strategies. Symptoms of HD (bleeding, pruritus, pain at rest, pain at defecation and prolapse) were assessed at days 0, 7, and 28 by using a severity grading scale (0 to 4/5). A Global Symptom score was constructed to assess the overall severity and compare the overall improvements of the HD symptoms between the 2 most frequently used strategies. RESULTS: Nineteen patients underwent the combined treatment (RBL + MPFF group) and 25 the RBL treatment (RBL group). A comparison of the 2 treatment groups showed significant improvements in the combined treatment group in terms of bleeding at days 7 (P = 0.001) and 28 (P = 0.002) and in the pruritus intensity during the first week (P < 0.001). A trend toward clinical benefit was also verified in the combined treatment group for all other HD symptoms (pain at rest, pain at defecation and prolapse). CONCLUSION: A combined treatment approach with MPFF and RBL significantly reduced the intensity of bleeding during the first month and the pruritus during the first week.", "provenance": [ { "field": "n", "quote": "Nineteen patients underwent the combined treatment (RBL + MPFF group) and 25 the RBL treatment (RBL group)." }, { "field": "population", "quote": "Patients who received nonsurgical treatment for HD by proctology appointment at the Gastroenterology Department of Braga Hospital were evaluated." }, { "field": "intervention", "quote": "a combination of RBL with a micronized purified flavonoid fraction (MPFF)" }, { "field": "comparator", "quote": "Isolated rubber band ligation (RBL)" }, { "field": "primaryOutcome", "quote": "Symptoms of HD (bleeding, pruritus, pain at rest, pain at defecation and prolapse) were assessed at days 0, 7, and 28 by using a severity grading scale (0 to 4/5)." }, { "field": "result", "quote": "significant improvements in the combined treatment group in terms of bleeding at days 7 (P = 0.001) and 28 (P = 0.002) and in the pruritus intensity during the first week (P < 0.001). A trend toward clinical benefit was also verified in the combined treatment group for all other HD symptoms (pain at rest, pain at defecation and prolapse)." } ] }, { "id": "pmid:31912937", "pmid": "31912937", "doi": "10.1111/codi.14954", "nctId": null, "pmcid": null, "title": "Long-term functional results after excisional haemorrhoidectomy", "firstAuthor": "Lehmann", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2020, "design": "rct", "n": 151, "nField": "reported", "population": "adults who had surgery for haemorrhoids in Sweden between 1999 and 2003", "intervention": "excisional haemorrhoidectomy using the Milligan technique", "comparator": "excisional haemorrhoidectomy using the Ferguson technique", "primaryOutcome": "long-term bowel and anal symptoms such as pain, bleeding, soiling and a sense of narrowing", "result": "Pain at defecation fell from 25% before surgery to 11% at long-term follow-up, and other symptoms like bleeding and soiling also dropped, though a sense of anal narrowing and perceived recurrence remained common", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "It was a long-term follow-up of a randomized surgical trial, but it relied on patient questionnaires years later with only 76% response and no non-surgery comparison group.", "directness": "indirect", "limitations": "Questionnaire-based follow-up with 24% non-participation, no untreated comparison group, and symptoms were self-reported long after surgery", "followUp": "10.7 years", "plainFinding": "Less pain years after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31912937/", "sourceText": "AIM: The aim of this work was to perform a long-term evaluation of a randomized trial focusing on functional aspects after excisional haemorrhoidectomy with a minimum follow-up of 9 years. METHOD: A questionnaire-based study including patients operated on for haemorrhoids in Sweden between 1999 and 2003. A total of 225 patients were randomized to Milligan's or Ferguson's operation. Twenty-six patients had died and 151 (76%) participated after a median follow-up of 10.7 years (range 9.2-12.6 years). RESULTS: Seventy-seven patients were in the Milligan group and 74 in the Ferguson group. Forty-eight (32%) reported recurrence. Anal bleeding was reported in 80% at baseline but in 28% at long-term follow-up (P < 0.0001). At baseline, 49% had spontaneous anal pain and 25% pain at defaecation. At follow-up, these figures were 17% and 11%. At follow-up, 19% described a sense of anal stenosis. At baseline, soiling was reported in 51% but in 20% at long-term follow-up (P < 0.001). Nineteen per cent used pads preoperatively and 6% at follow-up (P < 0.0001). Straining at defaecation was reported by 35% at baseline. At follow-up, this figure was 25% (P = 0.055). CONCLUSION: Symptoms associated with haemorrhoids were reduced at long-term follow-up. The most common problems were perceived recurrence and a sense of anal stenosis.", "provenance": [ { "field": "population", "quote": "patients operated on for haemorrhoids in Sweden between 1999 and 2003" }, { "field": "intervention", "quote": "randomized to Milligan's or Ferguson's operation" }, { "field": "comparator", "quote": "randomized to Milligan's or Ferguson's operation" }, { "field": "primaryOutcome", "quote": "a long-term evaluation of a randomized trial focusing on functional aspects after excisional haemorrhoidectomy" }, { "field": "result", "quote": "At baseline, 49% had spontaneous anal pain and 25% pain at defaecation. At follow-up, these figures were 17% and 11%." }, { "field": "n", "quote": "151 (76%) participated after a median follow-up of 10.7 years" } ] }, { "id": "pmid:31116312", "pmid": "31116312", "doi": "10.1590/1414-431X20198102", "nctId": null, "pmcid": "PMC6526753", "title": "Segmental resection combined with anoplasty for the treatment of circumferential mixed hemorrhoids", "firstAuthor": "Wu", "multipleAuthors": true, "journal": "Braz J Med Biol Res", "year": 2019, "design": "rct", "n": 300, "nField": "reported", "population": "patients with circumferential mixed hemorrhoids", "intervention": "segmented and plastic hemorrhoidectomy (SPH) surgery", "comparator": "Milligan-Morgan hemorrhoidectomy surgery", "primaryOutcome": "healing time, recovery time, anal function, and pain after bowel movements", "result": "SPH group healed faster, recovered sooner, had better anal function, and less pain with defecation than the standard surgery group", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial with a reasonable number of patients but this specific study is about a surgical technique for a specific condition (hemorrhoids), not a direct answer to general post-defecation anal pain.", "directness": "indirect", "limitations": "The abstract does not report blinding, dropout rates, or the exact statistical significance of all differences described.", "followUp": "18 months", "plainFinding": "Less pain with newer hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31116312/", "sourceText": "Circumferential mixed hemorrhoids are very difficult to treat non-surgically. Therefore, it is important to explore the surgical methods for its complete resolution as well as maintenance of normal anal anatomy and function. The present study was designed to evaluate the effect of segmented and plastic hemorrhoidectomy (SPH) on patients with circumferential mixed hemorrhoids. A total of 300 patients with circumferential mixed hemorrhoids were divided into experimental group (n=150) undergoing SPH and control group (n=150) undergoing Milligan-Morgan hemorrhoidectomy. There were no differences in cure and effectiveness rates between two groups. Compared with the control group, patients in the experimental group had shorter healing time (15.7±1.3 vs 12.5±0.7 days) and recovery to normal activity (18.5±2.7 vs 14.7±1.2 days). In addition, anal function of all patients in the experimental group was normal during short- and long-term follow-up. However, more cases in the control group showed anal dampness and itching, and poor control of intestinal liquid. Compared with the control group, patients in the experimental group had better outcomes in overall anal function and smoothness at 6, 12, and 18 months after operation as well as patient satisfaction. Furthermore, the rating in the visual analogue scale for defecation pain and edema in the experimental group was less than that in the control group. SPH was more effective, had fewer complications, better protection of anal function, and a better cosmetic result.", "provenance": [ { "field": "population", "quote": "300 patients with circumferential mixed hemorrhoids" }, { "field": "intervention", "quote": "experimental group (n=150) undergoing SPH" }, { "field": "comparator", "quote": "control group (n=150) undergoing Milligan-Morgan hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "the rating in the visual analogue scale for defecation pain and edema" }, { "field": "result", "quote": "the rating in the visual analogue scale for defecation pain and edema in the experimental group was less than that in the control group" }, { "field": "n", "quote": "A total of 300 patients with circumferential mixed hemorrhoids were divided into experimental group (n=150) undergoing SPH and control group (n=150) undergoing Milligan-Morgan hemorrhoidectomy." } ] }, { "id": "pmid:30872911", "pmid": "30872911", "doi": "10.20524/aog.2018.0340", "nctId": null, "pmcid": "PMC6394260", "title": "Beware of anal fissures: pemphigus vulgaris of the anal canal", "firstAuthor": "Karatzi", "multipleAuthors": true, "journal": "Ann Gastroenterol", "year": 2019, "design": "case-series", "n": 1, "nField": "reported", "population": "49-year-old woman with pemphigus vulgaris (an autoimmune blistering skin disease) affecting her mouth", "intervention": "combination of rituximab and corticosteroid medication", "comparator": "no comparator (single case report)", "primaryOutcome": "anal pain, bleeding, and erosions from anal pemphigus vulgaris, and whether treatment led to remission", "result": "treatment with rituximab plus corticosteroids achieved complete remission after the condition did not respond to earlier treatment", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, which cannot show whether the treatment works in general.", "directness": "indirect", "limitations": "only one patient; no comparison group; the abstract does not describe how long remission lasted after treatment", "followUp": "", "plainFinding": "Rare disease mimicking fissures, treated successfully", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30872911/", "sourceText": "A case of anal pemphigus vulgaris in a 49-year-old female suffering from pemphigus vulgaris of the oral cavity is reported. The oral manifestations were in remission until she presented with episodes of anal pain and bleeding on defecation, initially mimicking anal fissures. Inspection revealed prominent painful erosions in the anal canal with external hemorrhoids and strands of sloughing skin and maceration in the anal verge. Histology and direct immunofluorescence test were consistent with pemphigus vulgaris. The disease was refractory to treatment and complete remission was only achieved with the combination of rituximab and corticosteroids. Anal involvement seems to be an uncommon or underreported manifestation of pemphigus vulgaris. Gastroenterologists should be aware of this entity, especially in areas with a high incidence of the disease, for appropriate diagnosis and management.", "provenance": [ { "field": "n", "quote": "A case of anal pemphigus vulgaris in a 49-year-old female" }, { "field": "population", "quote": "49-year-old female suffering from pemphigus vulgaris of the oral cavity" }, { "field": "intervention", "quote": "complete remission was only achieved with the combination of rituximab and corticosteroids" }, { "field": "comparator", "quote": "The disease was refractory to treatment" }, { "field": "primaryOutcome", "quote": "episodes of anal pain and bleeding on defecation, initially mimicking anal fissures" }, { "field": "result", "quote": "complete remission was only achieved with the combination of rituximab and corticosteroids" } ] }, { "id": "pmid:30781931", "pmid": "30781931", "doi": "10.3393/ac.2017.10.16", "nctId": null, "pmcid": "PMC6732331", "title": "Bilateral Rotational S Flap Technique for Preventing Restenosis in Patients With Severe Circular Anal Stenosis: A Review of 2 Cases", "firstAuthor": "Handaya", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2019, "design": "case-series", "n": 2, "nField": "reported", "population": "patients with severe circular anal stenosis after hemorrhoidectomy", "intervention": "bilateral rotational S flap surgery to rebuild the anal canal", "comparator": "none", "primaryOutcome": "defecation problems and pain after surgery", "result": "at 1-year follow-up, no complaints of defecation problems or pain, and no longer needed laxatives", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "Only two patients were studied, so it's hard to know if this works for most people.", "directness": "indirect", "limitations": "Extremely small sample size (2 cases), no comparison group, condition described is anal stenosis from scarring, not typical post-defecation pain in a general population.", "followUp": "1 year", "plainFinding": "Surgery relieved stenosis pain and straining.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30781931/", "sourceText": "Anal stenosis is a late hemorrhoidectomy complication. Sphincterotomy and various anoplasty techniques are used for treatment severe anal stenosis, such as the C flap, House flap, U flap, and rotational S flap, but no procedure is ideal for every patient. We review 2 cases of severe circular anal stenosis. Their complaints included narrow caliber of the stool and feeling unsatisfied defecation. Excision of scar tissue using the circular technique was followed by reconstruction using the bilateral rotational S flap procedure. At the 1-year follow-up, the patient had complaints about neither defecation nor pain, and no longer needed laxative agents. In conclusion, the bilateral rotational S flap technique should be considered as a viable treatment because it can also prevent the occurrence of restenosis, especially given the consideration of adequate blood supply.", "provenance": [ { "field": "n", "quote": "We review 2 cases of severe circular anal stenosis." }, { "field": "population", "quote": "2 cases of severe circular anal stenosis" }, { "field": "intervention", "quote": "reconstruction using the bilateral rotational S flap procedure" }, { "field": "comparator", "quote": "no procedure is ideal for every patient" }, { "field": "primaryOutcome", "quote": "Their complaints included narrow caliber of the stool and feeling unsatisfied defecation." }, { "field": "result", "quote": "At the 1-year follow-up, the patient had complaints about neither defecation nor pain, and no longer needed laxative agents." } ] }, { "id": "pmid:30397849", "pmid": "30397849", "doi": "10.1007/s11938-018-0205-z", "nctId": null, "pmcid": null, "title": "The Role of Botox in Colorectal Disorders", "firstAuthor": "Carter", "multipleAuthors": true, "journal": "Curr Treat Options Gastroenterol", "year": 2018, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with lower gastrointestinal and anorectal disorders, including anal fissures and chronic anal pain", "intervention": "botulinum toxin (Botox) injection", "comparator": "surgical treatment (for anal fissures); no clear comparator for chronic anal pain", "primaryOutcome": "how well Botox treats anorectal conditions including anal fissures, chronic anal pain, and related disorders", "result": "Botox was less effective than surgery for healing anal fissures; for chronic anal pain, only a small number of patients improved", "resultDirection": "mixed", "quality": "low", "qualityWhy": "this is a narrative overview of existing studies rather than new original research, and the authors say evidence on anal pain is limited and more research is needed.", "directness": "indirect", "limitations": "abstract states data on chronic anal pain treatment is limited and effects were seen in only a minority of patients; no study sizes or methods are given.", "followUp": "", "plainFinding": "Botox rarely helps chronic anal pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30397849/", "sourceText": "PURPOSE OF REVIEW: To overview the current medical literature on the efficacy of botulism toxin treatment (BTX-A) for lower gastrointestinal disorders (GIT). RECENT FINDINGS: BTX-A was found to have a short-term efficacy for the treatment of dyssynergic defecation. Surgical treatment was found to be more effective than BTX-A for the healing of chronic anal fissures, and BTX-A can be considered when surgery is undesirable. Data regarding the effects of BTX-A injection for the treatment of chronic anal pain is limited. Beneficial effects were observed only in a minority of patients. BTX-A treatment was found to be effective for the treatment of obstructive symptoms after surgery for Hirsprung's disease as well as for the treatment of internal anal sphincter achalasia. BTX-A treatment has a short-term efficacy and is safe. Further research is still needed in order to establish the exact place of BTX-A treatment of lower GIT disorders.", "provenance": [ { "field": "population", "quote": "lower gastrointestinal disorders (GIT)" }, { "field": "intervention", "quote": "botulism toxin treatment (BTX-A)" }, { "field": "comparator", "quote": "Surgical treatment was found to be more effective than BTX-A for the healing of chronic anal fissures" }, { "field": "primaryOutcome", "quote": "the efficacy of botulism toxin treatment (BTX-A) for lower gastrointestinal disorders" }, { "field": "result", "quote": "Data regarding the effects of BTX-A injection for the treatment of chronic anal pain is limited. Beneficial effects were observed only in a minority of patients." } ] }, { "id": "pmid:30366766", "pmid": "30366766", "doi": "10.1016/j.asjsur.2018.10.001", "nctId": null, "pmcid": null, "title": "Treatment of chronic anal fissure: Is open lateral internal sphincterotomy (LIS) a safe and adequate option?", "firstAuthor": "Acar", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2019, "design": "retrospective", "n": 417, "nField": "reported", "population": "adults with chronic anal fissure (a tear near the anus) having surgery", "intervention": "lateral internal sphincterotomy (a cut in the anal muscle to relieve fissure)", "comparator": "no comparison group; outcomes tracked in the same patients", "primaryOutcome": "return of the fissure and bowel control problems after surgery", "result": "low rate of fissure returning and a small number developed gas or stool leakage, mostly temporary", "resultDirection": "benefit", "quality": "low", "qualityWhy": "it only looked back at records of one treatment with no comparison group, so it can't prove the surgery is better than other options", "directness": "indirect", "limitations": "retrospective design, no control group, and this is about surgical treatment of an already-diagnosed fissure rather than explaining why pain happens after bowel movements in general", "followUp": "", "plainFinding": "Surgery cured fissure pain, rare leakage risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30366766/", "sourceText": "BACKGROUND: Anal fissure which is defined as a longitudinal tear in anoderm under the dentate line is one of the most common benign diseases of anorectal area, and due to the severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. There are several treatment methods such as medical substances and surgical procedures. In this retrospective study, we aimed to evaluate the safe and adequate option of lateral internal sphincterotomy (LIS) in chronic anal fissure treatment. METHODS: This study is a retrospective study in which 417 patients who were treated for chronic anal fissure were included. RESULTS: Of 417 patients included in the study, 228 (54.7%) were female and the mean ± SD age was 36.1 ± 8.96 years (ranging from 17 to 73 years). Major complaints of patients; pain, bleeding, constipation, pruritus, perianal discharge. Recurrence occurred in 15 patients (3.6%) (12 males, three females) and eight patients (1.9%) developed incontinence (four with gas, four with soiling and seven females, one male). The complaints of all patients with gas incontinence and a patient with fluid incontinence regressed, whereas three patients had permanent fluid incontinence. CONCLUSION: LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.", "provenance": [ { "field": "n", "quote": "417 patients included in the study" }, { "field": "population", "quote": "417 patients who were treated for chronic anal fissure were included" }, { "field": "intervention", "quote": "lateral internal sphincterotomy (LIS)" }, { "field": "primaryOutcome", "quote": "Recurrence occurred in 15 patients (3.6%)" }, { "field": "result", "quote": "Recurrence occurred in 15 patients (3.6%) (12 males, three females) and eight patients (1.9%) developed incontinence" }, { "field": "comparator", "quote": "This study is a retrospective study in which 417 patients who were treated for chronic anal fissure were included." } ] }, { "id": "pmid:30189793", "pmid": "30189793", "doi": "10.1080/00015458.2018.1500802", "nctId": null, "pmcid": null, "title": "High post-operative pain scores despite multimodal analgesia in ambulatory anorectal surgery: a prospective cohort study", "firstAuthor": "Ceulemans", "multipleAuthors": true, "journal": "Acta Chir Belg", "year": 2019, "design": "prospective-cohort", "n": 42, "nField": "reported", "population": "patients who had outpatient surgery on the anus or rectum, including for hemorrhoids or anal fissures", "intervention": "multimodal pain treatment (local anesthetic injection, multiple oral painkillers, and written pain management information)", "comparator": "different combinations of these pain treatments compared within the same group of patients", "primaryOutcome": "pain levels, including pain during pooping, over the two weeks after surgery", "result": "despite multimodal pain treatment, patients having surgery for hemorrhoids or anal fissures still had high pain scores and used painkillers for longer; pain during defecation remained a persistent problem", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "this was a small, uncontrolled observational study of only 42 patients without a true comparison group, so it can't reliably prove what works.", "directness": "direct", "limitations": "small sample size (only 42 patients completed diaries), no control group without multimodal treatment, single-center design", "followUp": "21 days", "plainFinding": "Pain after pooping remains hard to treat.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30189793/", "sourceText": "Background: Ambulatory surgery for anorectal procedures has become widely accepted. Recent reviews recommend a multimodal approach to pain management. However, these recommendations are largely based on single intervention studies. Our goal was to evaluate post-operative pain in patients receiving a multimodal analgesic regimen. Methods: All patients undergoing an ambulatory anorectal procedure between December 2015 and September 2016 received a pain diary. Mean pain throughout the day and pain during defecation where recorded on day 0-14 and day 21 postoperatively using a numeric rating scale-11. Use of oral analgesics was also recorded. Results: Forty-two patients completed the pain diary. The use of local anesthetic infiltration did not result in a significant difference in pain scores in this study. Patients who received written information on postoperative pain management and hygienic measures had higher intake of oral analgesics. Despite receiving multimodal analgesic treatment, patients undergoing surgery for hemorrhoids or anal fissures reported pain scores ≥4 and used analgesics longer. Conclusion: A multimodal analgesic approach consisting of local anesthetic infiltration, multiple oral analgesics and written information seems to be insufficient for certain patient groups after ambulatory anorectal surgery. Especially patients undergoing surgery for hemorrhoids or an anal fissure should receive adequate analgesia. Pain during defecation is problematic and finding a solution for this problem remains challenging. Further research into the combined use of different analgesic modalities is recommended.", "provenance": [ { "field": "n", "quote": "Forty-two patients completed the pain diary." }, { "field": "population", "quote": "patients undergoing surgery for hemorrhoids or anal fissures" }, { "field": "intervention", "quote": "multimodal analgesic approach consisting of local anesthetic infiltration, multiple oral analgesics and written information" }, { "field": "comparator", "quote": "The use of local anesthetic infiltration did not result in a significant difference in pain scores in this study." }, { "field": "primaryOutcome", "quote": "Mean pain throughout the day and pain during defecation where recorded on day 0-14 and day 21 postoperatively using a numeric rating scale-11." }, { "field": "result", "quote": "Despite receiving multimodal analgesic treatment, patients undergoing surgery for hemorrhoids or anal fissures reported pain scores ≥4 and used analgesics longer." }, { "field": "result", "quote": "Pain during defecation is problematic and finding a solution for this problem remains challenging." } ] }, { "id": "pmid:30171745", "pmid": "30171745", "doi": "10.1111/codi.14393", "nctId": null, "pmcid": "PMC7379620", "title": "Psychometric properties of a questionnaire (HEMO-FISS-QoL) to evaluate the burden associated with haemorrhoidal disease and anal fissures", "firstAuthor": "Abramowitz", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2019, "design": "case-series", "n": 256, "nField": "reported", "population": "adults with haemorrhoids or anal fissures (mean age 46.2 years)", "intervention": "none (questionnaire administered, no treatment given)", "comparator": "none", "primaryOutcome": "reliability and validity of a new symptom-burden questionnaire (HEMO-FISS-QoL)", "result": "the questionnaire reliably measured the impact of haemorrhoidal disease and anal fissures on daily life and correlated with other quality-of-life scores", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this study only tests a symptom questionnaire and does not investigate why pain occurs after bowel movements or test any treatment", "directness": "indirect", "limitations": "abstract does not address causes of post-defecation pain; only reports development of a measurement tool", "followUp": "", "plainFinding": "Validated symptom questionnaire, not pain cause.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30171745/", "sourceText": "AIM: Current questionnaires designed to evaluate the burden of haemorrhoidal disease ignore symptoms such as bleeding, pain and itching. A specific questionnaire is needed to evaluate the global impact of anal disorders on patients' daily lives. METHOD: We developed a questionnaire (HEMO-FISS-QoL) to assess the symptom burden of anal disorders and administered it to 256 patients (mean age 46.2 years; men 60.4%) with haemorrhoidal disease (67.2%), anal fissure (29.3%) or both (3.5%). Psychometric properties were evaluated by testing the acceptability, construct validity and reliability of the questionnaire. Principal components and multi-trait analyses were used to identify dimensions and to assess construct validity. Backward Cronbach alpha curves and a graded response model were used to reduce the number of items and modalities. External validity was evaluated against SF-12 and the Psychological Global Well-Being Index (PGWBI) using Spearman's correlation coefficient. RESULTS: Principal component analysis defined four dimensions: physical disorders, psychology, defaecation and sexuality. The number of questions was reduced from 38 to 23. The HEMO-FISS-QoL scores correlated well with those of the SF-12 and PGWBI (P < 0.001). Cronbach's coefficients (all > 0.7) reflected good internal reliability of the different dimensions. The total score increased with the severity of the anal disorders and with their consequences (days off work and personal spending related to the disease). CONCLUSION: The HEMO-FISS-QoL questionnaire reliably evaluates the global impact of haemorrhoids and anal fissures on patients' daily lives. This simple tool may prove useful for treatment evaluation in clinical trials and daily practice.", "provenance": [ { "field": "n", "quote": "administered it to 256 patients (mean age 46.2 years; men 60.4%)" }, { "field": "population", "quote": "256 patients (mean age 46.2 years; men 60.4%) with haemorrhoidal disease (67.2%), anal fissure (29.3%) or both (3.5%)" }, { "field": "intervention", "quote": "We developed a questionnaire (HEMO-FISS-QoL) to assess the symptom burden of anal disorders" }, { "field": "comparator", "quote": "External validity was evaluated against SF-12 and the Psychological Global Well-Being Index (PGWBI)" }, { "field": "primaryOutcome", "quote": "Psychometric properties were evaluated by testing the acceptability, construct validity and reliability of the questionnaire." }, { "field": "result", "quote": "The HEMO-FISS-QoL questionnaire reliably evaluates the global impact of haemorrhoids and anal fissures on patients' daily lives." } ] }, { "id": "pmid:30122979", "pmid": "30122979", "doi": "10.2147/JPR.S166953", "nctId": null, "pmcid": "PMC6084088", "title": "Effect of acupuncture on post-hemorrhoidectomy pain: a randomized controlled trial", "firstAuthor": "Wu", "multipleAuthors": true, "journal": "J Pain Res", "year": 2018, "design": "rct", "n": 72, "nField": "reported", "population": "patients with mixed hemorrhoids who had undergone hemorrhoidectomy surgery", "intervention": "electroacupuncture (surround needling) given right after surgery", "comparator": "sham acupuncture", "primaryOutcome": "pain intensity measured by visual analog scale after surgery and during bowel movements", "result": "Lower pain scores in the acupuncture group at several time points including 6 hours, 24 hours, and during defecation", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small single-center trial with only 36 people per group, measuring pain after surgery rather than everyday post-bowel-movement pain.", "directness": "indirect", "limitations": "Small sample size, single-center, single-blind design, and population is post-surgical hemorrhoidectomy patients rather than people with ordinary anal pain after pooping.", "followUp": "48 h", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30122979/", "sourceText": "OBJECTIVES: To observe the clinical efficacy and safety of electroacupuncture (EA) in relieving pain after hemorrhoidectomy treatment for mixed hemorrhoids. DESIGN: This was a randomized controlled trial. METHODS: We 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. RESULTS: The 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. CONCLUSION: Acupuncture is effective in alleviating postoperative pain in patients who have undergone hemorrhoidectomy.", "provenance": [ { "field": "n", "quote": "Seventy-two patients with mixed hemorrhoids who had undergone hemorrhoidectomy were randomly assigned" }, { "field": "population", "quote": "Seventy-two patients with mixed hemorrhoids who had undergone hemorrhoidectomy" }, { "field": "intervention", "quote": "the EA treatment group (EA) received surround needling with EA (n=36)" }, { "field": "comparator", "quote": "the control group received sham acupuncture (SA) treatment (n=36)" }, { "field": "primaryOutcome", "quote": "The pain intensity was recorded by using the visual analog scale as the primary outcome." }, { "field": "result", "quote": "The 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)." } ] }, { "id": "pmid:30058630", "pmid": "30058630", "doi": null, "nctId": null, "pmcid": "PMC8997320", "title": "Prevalence of Organic Colonic Lesions by Colonoscopy in Patients Fulfilling ROME IV Criteria of Irritable Bowel Syndrome", "firstAuthor": "Paudel", "multipleAuthors": true, "journal": "JNMA J Nepal Med Assoc", "year": 2018, "design": "case-series", "n": 140, "nField": "reported", "population": "adults with irritable bowel syndrome diagnosed by ROME IV criteria", "intervention": "full colonoscopy with biopsy to look for other bowel diseases", "comparator": "none", "primaryOutcome": "how often colonoscopy found other bowel diseases in IBS patients", "result": "27.85% had some other bowel finding, including hemorrhoids in 4.2% of patients", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a single-center survey of colonoscopy findings in IBS patients with no comparison group, and it was not designed to study anal pain after bowel movements specifically", "directness": "indirect", "limitations": "cross sectional design, single hospital, and hemorrhoids were only an incidental finding rather than the focus of the study", "followUp": "", "plainFinding": "Hemorrhoids found incidentally in some patients", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30058630/", "sourceText": "INTRODUCTION: Irritable bowel syndrome occurs as recurrent abdominal pain that is related to defecation and associated with change in frequency and/or form of stool. Few Patients with IBS may have organic lesions detectable at colonoscopy. METHODS: A cross sectional study was carried out in 140 consecutive patients of IBS fulfilling the ROME IV criteria. The study was conducted in Gastroenterology unit, Department of Medicine, Bir hospital, Kathmandu from July 2016 to September 2017. All patients underwent full colonoscopy along with biopsy from sigmoid colon and any visibly abnormal areas. RESULTS: The average age of patients was 37.5 years with 76 (52.8%) males. Forty-two (30%) had IBS-D, 36 (26%) had IBS-C, 31 (22%) had IBS-M and 31 (22%) had IBS-U. Dyspepsia was seen in 16 (11.4%) and fear of TB/Malignancy/IBD was seen in 27 (19.2%). Organic lesions were seen in 39 (27.85%) patients. Nonspecific colitis was seen in 10 (7.1%) followed by ileal erosions in 7 (5%), polyps in 8 (5.7%), hemorrhoids in 6 (4.2%) and diverticula in 3 (2.1%). Only one (0.71%) patient had microscopic colitis and one (0.71%) had malignant lesion seen at histopathological examination. Females with IBS-D had more organic findings than males (P=0.03, RR=4.13, 95% CI=1.21-15.71). CONCLUSIONS: The prevalence of organic lesions in patients with IBS fulfilling ROME IV criteria is 27%. Dyspepsia is the most common comorbidity and fear of TB/malignancy/IBD is the most common reason for seeking health care. Females with IBS-D have a higher risk of detecting organic lesions by colonoscopy and histopathology examination.", "provenance": [ { "field": "population", "quote": "140 consecutive patients of IBS fulfilling the ROME IV criteria" }, { "field": "intervention", "quote": "All patients underwent full colonoscopy along with biopsy from sigmoid colon and any visibly abnormal areas." }, { "field": "comparator", "quote": "A cross sectional study was carried out in 140 consecutive patients of IBS fulfilling the ROME IV criteria." }, { "field": "primaryOutcome", "quote": "Organic lesions were seen in 39 (27.85%) patients." }, { "field": "result", "quote": "Organic lesions were seen in 39 (27.85%) patients. Nonspecific colitis was seen in 10 (7.1%) followed by ileal erosions in 7 (5%), polyps in 8 (5.7%), hemorrhoids in 6 (4.2%) and diverticula in 3 (2.1%)." }, { "field": "n", "quote": "A cross sectional study was carried out in 140 consecutive patients of IBS fulfilling the ROME IV criteria." } ] }, { "id": "pmid:29844250", "pmid": "29844250", "doi": null, "nctId": null, "pmcid": null, "title": "Comparison of Flavonoids and Centella asiatica for the treatment of chronic anal fissure. A randomized clinical trial", "firstAuthor": "Chiaretti", "multipleAuthors": true, "journal": "Ann Ital Chir", "year": 2018, "design": "rct", "n": 98, "nField": "reported", "population": "people with chronic anal fissure (tear near the anus)", "intervention": "Flavonoids or Centella asiatica added to standard treatment", "comparator": "traditional treatment alone", "primaryOutcome": "time to stop bleeding and pain score", "result": "Flavonoids stopped bleeding fastest (1 week vs 3 vs 4 weeks); both Flavonoids and Centella asiatica reduced pain earlier than traditional treatment; all healed by 8 weeks", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small randomized trial with short follow-up and no mention of blinding, so results may be less reliable.", "directness": "direct", "limitations": "No mention of blinding; small group sizes; only 8 weeks of observation", "followUp": "8 weeks", "plainFinding": "Faster healing, less pain, less bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29844250/", "sourceText": "AIMS: We aim to test and compare the effects of Flavonoids (Fs) and Centella asiatica (Ca), and the traditional treatment to find out which best deals with healing time, bleeding and pain in the treatment of chronic Anal Fissure (AF). Materials of Study: 98 outpatients were divided randomly into treated (either Fs or Ca) and control group. The control group (Group C, n=32) received the traditional treatment along with the other two subgroups which were treated, additionally, with Fs (Group A, n=30) or Ca (Group B, n=36). Patients were observed once weekly over 8 consecutive weeks. RESULTS: The median time to stop bleeding in the group A was 1 week, in the Group B was 3 weeks and in the group C was 4 weeks. There were significant differences between Groups in terms of time to end bleeding (A vs B: p-value= 0.022; A vs C: p-value<0.001; B vs C: p-value=0.070). As for pain score from baseline to the 2nd week were statistically different between Groups A and B on the one hand and Group C on the other hand (A vs C: p-value=0.004; B vs C: p-value 0.035). All patients healed within 8th week. DISCUSSION: Either patients treated with Fs or Ca experienced early pain disappearance. Fs and Ca did not show side effects CONCLUSIONS: The treatment with Fs is the most effective for bleeding. Patients additionally treated with either Fs or Ca experienced an earlier healing and disappearance of pain in comparison with patients underwent to the traditional treatment. KEY WORDS: Anal bleeding, Anal fissure, Defecation pain.", "provenance": [ { "field": "n", "quote": "98 outpatients were divided randomly into treated (either Fs or Ca) and control group." }, { "field": "population", "quote": "treatment of chronic anal fissure" }, { "field": "intervention", "quote": "treated, additionally, with Fs (Group A, n=30) or Ca (Group B, n=36)" }, { "field": "comparator", "quote": "The control group (Group C, n=32) received the traditional treatment" }, { "field": "primaryOutcome", "quote": "healing time, bleeding and pain in the treatment of chronic Anal Fissure" }, { "field": "result", "quote": "The median time to stop bleeding in the group A was 1 week, in the Group B was 3 weeks and in the group C was 4 weeks." }, { "field": "result", "quote": "All patients healed within 8th week." }, { "field": "followUp", "quote": "Patients were observed once weekly over 8 consecutive weeks." } ] }, { "id": "pmid:29521831", "pmid": "29521831", "doi": "10.1097/DCR.0000000000001025", "nctId": null, "pmcid": null, "title": "Stapled Hemorrhoidopexy: Results at 10-Year Follow-up", "firstAuthor": "Bellio", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2018, "design": "retrospective", "n": 86, "nField": "reported", "population": "adults with grade 3 hemorrhoidal prolapse", "intervention": "stapled hemorrhoidopexy surgery for hemorrhoids", "comparator": "no control group; outcomes tracked over time in same patients", "primaryOutcome": "patient satisfaction and recurrence of hemorrhoid prolapse", "result": "39% had recurrent hemorrhoidal prolapse and satisfaction was 68% at 10 years, with some patients reporting urge to defecate or gas leakage", "resultDirection": "harm", "quality": "low", "qualityWhy": "This was a small study without a comparison group, so it can't reliably show whether the surgery works better than other options long-term.", "directness": "indirect", "limitations": "small sample size and lack of a control group", "followUp": "119.0 months", "plainFinding": "High recurrence, declining satisfaction over years.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29521831/", "sourceText": "BACKGROUND: Despite the advantages of stapled hemorrhoidopexy reported in the literature in terms of postoperative pain, hospital stay, and duration of convalescence, it was described to have a higher recurrence rate compared with conventional hemorrhoidectomy. OBJECTIVE: The aim of this study was to evaluate clinical outcomes and patient satisfaction after stapled hemorrhoidopexy at 10-year follow-up. DESIGN: This was a retrospective cohort analysis conducted on prospectively collected data. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse between January and December 2006 were included. MAIN OUTCOME MEASURES: Patients satisfaction and recurrence rates were measured. RESULTS: Eighty-six patients (45 men and 41 women; median age, 49 y (range, 31-74 y)) underwent stapled hemorrhoidopexy. Eight patients had urinary retention during the immediate postoperative period, and 2 patients required a reoperation for suture line bleeding. The median hospital stay was 12 hours (range, 12-96 h). No suture line dehiscence, rectovaginal fistula, pelvic sepsis, anal abscess, or anal stenosis was recorded during the follow-up. Seventy-seven patients (90%) completed the expected follow-up, with a median duration of 119.0 months (range 115.4-121.8 mo). Among them, 30 patients (39%) experienced a recurrent hemorrhoidal prolapse, 8 of whom needed a reoperation. Thirty-four patients (44%) reported urge to defecate with a median visual analog scale of 1 (range, 1-7). Six patients (8%) reported gas leakage at the last follow-up visit, whereas no liquid or solid stool leakage was recorded. Satisfaction rate at 10-year follow-up was 68%. LIMITATIONS: The study was limited by its small sample size and lack of a control group. CONCLUSIONS: The high recurrence rate and low patient satisfaction rate showed that stapled hemorrhoidopexy reduces its efficacy in the long-term. See Video Abstract at http://links.lww.com/DCR/A510.", "provenance": [ { "field": "n", "quote": "Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse" }, { "field": "population", "quote": "Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse between January and December 2006 were included." }, { "field": "intervention", "quote": "underwent stapled hemorrhoidopexy" }, { "field": "comparator", "quote": "The study was limited by its small sample size and lack of a control group." }, { "field": "primaryOutcome", "quote": "Patients satisfaction and recurrence rates were measured." }, { "field": "result", "quote": "30 patients (39%) experienced a recurrent hemorrhoidal prolapse, 8 of whom needed a reoperation." }, { "field": "result", "quote": "Satisfaction rate at 10-year follow-up was 68%." }, { "field": "followUp", "quote": "median duration of 119.0 months (range 115.4-121.8 mo)" } ] }, { "id": "pmid:32258781", "pmid": "32258781", "doi": "10.1016/j.pbj.2017.04.005", "nctId": null, "pmcid": "PMC6806753", "title": "Botulinum toxin improves pain in chronic anal fissure", "firstAuthor": "Amorim", "multipleAuthors": true, "journal": "Porto Biomed J", "year": 2017, "design": "retrospective", "n": 81, "nField": "reported", "population": "patients with chronic anal fissure causing intense pain", "intervention": "botulinum toxin injection", "comparator": "before vs after treatment (no control group)", "primaryOutcome": "pain intensity at rest and after pooping", "result": "pain scores at rest and after defecation significantly improved after botulinum toxin injection", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective study without a comparison group, so it can't rule out other reasons pain improved over time.", "directness": "direct", "limitations": "Retrospective cohort design without a control group; notable long-term treatment failure (23.5% needed surgery).", "followUp": "4 year period", "plainFinding": "Less pain after botulinum toxin injection.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32258781/", "sourceText": "HIGHLIGHTS: Chronic anal fissure is a common condition associated with intense pain.Local botulinum toxin injection is a valid option in its management.Pain intensity scores significantly improved after BoNT injection.Side effects were rare and mild.Our results support the inclusion of BoNT in the management algorithm of chronic anal fissure. INTRODUCTION: Chronic anal fissure is a common condition associated with intense pain. Local botulinum toxin injection is a valid option in its management. The purpose of this study was to evaluate the efficacy of botulinum toxin on pain relief in chronic anal fissure patients. METHODS: We conducted a retrospective cohort study, involving 81 consecutive patients referred to a chronic pain management unit due to a chronic anal fissure for treatment with botulinum toxin, during a 4 year period. Data were collected from hospital records regarding pre-treatment and post-treatment pain (numeric rating scale), side effects, need for botulinum toxin reinjection and need for surgical treatment. We used standard statistical methods for inter (t-test and qui2) and intra-group (paired sample t-test) comparisons, according to variables distribution. RESULTS: Pain intensity rest score significantly improved after BoNT injection [variation: -4.2 ± 2.9 (p < 0.001)], as did pain post-defecation score [variation: -5.1 ± 3.0 (p < 0.001)]. 8.6% needed botulinum toxin reinjection and 23.5% were submitted to surgery. Side effects were reported in 8.6%. DISCUSSION: The efficacy of botulinum toxin use on pain reduction along with its non-permanent and minor side effects support its role in the resolution of chronic anal fissure. However, treatment failure in the long term is still significant. CONCLUSION: Botulinum toxin is effective on pain relief in patients with chronic anal fissure, which supports its inclusion in the management algorithm of this condition.", "provenance": [ { "field": "n", "quote": "involving 81 consecutive patients" }, { "field": "population", "quote": "patients referred to a chronic pain management unit due to a chronic anal fissure" }, { "field": "intervention", "quote": "treatment with botulinum toxin" }, { "field": "comparator", "quote": "pre-treatment and post-treatment pain (numeric rating scale)" }, { "field": "primaryOutcome", "quote": "pain post-defecation score" }, { "field": "result", "quote": "Pain intensity rest score significantly improved after BoNT injection [variation: -4.2 ± 2.9 (p < 0.001)], as did pain post-defecation score [variation: -5.1 ± 3.0 (p < 0.001)]" } ] }, { "id": "pmid:29076869", "pmid": "29076869", "doi": "10.1097/MOG.0000000000000408", "nctId": null, "pmcid": null, "title": "Hemorrhoids: what are the options in 2018?", "firstAuthor": "Jacobs", "multipleAuthors": false, "journal": "Curr Opin Gastroenterol", "year": 2018, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with symptomatic hemorrhoids", "intervention": "various hemorrhoid treatments including newer surgical techniques", "comparator": "traditional hemorrhoidectomy and conservative management", "primaryOutcome": "treatment efficiency, pain, blood loss, symptom control and recurrence", "result": "no definitive best alternative identified; conservative measures and managing expectations emphasized as important", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general narrative review without original data, patient numbers, or controlled comparisons.", "directness": "indirect", "limitations": "Abstract notes heterogeneity in diagnosis, intervention, and outcome measures makes comparing therapies difficult, and long-term data are still being accumulated.", "followUp": "", "plainFinding": "No clear best hemorrhoid treatment yet.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29076869/", "sourceText": "PURPOSE OF REVIEW: Efforts continue to improve the treatment of patients with symptomatic hemorrhoidal disease by interventions designed to improve efficiency and effectiveness, including by reducing intraoperative and postoperative pain, decreasing operating times, minimizing blood loss and controlling symptoms and recurrence rates. Simultaneously, there are also renewed efforts to minimize the number of patients who will require procedural intervention by focusing on conservative measures that encourage better bowel regulation and habits. The purpose of this brief report is to review the current status of the diagnosis and treatment of patients with hemorrhoidal disease. Overall, new procedures or procedural refinements to existing techniques continue to be introduced with promising short-term outcomes - at least in some instances. In most instances, long-term follow-up or equivalency data are still being accumulated such that a definitive, unequivocal answer to what is truly the best alternative to traditional hemorrhoidectomy remains controversial. One of the challenges is heterogeneity as regards diagnosis, intervention and, especially, outcomes measures such that comparing therapies is too difficult. A recent initiative to standardize metrics has promise. RECENT FINDINGS: Recent studies largely appear to suggest that conservative treatment approaches and managing patient expectations are critically important in which a primary objective should be to minimize the progression to symptomatic disease and complications in patients who are diagnosed with hemorrhoids. The pace of change as regards the development of new or improved surgical techniques appears may be accelerating. SUMMARY: Progress is being made and the knowledge base is being expanded as regards the treatment options for patients with hemorrhoids and expected outcomes. A key initiative to standardize the approaches to diagnosis and treatment about staging, procedural interventions and outcomes will facilitate comparative analytics, if successful.", "provenance": [ { "field": "population", "quote": "patients with symptomatic hemorrhoidal disease" }, { "field": "intervention", "quote": "new procedures or procedural refinements to existing techniques continue to be introduced with promising short-term outcomes" }, { "field": "comparator", "quote": "the best alternative to traditional hemorrhoidectomy remains controversial" }, { "field": "primaryOutcome", "quote": "reducing intraoperative and postoperative pain, decreasing operating times, minimizing blood loss and controlling symptoms and recurrence rates" }, { "field": "result", "quote": "a definitive, unequivocal answer to what is truly the best alternative to traditional hemorrhoidectomy remains controversial" }, { "field": "limitations", "quote": "heterogeneity as regards diagnosis, intervention and, especially, outcomes measures such that comparing therapies is too difficult" } ] }, { "id": "pmid:28871428", "pmid": "28871428", "doi": "10.1007/s10151-017-1673-1", "nctId": null, "pmcid": null, "title": "A prospective randomized trial of transanal hemorrhoidal dearterialization with mucopexy versus ultrasonic scalpel hemorrhoidectomy for grade III hemorrhoids", "firstAuthor": "Tsunoda", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2017, "design": "rct", "n": 44, "nField": "reported", "population": "patients with grade III (third-degree) hemorrhoids", "intervention": "Doppler-guided hemorrhoidal dearterialization with mucopexy (DM)", "comparator": "ultrasonic scalpel hemorrhoidectomy (US)", "primaryOutcome": "pain after surgery", "result": "Pain was less in the DM group during the first week, but no difference after 2 weeks; quality of life was similar between groups", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Small trial of only 44 patients comparing two surgical techniques, not addressing typical post-bowel-movement pain in the general population.", "directness": "indirect", "limitations": "Small sample size; studies specific surgical procedures for hemorrhoids rather than general post-defecation anal pain.", "followUp": "median 33-month follow-up (range 12-46 months)", "plainFinding": "Less pain with one surgery type early on", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28871428/", "sourceText": "BACKGROUND: The aim of the present study was to compare short- and medium-term results of transanal Doppler-guided hemorrhoidal dearterialization with mucopexy (DM) versus hemorrhoidectomy using an ultrasonic scalpel (US) for third-degree hemorrhoids. METHODS: Forty-four patients were randomly assigned to undergo either DM or US. The patients were followed up at 1, 2, 3 months at our clinic, and by telephone interview when the study was completed in May 2017. The primary endpoint was postoperative pain with quality of life, length of stay, return to normal activities, and incontinence among secondary endpoints. RESULTS: Postoperative pain was less intense in the DM group than in the US group during week 1 (p < 0.05), but no difference was seen after 2 weeks. More DM patients returned to normal daily activities within 3 days (p < 0.05). There were no between-group differences in quality of life. One patient in each group developed postoperative hemorrhage requiring readmission. No differences were found between the groups in postoperative incontinence, obstructed defecation scores, or SF-36. During a median 33-month follow-up (range 12-46 months), two patients in the DM group and one patient in the US group underwent further surgery for residual hemorrhoid related problems. Two patients in the DM group required further rubber band ligation. CONCLUSIONS: Medium-term results demonstrated that DM and US have similar effects on quality of life in the treatment of third-degree hemorrhoids. However, DM was associated with less early postoperative pain than US and a faster return to normal activities.", "provenance": [ { "field": "population", "quote": "third-degree hemorrhoids" }, { "field": "n", "quote": "Forty-four patients were randomly assigned" }, { "field": "intervention", "quote": "transanal Doppler-guided hemorrhoidal dearterialization with mucopexy (DM)" }, { "field": "comparator", "quote": "hemorrhoidectomy using an ultrasonic scalpel (US)" }, { "field": "primaryOutcome", "quote": "The primary endpoint was postoperative pain with quality of life" }, { "field": "result", "quote": "Postoperative pain was less intense in the DM group than in the US group during week 1 (p < 0.05), but no difference was seen after 2 weeks." }, { "field": "followUp", "quote": "median 33-month follow-up (range 12-46 months)" } ] }, { "id": "pmid:28863202", "pmid": "28863202", "doi": null, "nctId": null, "pmcid": null, "title": "Immigrant with stomach pain, distension, nausea, and fever · Dx?", "firstAuthor": "Tessier", "multipleAuthors": true, "journal": "J Fam Pract", "year": 2017, "design": "case-series", "n": 1, "nField": "reported", "population": "34-year-old man from Eritrea, recently emigrated, after hemorrhoid surgery", "intervention": "none (case report of symptoms after hemorrhoidectomy)", "comparator": "", "primaryOutcome": "cause of abdominal pain, distention, nausea, fever after recent hemorrhoid surgery", "result": "Patient developed worsening abdominal pain, distention, inability to urinate, no bowel movement for 6 days, fevers, night sweats, chills, and weight loss; underlying cause not given in this excerpt", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, which cannot show whether any treatment works or what typically causes pain after bowel movements.", "directness": "indirect", "limitations": "Single case report; abstract does not give a final diagnosis or explain why the anus hurts after pooping in general; findings concern a rare, complex post-surgical case, not typical post-defecation anal pain.", "followUp": "", "plainFinding": "One unusual post-surgery complication case.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28863202/", "sourceText": "A 34-year-old Eritrean man presented to the emergency department with complaints of diffuse abdominal pain and distention. He had emigrated to the United States 3 months earlier, following 5 years in a refugee camp in Ethiopia. Two weeks earlier, the patient sought care at his primary care clinic and was diagnosed with post-operative urinary retention and constipation following a recent hemorrhoidectomy. A Foley catheter was inserted and provided a short period of relief. Following the visit, however, his abdominal pain worsened. He also experienced increasing abdominal distention, a declining appetite, and persistent nausea. The patient said that he was unable to urinate and had not had a bowel movement in 6 days. He also described fevers, drenching night sweats, chills, and a 4-kg weight loss over 2 months.", "provenance": [ { "field": "n", "quote": "A 34-year-old Eritrean man presented to the emergency department" }, { "field": "population", "quote": "A 34-year-old Eritrean man presented to the emergency department with complaints of diffuse abdominal pain and distention." }, { "field": "intervention", "quote": "following a recent hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "complaints of diffuse abdominal pain and distention" }, { "field": "result", "quote": "he was unable to urinate and had not had a bowel movement in 6 days. He also described fevers, drenching night sweats, chills, and a 4-kg weight loss over 2 months." } ] }, { "id": "pmid:28844211", "pmid": "28844211", "doi": "10.1016/S2095-4964(17)60340-6", "nctId": null, "pmcid": null, "title": "Effectiveness of Myrtus communis in the treatment of hemorrhoids", "firstAuthor": "Mahboubi", "multipleAuthors": false, "journal": "J Integr Med", "year": 2017, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids (grades I and II)", "intervention": "Myrtus communis essential oil (as a lotion or ointment)", "comparator": "current chemical anti-hemorrhoid ointment treatments (in patients who had not responded to them)", "primaryOutcome": "bleeding, ongoing pain, pain during defecation, anal irritation, itching and heaviness", "result": "essential oil significantly improved bleeding, pain, pain during defecation, anal irritation, itching and heaviness, including in patients who had not responded to standard treatments", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a narrative review summarizing other studies without describing study design, sample sizes, or methods, so its claims can't be checked or weighed reliably.", "directness": "direct", "limitations": "The abstract gives no details on the number or design of the clinical studies referenced, no statistics, and states further studies (e.g. suppository form) are still needed.", "followUp": "", "plainFinding": "Less hemorrhoid pain and bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28844211/", "sourceText": "Myrtus communis is an important plant in the treatment of many different diseases. The aim of this review was to determine the importance of M. communis essential oil in the treatment of hemorrhoids. For preparing this manuscript, the information was extracted from different resources. The results of clinical studies showed that M. communis essential oil (lotion or ointment) can significantly improve bleeding, permanent pain, pain during defecation, anal irritation, anal itching and anal heaviness in patients with hemorrhoids types I and II. M. communis was also effective in treating patients who did not respond to current chemical treatments (anti-hemorrhoids ointment). Further clinical studies should look into designing a suppository form of M. communis essential oil and compare its effect with the lotion and ointment forms.", "provenance": [ { "field": "population", "quote": "patients with hemorrhoids types I and II" }, { "field": "intervention", "quote": "M. communis essential oil (lotion or ointment)" }, { "field": "comparator", "quote": "patients who did not respond to current chemical treatments (anti-hemorrhoids ointment)" }, { "field": "primaryOutcome", "quote": "bleeding, permanent pain, pain during defecation, anal irritation, anal itching and anal heaviness" }, { "field": "result", "quote": "can significantly improve bleeding, permanent pain, pain during defecation, anal irritation, anal itching and anal heaviness in patients with hemorrhoids types I and II" } ] }, { "id": "pmid:28722093", "pmid": "28722093", "doi": null, "nctId": null, "pmcid": null, "title": "[A multicenter, randomized controlled trial of wheat cellulose particles in the treatment of internal hemorrhoids]", "firstAuthor": "Peng", "multipleAuthors": true, "journal": "Zhonghua Wei Chang Wai Ke Za Zhi", "year": 2017, "design": "rct", "n": 60, "nField": "reported", "population": "adults aged 18 to 65 with grade 2 or 3 internal hemorrhoids", "intervention": "wheat cellulose particles (Fiberform) plus Diosmin tablets", "comparator": "Diosmin tablets alone", "primaryOutcome": "improvement in hemorrhoid symptoms including bleeding, pain, prolapse, stool shape, defecation frequency and duration, scored and compared as an overall effective rate", "result": "the combined treatment group had a higher overall effective rate than the Diosmin-only group, but pain scores specifically did not differ significantly between the groups", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it is a small, short (7-day) trial comparing an added fiber product to a drug alone, with no mention of blinding, so it offers only weak evidence.", "directness": "indirect", "limitations": "small sample size of 60 patients, short 7-day treatment course, and no significant improvement specifically in pain scores between groups", "followUp": "7 days", "plainFinding": "No real improvement in pain itself", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28722093/", "sourceText": "OBJECTIVE: To evaluate the efficacy and safety of wheat cellulose particles (testa triticum tricum purify, Fiberform) in the treatment of internal hemorrhoid. METHODS: A multicenter randomized controlled clinical trial was adopted. From October 2015 to July 2016, 60 patients with internal hemorrhoid were enrolled from three medical centers, including Department of Anorectum, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Department of Anorectum, The Third Affiliated Hospital of Nanjing University of Chinese Medicine, Department of Anorectum, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine. Enrollment criteria: Patients aging from 18 to 65 years old; being diagnosed with the second or third grade internal hemorrhoid; having good communication skills and being able to complete the records and follow-ups according to the research program requirements. EXCLUSION CRITERIA: Patients combined with other anal diseases, or whose anus tube or rectum suffering occupying lesions; patients currently using other methods and defecation drugs in the treatment of their hemorrhoids; patients in pregnancy or with diseases of heart, liver, kidney or metabolic disorders; patients suffering from constipation due to other diseases and drugs, and long-term laxatives abusers. According to the random number table method, 60 patients were randomly divided into the combined treatment group [30 cases, wheat cellulose particles 1 bag each time, 2 times per day; Diosmin tablet 2 pills, 2 times per day] and the single treatment group [30 cases, Diosmin tablet 2 pills, 2 times per day]. The treatment courses for both groups were 7 days. According to the four-grade scoring method, the efficacy evaluation would be made on six indicators, which were the degree of hematochezia or bleeding, the degree of pain, hemorrhoid prolapse, the shapes and properties of stool, the defecation frequency and the defecation duration. The higher the score a participant got, the more severe the symptom was. The effectiveness was evaluated by the scoring reduction rate, and marked effectiveness and effectiveness were both found to be effective. Incidence of adverse events was compared between two groups before the treatment, and on postoperative 3-day and 7-day respectively. RESULTS: There were no significant differences between two groups in gender, age, internal hemorrhoids gradings, disease course, and onset time as well as the baseline data, such as the degree of hematochezia or bleeding before the treatment, the degree of pain, hemorrhoid prolapse, the shapes and properties of stool, the defecation frequency and the defecation duration (all P>0.05). After the seven-day treatment, there was significant difference in effective rate between combination group and single group [96.7%(29/30) vs. 66.7%(20/30), Z=-4.376, P=0.000]. Meanwhile, the scores of combined group and single group in hematochezia or bleeding were 0(0, 1) and 0(0, 2) (Z=9.241, P=0.002); in shapes and properties of stool were 0(0, 1) and 0(0, 1) (Z=5.364, P=0.021); in defecation frequency were 0(0, 1) and 0(0, 2) (Z=7.552, P=0.006); and in defecation duration were 0(0, 1) and 0(0, 2) (Z=4.425, P=0.035), whose differences were all significant. The scores of pain degree and hemorrhoid prolapse of two groups also decreased, but the difference was not statistically significant (P>0.05). During the treatment, abdominal pain, diarrhea and other adverse reactions were not observed in participants of two groups. CONCLUSION: Combination therapy of wheat cellulose particles (testa triticum tricum purify, Fiberform) can significantly improve the efficacy of internal hemorrhoid with safety and tolerance.", "provenance": [ { "field": "n", "quote": "60 patients with internal hemorrhoid were enrolled" }, { "field": "population", "quote": "Patients aging from 18 to 65 years old; being diagnosed with the second or third grade internal hemorrhoid" }, { "field": "intervention", "quote": "wheat cellulose particles 1 bag each time, 2 times per day; Diosmin tablet 2 pills, 2 times per day" }, { "field": "comparator", "quote": "Diosmin tablet 2 pills, 2 times per day" }, { "field": "primaryOutcome", "quote": "the efficacy evaluation would be made on six indicators, which were the degree of hematochezia or bleeding, the degree of pain, hemorrhoid prolapse, the shapes and properties of stool, the defecation frequency and the defecation duration" }, { "field": "result", "quote": "there was significant difference in effective rate between combination group and single group [96.7%(29/30) vs. 66.7%(20/30), Z=-4.376, P=0.000]" }, { "field": "result", "quote": "The scores of pain degree and hemorrhoid prolapse of two groups also decreased, but the difference was not statistically significant (P>0.05)." } ] }, { "id": "pmid:30254394", "pmid": "30254394", "doi": "10.4103/ayu.AYU_147_17", "nctId": null, "pmcid": "PMC6153903", "title": "Management of internal bleeding piles by ligation and plication followed by Matra Basti - A case report", "firstAuthor": "Shekhawat", "multipleAuthors": true, "journal": "Ayu", "year": 2017, "design": "case-series", "n": 1, "nField": "reported", "population": "a 45-year-old man with internal hemorrhoids causing pain, bleeding and prolapse during bowel movements", "intervention": "surgical tying and stitching of the piles followed by an Ayurvedic medicated oil enema (Matra Basti with Jatyadi oil)", "comparator": "none - single patient treated, no comparison group", "primaryOutcome": "resolution of pile mass, bleeding, and symptoms; recurrence on follow-up", "result": "pile mass and bleeding resolved in 10 days, full symptom relief by 4 weeks, no recurrence seen at 3 months follow-up", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report with no comparison group, so it cannot show whether the treatment caused the improvement.", "directness": "indirect", "limitations": "only one patient was treated and described, with no control group and no blinding mentioned.", "followUp": "3 months", "plainFinding": "Symptoms resolved after combined procedure.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30254394/", "sourceText": "Arsha (hemorrhoids) is engorgement of the hemorrhoidal venous plexus, characterized by bleeding per rectum, constipation, pain in ano, prolapse and discharge per anum. It is a primary disease, with impaired digestion as the underlying pathogenesis. It is manifested due to improper diet, prolonged standing and faulty habits of defecation causing derangement of Tridosha, mainly VataDosha. Vitiated Dosha localizes in Houstan's Valve, rectal arteries, fascia and vitiates Skin, muscles, adipose tissue and blood due to AnnavahaSrotodushti (vitiation of gastrointestinal tract). A 45-year-old male patient came to the OPD of Dr. Sarvepalli Radhakrishnan Rajasthan Ayurved University hospital, Jodhpur, Rajasthan, with complaints of prolapsing pile mass during defecation, pain per anum with erosion and bleeding per anum while passing stool. On proctoscopy, pile masses were seen at 11 and 3 O'clock positions and few erosions were seen near the 3 O'clock pile mass. The case was diagnosed as \"Raktarsha\"- later stage of 2nd degree internal hemorrhoids at 11 and 3 O'clock positions, deeply situated, projecting one and caused by Pitta and RaktaDosha; with bleeding tendency. Ligation of pile mass by surgical linen barbour thread number 20 on 11 O'clock positions and plication by absorbable chromic catgut on 3 O'clock positions of internal hemorrhoid were done under local anesthesia followed by Matra Basti (therapeutic oil enema) with Jatyadi oil. The pile mass and per rectal bleeding resolved in 10 days and the patient got relief from all the symptoms within 4 weeks. No complications were reported after the procedure. The patient was followed up regularly from the registered date onward till 3 months and proctoscopic examination did not revealed any evidence of recurrence of the hemorrhoids.", "provenance": [ { "field": "n", "quote": "A 45-year-old male patient came to the OPD" }, { "field": "population", "quote": "complaints of prolapsing pile mass during defecation, pain per anum with erosion and bleeding per anum while passing stool" }, { "field": "intervention", "quote": "Ligation of pile mass by surgical linen barbour thread number 20 on 11 O'clock positions and plication by absorbable chromic catgut on 3 O'clock positions of internal hemorrhoid were done under local anesthesia followed by Matra Basti (therapeutic oil enema) with Jatyadi oil." }, { "field": "comparator", "quote": "A 45-year-old male patient came to the OPD" }, { "field": "primaryOutcome", "quote": "The pile mass and per rectal bleeding resolved in 10 days and the patient got relief from all the symptoms within 4 weeks." }, { "field": "result", "quote": "The pile mass and per rectal bleeding resolved in 10 days and the patient got relief from all the symptoms within 4 weeks. No complications were reported after the procedure." }, { "field": "followUp", "quote": "followed up regularly from the registered date onward till 3 months" } ] }, { "id": "pmid:28658138", "pmid": "28658138", "doi": "10.1097/MD.0000000000007309", "nctId": null, "pmcid": "PMC5500060", "title": "A novel technique for the treatment of stages III to IV hemorrhoids: Homemade anal cushion suspension clamp combined with harmonic scalpel", "firstAuthor": "Lin", "multipleAuthors": true, "journal": "Medicine (Baltimore)", "year": 2017, "design": "retrospective", "n": 99, "nField": "reported", "population": "patients hospitalized with severe (stage III-IV) hemorrhoids undergoing surgery", "intervention": "homemade anal cushion suspension clamp combined with harmonic scalpel (ACS)", "comparator": "Milligan-Morgan hemorrhoidectomy combined with electric knife (MMH)", "primaryOutcome": "postoperative pain and complications after hemorrhoid surgery", "result": "ACS technique caused less pain during bowel movements and fewer complications than standard MMH surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective (not randomized) study comparing two surgical techniques, so it can't rule out bias in how patients were selected for each treatment.", "directness": "indirect", "limitations": "Retrospective design, not randomized, specific to surgical patients with advanced (stage III-IV) hemorrhoids rather than general post-defecation anal pain.", "followUp": "20 days", "plainFinding": "Less pain after hemorrhoid surgery, newer technique.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28658138/", "sourceText": "To compare the efficacy of homemade anal cushion suspension clamp combined with harmonic scalpel (ACS) and Milligan-Morgan hemorrhoidectomy combined with electric knife (MMH) in the treatment of stages III to IV hemorrhoids. We conducted a retrospective study of 99 patients with stages III to IV hemorrhoids hospitalized from January to December in 2013. Among them, 51 patients were treated with ACS, while 48 patients received MMH. Data from clinical recording and follow-up included operative time, intraoperative blood loss, hospitalization information, postoperative pain, and postoperative complications. Operative time, intraoperative blood loss and hospitalization time in ACS group were significantly less than those in MMH group (P < .05). Compared with MMH group, ACS group had a lower postoperative static pain score from days 1 to 14 (P < .01). The patients in ACS group exhibited less postoperative defecation pain scores from days 3 to 20 than those of MMH group (P < .05). The incidence of postoperative anal edema and delayed wound healing in ACS group was lower than that in MMH group (P < .05). Compared with MMH, our novel technique ACS was more effective and had fewer postoperative complications in the treatment of stages III to IV hemorrhoids.", "provenance": [ { "field": "n", "quote": "We conducted a retrospective study of 99 patients with stages III to IV hemorrhoids hospitalized from January to December in 2013." }, { "field": "population", "quote": "patients with stages III to IV hemorrhoids hospitalized from January to December in 2013" }, { "field": "intervention", "quote": "homemade anal cushion suspension clamp combined with harmonic scalpel (ACS)" }, { "field": "comparator", "quote": "Milligan-Morgan hemorrhoidectomy combined with electric knife (MMH)" }, { "field": "primaryOutcome", "quote": "postoperative pain, and postoperative complications" }, { "field": "result", "quote": "The patients in ACS group exhibited less postoperative defecation pain scores from days 3 to 20 than those of MMH group (P < .05)." } ] }, { "id": "pmid:28655981", "pmid": "28655981", "doi": "10.20524/aog.2017.0154", "nctId": null, "pmcid": "PMC5479997", "title": "Anal self-massage in the treatment of acute anal fissure: a randomized prospective study", "firstAuthor": "Gaj", "multipleAuthors": true, "journal": "Ann Gastroenterol", "year": 2017, "design": "rct", "n": 50, "nField": "reported", "population": "adults with a newly diagnosed anal fissure", "intervention": "self-massage of the anal sphincter using a finger", "comparator": "passive anal dilatation using dilators", "primaryOutcome": "healing of the anal fissure and reduction in anal pain and bleeding after bowel movements", "result": "80% of the finger-massage group had their fissure heal versus 60% of the dilator group, with greater pain reduction at 6 months in the massage group", "resultDirection": "benefit", "quality": "low", "qualityWhy": "It was a small randomized trial of only 50 patients with no mention of blinding, which limits confidence in the results.", "directness": "direct", "limitations": "Small sample size; abstract does not mention blinding or long-term fissure recurrence data.", "followUp": "6 months", "plainFinding": "Finger massage healed fissures faster.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28655981/", "sourceText": "BACKGROUND: An anal fissure (AF) is a tear in the epithelial lining of the anal canal. This is a very common condition, but the choice of treatment is unclear. The use of anal dilators is effective, economic, and safe. The aim of the study was to compare the efficacy of two conservative treatments, the use of anal dilators or a finger for anal dilatation, in reducing anal pressure and resolving anal fissures. METHODS: Fifty patients with a clinical diagnosis of AF were randomly assigned to one of the treatments, self-massage of the anal sphincter (group A, 25 patients) or passive dilatation using dilators (group B, 25 patients). All patients were evaluated at baseline, at the end of treatment, and after 12 weeks and 6 months. Pain was measured using a visual analog scale. RESULTS: After the treatment, 60% of patients treated with dilators and 80% of patients treated with anal self-massage using a finger showed disappearance of their anal fissures. A comparison between signs and symptoms reported by the patients in the two groups showed a statistically significant reduction in anal pain (group A, P=0.0001; group B, P=0.0001) and bleeding after defecation (group A, P=0.001, group B, P=0.001). At 6 months after treatment, a significantly greater reduction in anal pain was observed in Group A compared to Group B (P=0.02). CONCLUSION: The use of anal self-massage with a finger appears to induce a better resolution of acute anal fissure than do anal dilators, and in a shorter time.", "provenance": [ { "field": "n", "quote": "Fifty patients with a clinical diagnosis of AF were randomly assigned" }, { "field": "population", "quote": "Fifty patients with a clinical diagnosis of AF" }, { "field": "intervention", "quote": "self-massage of the anal sphincter (group A, 25 patients)" }, { "field": "comparator", "quote": "passive dilatation using dilators (group B, 25 patients)" }, { "field": "primaryOutcome", "quote": "reducing anal pressure and resolving anal fissures" }, { "field": "result", "quote": "60% of patients treated with dilators and 80% of patients treated with anal self-massage using a finger showed disappearance of their anal fissures" }, { "field": "result", "quote": "a significantly greater reduction in anal pain was observed in Group A compared to Group B (P=0.02)" } ] }, { "id": "pmid:28589634", "pmid": "28589634", "doi": "10.1111/codi.13755", "nctId": null, "pmcid": null, "title": "Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief", "firstAuthor": "Lyons", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2017, "design": "meta-analysis", "n": 437, "nField": "reported", "population": "patients who had surgery to remove haemorrhoids", "intervention": "metronidazole (an antibiotic) after haemorrhoidectomy surgery", "comparator": "no metronidazole (placebo or standard care)", "primaryOutcome": "pain levels after surgery, including pain during the first bowel movement", "result": "metronidazole significantly reduced pain on days 1, 2, and 7 after surgery and during the first bowel movement", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "this pools several randomized trials, but the studies varied in quality and in the severity of haemorrhoids treated, and this is about pain after surgical removal of haemorrhoids, not pain after a normal bowel movement.", "directness": "indirect", "limitations": "variation in the grade of haemorrhoids treated and variability in the quality of included studies", "followUp": "7 days", "plainFinding": "Less pain after haemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28589634/", "sourceText": "AIM: 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. METHOD: 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. RESULTS: 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. CONCLUSION: Metronidazole is a cheap, safe and effective intervention for reducing postoperative pain following conventional haemorrhoidectomy.", "provenance": [ { "field": "population", "quote": "Conventional haemorrhoidectomy is still considered the reference standard for the management of severe or recurrent haemorrhoids." }, { "field": "intervention", "quote": "metronidazole is often used to reduce postoperative pain" }, { "field": "comparator", "quote": "investigated the use of metronidazole for pain relief after haemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "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." }, { "field": "result", "quote": "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)." }, { "field": "n", "quote": "a total population of 437 patients" } ] }, { "id": "pmid:28373769", "pmid": "28373769", "doi": "10.3748/wjg.v23.i11.2029", "nctId": null, "pmcid": "PMC5360644", "title": "Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders", "firstAuthor": "Bildstein", "multipleAuthors": true, "journal": "World J Gastroenterol", "year": 2017, "design": "retrospective", "n": 108, "nField": "reported", "population": "adults with constipation or fecal incontinence being trained in transanal irrigation", "intervention": "transanal irrigation (TAI) therapy", "comparator": "no comparison group; patients compared by whether they continued or stopped TAI", "primaryOutcome": "whether patients kept using transanal irrigation one year after training", "result": "43% of patients were still using TAI after one year, and common reasons for stopping included pain during irrigation, anal fissure and anal bleeding", "resultDirection": "unclear", "quality": "low", "qualityWhy": "It is a retrospective, single-center study without a control group, so it only tracks compliance and side effects rather than proving benefit or harm.", "directness": "indirect", "limitations": "Retrospective design, single institution, no control group, and outcomes assessed by intention-to-treat with discontinuation reasons self-reported by patients.", "followUp": "one year", "plainFinding": "Pain and fissures caused treatment dropout.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28373769/", "sourceText": "AIM: To investigate compliance with transanal irrigation (TAI) one year after a training session and to identify predictive factors for compliance. METHODS: The compliance of one hundred eight patients [87 women and 21 men; median age 55 years (range 18-83)] suffering from constipation or fecal incontinence (FI) was retrospectively assessed. The patients were trained in TAI over a four-year period at a single institution. They were classified as adopters if they continued using TAI for at least one year after beginning the treatment or as non-adopters if they stopped. Predictive factors of compliance with TAI were based on pretreatment assessments and training progress. The outcomes of the entire cohort of patients who had been recruited for the TAI treatment were expressed in terms of intention-to-treat. RESULTS: Forty-six of the 108 (43%) trained patients continued to use TAI one year after their training session. The patients with FI had the best results, with 54.5% remaining compliant with TAI. Only one-third of the patients who complained of slow transit constipation or obstructed defecation syndrome continued TAI. There was an overall discontinuation rate of 57%. The most common reason for discontinuing TAI was the lack of efficacy (41%). However, 36% of the patients who discontinued TAI gave reasons independent of the efficacy of the treatment such as technical problems (catheter expulsion, rectal balloon bursting, instilled water leakage or retention, pain during irrigation, anal bleeding, anal fissure) while 23% said that there were too many constraints. Of the patients who reported discontinuing TAI, the only predictive factor was the progress of the training (OR = 4.9, 1.3-18.9, P = 0.02). CONCLUSION: The progress of the training session was the only factor that predicted patient compliance with TAI.", "provenance": [ { "field": "n", "quote": "one hundred eight patients" }, { "field": "population", "quote": "suffering from constipation or fecal incontinence (FI)" }, { "field": "intervention", "quote": "compliance with transanal irrigation (TAI) one year after a training session" }, { "field": "comparator", "quote": "classified as adopters if they continued using TAI for at least one year after beginning the treatment or as non-adopters if they stopped" }, { "field": "primaryOutcome", "quote": "To investigate compliance with transanal irrigation (TAI) one year after a training session and to identify predictive factors for compliance" }, { "field": "result", "quote": "Forty-six of the 108 (43%) trained patients continued to use TAI one year after their training session" }, { "field": "result", "quote": "technical problems (catheter expulsion, rectal balloon bursting, instilled water leakage or retention, pain during irrigation, anal bleeding, anal fissure)" } ] }, { "id": "pmid:28289661", "pmid": "28289661", "doi": "10.3393/ac.2017.33.1.28", "nctId": null, "pmcid": "PMC5346778", "title": "Early Experience With a Partial Stapled Hemorrhoidopexy for Treating Patients With Grades III-IV Prolapsing Hemorrhoids", "firstAuthor": "Jeong", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2017, "design": "retrospective", "n": 58, "nField": "reported", "population": "patients with grade III-IV prolapsing hemorrhoids", "intervention": "partial stapled hemorrhoidopexy surgery", "comparator": "none (single group, compared to typical circular stapled hemorrhoidopexy complications from prior knowledge)", "primaryOutcome": "surgical complications and safety", "result": "low complication rates with no urge to defecate, tenesmus, abscess, fistula, stricture, incontinence, or recurrence", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a small retrospective case series without a comparison group, so it cannot reliably prove the technique is better or explain why pooping hurts.", "directness": "indirect", "limitations": "Retrospective design, no control group, small sample size, short follow-up implied by hospital stay data only.", "followUp": "", "plainFinding": "New hemorrhoid surgery had few complications.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28289661/", "sourceText": "PURPOSE: Circular stapled hemorrhoidopexy (CSH) is widely used to treat patients with grades III-IV hemorrhoids because of less pain and short hospital stay. However, this procedure is associated with some complications, such as urge to defecate, anal stenosis, staple line dehiscence, abscess and sepsis. To avoid these complications, surgeons perform a partial stapled hemorrhoidopexy (PSH). The aim of this study is to present our early experience with the PSH. METHODS: We retrospectively reviewed the medical records of 58 patients with hemorrhoids who were treated with a PSH at Busan Hang-Un Hospital from January 2016 to June 2016. A specially designed tri-window anoscope was used, and a purse string suture was made at the mucosae of the protruding hemorrhoids through the window of the anoscope. The hemorrhoidopexy was done by using a circular stapler. RESULTS: Of the 58 patients included in this study, 34 were male and 24 were female patients (mean age, 50.4 years). The mean operation time was 12.4 minutes, and the mean postoperative hospital stay was 3.8 days. Three patients experienced bleeding (5.1%) 5 urinary retention (8.6%) and 5 skin tags (8.6%). Urge to defecate, tenesmus, abscess, rectovaginal fistula, anal stricture, incontinence, and recurrence did not occur. CONCLUSION: PSH is a minimally invasive, feasible, and safe technique for treating patients with grades III-IV hemorrhoids. A PSH, instead of a CSH, can be used to treat certain patients with hemorrhoids.", "provenance": [ { "field": "n", "quote": "58 patients with hemorrhoids who were treated with a PSH" }, { "field": "population", "quote": "patients with grades III-IV hemorrhoids" }, { "field": "intervention", "quote": "partial stapled hemorrhoidopexy (PSH)" }, { "field": "comparator", "quote": "Circular stapled hemorrhoidopexy (CSH) is widely used to treat patients with grades III-IV hemorrhoids" }, { "field": "primaryOutcome", "quote": "present our early experience with the PSH" }, { "field": "result", "quote": "Urge to defecate, tenesmus, abscess, rectovaginal fistula, anal stricture, incontinence, and recurrence did not occur." } ] }, { "id": "pmid:28273604", "pmid": "28273604", "doi": "10.1016/j.ijscr.2017.02.020", "nctId": null, "pmcid": "PMC5338909", "title": "Mucocele complicating stapled hemorrhoidopexy", "firstAuthor": "Grapsi", "multipleAuthors": true, "journal": "Int J Surg Case Rep", "year": 2017, "design": "case-series", "n": 1, "nField": "reported", "population": "a 57-year-old woman who had surgery for hemorrhoids (stapled hemorrhoidopexy)", "intervention": "surgical drainage of a mucus-filled pocket (mucocele) near the rectum", "comparator": "no comparison group, just one patient's case", "primaryOutcome": "symptoms like perineal discomfort, anal spasm, and straining, and whether they resolved after treatment", "result": "after surgical drainage of the mucocele, the patient became symptom-free with normal bowel movements after one year", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common or typical this cause of pain is.", "directness": "indirect", "limitations": "only one patient described, no control group, and this applies specifically to people who previously had stapled hemorrhoid surgery rather than general post-defecation anal pain.", "followUp": "one year", "plainFinding": "Rare surgery complication caused pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28273604/", "sourceText": "INTRODUCTION: Stapled hemorrhoidopexy is a safe and effective treatment for circumferential hemorrhoidal prolapse. The overall rate of complications ranges from 12,7% to 36,4% and the surgeon should be aware about their early identification and adequate treatment. PRESENTATION OF CASE: Female patient, 57 years was treated with stapled hemorrhoidopexy. Two years after surgery she reported to our center the occurrence of perineal discomfort, anal spasm and tenesmus. The anal exploration showed a bulge of the right lateral wall of the rectum at the level of stapled line without any related pain. 3D 360° transanal ultrasound showed a pararectal fluid collection. A surgical operation was performed and a great amount of mucus was drained. After one year the patient is completely asymptomatic with normal defecation. DISCUSSION: Mucocele is a rare complication which usually occurs after months from the operation and it is considered a variant of rectal pocket and it is usually completely separated from the rectal lumen at the level of stapled line. The differential diagnosis between mucocele and pararectal lesions, especially abscess may be often difficult. Surgery is the treatment of choice with a transanal approach that is generally preferred to the trans-perineal. CONCLUSION: Mucocele is a rare complication of stapled hemorrhoidopexy that may remain asymptomatic for a long period. In case of perineal discomfort after stapled procedure the physical examination combined with 3D 360° transanal ultrasound is necessary to reach the diagnosis. The knowledge of the possible rare complications is at the base of a correct treatment.", "provenance": [ { "field": "population", "quote": "Female patient, 57 years was treated with stapled hemorrhoidopexy." }, { "field": "intervention", "quote": "A surgical operation was performed and a great amount of mucus was drained." }, { "field": "comparator", "quote": "PRESENTATION OF CASE: Female patient, 57 years was treated with stapled hemorrhoidopexy." }, { "field": "primaryOutcome", "quote": "she reported to our center the occurrence of perineal discomfort, anal spasm and tenesmus" }, { "field": "result", "quote": "After one year the patient is completely asymptomatic with normal defecation." }, { "field": "n", "quote": "Female patient, 57 years was treated with stapled hemorrhoidopexy." }, { "field": "followUp", "quote": "After one year the patient is completely asymptomatic with normal defecation." } ] }, { "id": "pmid:28176917", "pmid": "28176917", "doi": "10.2147/JPR.S128500", "nctId": null, "pmcid": "PMC5261852", "title": "Xiaozhi decoction reduced posthemorrhoidectomy pain and analgesic medication consumption: a prospective study", "firstAuthor": "Shen", "multipleAuthors": true, "journal": "J Pain Res", "year": 2017, "design": "rct", "n": 315, "nField": "reported", "population": "patients who had surgery to remove hemorrhoids", "intervention": "sitz bath with Xiaozhi decoction (a herbal medicine) after surgery", "comparator": "sitz bath with warm water after surgery", "primaryOutcome": "pain after surgery and pain during bowel movements", "result": "less pain and less need for pain medication at several points after surgery, including after pooping", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this studied pain after hemorrhoid surgery, not everyday pain after pooping without surgery, and does not describe blinding of patients or outcome assessors.", "directness": "indirect", "limitations": "abstract does not mention blinding; population is post-surgical hemorrhoidectomy patients, not general population with pain after defecation", "followUp": "28 days", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28176917/", "sourceText": "OBJECTIVE: The aim of this study was to investigate the effect of Xiaozhi decoction (XZD) on posthemorrhoidectomy pain and analgesic medication consumption. METHODS: From 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. RESULTS: No 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. CONCLUSION: XZD could effectively relieve postoperative pain and reduce analgesic medication consumption after hemorrhoidectomy.", "provenance": [ { "field": "n", "quote": "315 patients who underwent open hemorrhoidectomy in our hospital were enrolled in this study" }, { "field": "population", "quote": "patients who underwent open hemorrhoidectomy in our hospital" }, { "field": "intervention", "quote": "155 patients were randomly assigned to accept sitz bath with XZD" }, { "field": "comparator", "quote": "160 patients were randomly assigned to accept sitz bath with warm water after hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "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." }, { "field": "result", "quote": "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)" } ] }, { "id": "pmid:27813396", "pmid": "27813396", "doi": null, "nctId": null, "pmcid": null, "title": "Stapled anopexy versus transanal hemorrhoidal dearterialization for hemorrhoidal disease: a three-year follow-up from a randomized study", "firstAuthor": "Venturi", "multipleAuthors": true, "journal": "Minerva Chir", "year": 2016, "design": "rct", "n": 70, "nField": "reported", "population": "adults with third- or fourth-degree hemorrhoids needing surgery", "intervention": "stapled anopexy (a hemorrhoid surgery)", "comparator": "transanal hemorrhoidal dearterialization with anopexy (another hemorrhoid surgery)", "primaryOutcome": "hemorrhoids coming back after surgery", "result": "pain levels were about the same with both surgeries", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "small randomized study of a specific surgical population, so it says little about ordinary pain after a bowel movement in people without hemorrhoid surgery.", "directness": "indirect", "limitations": "Small groups (totaling 70 patients), specific to surgical hemorrhoid patients, and costs/complications differed by surgery type.", "followUp": "36±6 months", "plainFinding": "Similar pain between two hemorrhoid surgeries.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27813396/", "sourceText": "BACKGROUND: This randomized study compared the medium-term results of stapled anopexy (SA) and transanal hemorrhoidal dearterialization with anopexy (THD) in 4 homogeneous groups of patients, 2 with third- and 2 with fourth-degree hemorrhoids. METHODS: Forty patients with third-degree and 30 with fourth-degree hemorrhoids were randomly submitted to SA (N.=20+15) and THD (N.=20+15), respectively. Clinical controls were done every 6 months from 1 to 42 months after the operation, with incidence of recurrent hemorrhoids as primary outcome measure. Operative time, complications, pain, time to return to normal activity, costs, Short Form-36, and overall patient satisfaction were also evaluated. RESULTS: Frequencies of preoperative obstructed defecation symptoms and prolapse recurrence were higher in patients with fourth-degree hemorrhoids, and SA was more effective than THD in reducing the risk of recurrence at 36±6 months follow-up (P=0.049). Operative time, complications, pain, and time of return to normal activity were similar in the 4 groups. Costs were significantly higher for SA in patients with fourth-degree hemorrhoids (P>0.01). A significant improvement of quality of life was observed in all groups, and no significant difference was found in overall patient satisfaction. CONCLUSIONS: Both techniques are safe and effective in the mid-term period. SA is more effective in reducing prolapse and obstructed defecation symptoms in fourth-degree hemorrhoids, with the disadvantage of higher costs. Prolapse size and presence of obstructed defecation symptoms could be predictive criteria for choice of the best surgical technique.", "provenance": [ { "field": "population", "quote": "Forty patients with third-degree and 30 with fourth-degree hemorrhoids" }, { "field": "intervention", "quote": "stapled anopexy (SA)" }, { "field": "comparator", "quote": "transanal hemorrhoidal dearterialization with anopexy (THD)" }, { "field": "primaryOutcome", "quote": "incidence of recurrent hemorrhoids as primary outcome measure" }, { "field": "result", "quote": "Operative time, complications, pain, and time of return to normal activity were similar in the 4 groups." }, { "field": "n", "quote": "Forty patients with third-degree and 30 with fourth-degree hemorrhoids were randomly submitted to SA (N.=20+15) and THD (N.=20+15)" }, { "field": "followUp", "quote": "36±6 months follow-up" } ] }, { "id": "pmid:27738832", "pmid": "27738832", "doi": "10.1007/s00268-016-3749-x", "nctId": null, "pmcid": null, "title": "Effects of Topical Atorvastatin (2 %) on Posthemorrhoidectomy Pain and Wound Healing: A Randomized Double-Blind Placebo-Controlled Clinical Trial", "firstAuthor": "Ala", "multipleAuthors": true, "journal": "World J Surg", "year": 2017, "design": "rct", "n": 66, "nField": "reported", "population": "patients with third- and fourth-degree hemorrhoids who had surgery to remove them", "intervention": "atorvastatin gel applied to the wound after hemorrhoid surgery", "comparator": "placebo gel applied after hemorrhoid surgery", "primaryOutcome": "pain at rest and during bowel movements, pain medicine use, and wound healing", "result": "no difference in pain in the first 48 hours, but less pain during defecation at week 1 and 2, and better wound healing at week 2, with atorvastatin", "resultDirection": "mixed", "quality": "low", "qualityWhy": "small trial of only 66 patients studying a specific post-surgery condition, not ordinary pain after a normal bowel movement", "directness": "indirect", "limitations": "small sample size; studies pain after surgical hemorrhoid removal, not general anal pain after defecation", "followUp": "14 days", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27738832/", "sourceText": "BACKGROUND: 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. METHODS: 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 12 h for 14 days. 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. RESULTS: There was no significant difference in the average postoperative pain scores in the first 48 h (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 12 h and 24 h 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). CONCLUSIONS: Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy. TRIAL REGISTRATION NUMBER: IRCT201404013014N8.", "provenance": [ { "field": "population", "quote": "A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial." }, { "field": "intervention", "quote": "The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12 h for 14 days." }, { "field": "comparator", "quote": "The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12 h for 14 days." }, { "field": "primaryOutcome", "quote": "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." }, { "field": "result", "quote": "There was no significant difference in the average postoperative pain scores in the first 48 h (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)." }, { "field": "n", "quote": "A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial." } ] }, { "id": "pmid:27712641", "pmid": "27712641", "doi": "10.1016/j.mayocp.2016.08.011", "nctId": null, "pmcid": "PMC5123821", "title": "Anorectal and Pelvic Pain", "firstAuthor": "Bharucha", "multipleAuthors": true, "journal": "Mayo Clin Proc", "year": 2016, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anorectal and pelvic pain from functional disorders such as levator ani syndrome, unspecified anorectal pain, proctalgia fugax, bladder pain syndrome, or chronic prostatitis", "intervention": "multidisciplinary management including lifestyle changes, medications, behavioral therapy, and physical therapy", "comparator": "opioids or surgery, which the review says should mostly be avoided or have limited use", "primaryOutcome": "pelvic and anorectal pain symptoms", "result": "the review describes management as tailored to symptoms and only partly supported by clinical trials, without giving a specific outcome result", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general review article summarizing conditions and treatments rather than a study testing whether a specific treatment works.", "directness": "indirect", "limitations": "The review focuses on functional pelvic pain conditions like levator ani syndrome and bladder/prostate pain syndromes, and explicitly excludes structural causes like anal fissure, which may be more relevant to pain right after a bowel movement.", "followUp": "", "plainFinding": "General overview, no specific treatment result.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27712641/", "sourceText": "Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.", "provenance": [ { "field": "population", "quote": "this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome" }, { "field": "intervention", "quote": "includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy" }, { "field": "comparator", "quote": "Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis." }, { "field": "primaryOutcome", "quote": "pelvic pain is a symptom of several structural anorectal and pelvic disorders" }, { "field": "result", "quote": "The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy." } ] }, { "id": "pmid:27515194", "pmid": "27515194", "doi": "10.1016/j.mehy.2016.06.005", "nctId": null, "pmcid": null, "title": "Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex", "firstAuthor": "van Meegdenburg", "multipleAuthors": true, "journal": "Med Hypotheses", "year": 2016, "design": "narrative-review", "n": 1, "nField": "reported", "population": "people with chronic anal fissures (painful tears in the anal lining)", "intervention": "surgical cutting of the internal anal sphincter (lateral sphincterotomy)", "comparator": "anal pressure measured while anesthetic was still active versus after it had worn off", "primaryOutcome": "anal basal (resting) pressure after surgery", "result": "pressure dropped right after surgery while anesthetic was active, but rose again after the anesthetic wore off even though the internal sphincter had been cut, suggesting the external sphincter, not the internal one, is driving the high pressure", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a theoretical hypothesis paper based mainly on one patient's case and reasoning from other studies, not a controlled trial.", "directness": "indirect", "limitations": "based on a single patient case and indirect reasoning, no formal study testing the hypothesis in a group of patients", "followUp": "", "plainFinding": "Pain may come from sphincter muscle spasm.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27515194/", "sourceText": "Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections. In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing. Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated external anal sphincter, rather than the smooth internal anal sphincter. If our hypothesis is proved correct, the treatment option of lateral internal sphincterotomy should be abandoned in patients suffering from chronic anal fissures, since it fails to eliminate the cause of high anal basal pressure. Additionally, lateral internal sphincterotomy may cause damage to the anal-external sphincter continence reflex, resulting in fecal incontinence. Instead, higher doses of botulinum toxin should be administered to those patients suffering from chronic anal fissure who appeared unresponsive to lower doses.", "provenance": [ { "field": "population", "quote": "patients suffering from chronic anal fissure" }, { "field": "intervention", "quote": "lateral sphincterotomy" }, { "field": "comparator", "quote": "Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg" }, { "field": "primaryOutcome", "quote": "basal anal pressure decreased to 80mmHg" }, { "field": "result", "quote": "Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase." }, { "field": "n", "quote": "a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy" } ] }, { "id": "pmid:27037709", "pmid": "27037709", "doi": "10.1007/s10151-016-1458-y", "nctId": null, "pmcid": null, "title": "Tailored therapy for different presentations of chronic pain after stapled hemorrhoidopexy", "firstAuthor": "Asteria", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2016, "design": "retrospective", "n": 31, "nField": "reported", "population": "people with ongoing anal pain after stapled hemorrhoidopexy (a staple-based surgery for hemorrhoids)", "intervention": "tailored treatments chosen by pain type and cause (topical nifedipine, anal dilation, anesthetic/steroid injection, staple removal, scar excision)", "comparator": "pain levels before treatment (baseline), not a separate control group", "primaryOutcome": "change in pain score (VAS) from before to after treatment", "result": "pain scores dropped significantly after treatment and stayed low at follow-up, with response rates varying by specific treatment (13-94% depending on method)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small retrospective study without a comparison group, so improvement could be due to other factors besides the treatments themselves.", "directness": "indirect", "limitations": "Retrospective design, no control group, referred from other hospitals, and the abstract doesn't specify how long follow-up lasted.", "followUp": "", "plainFinding": "Post-surgery anal pain often improved with targeted treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27037709/", "sourceText": "BACKGROUND: As stapled hemorrhoidopexy (SH) becomes more widely used, we see more patients with chronic postoperative anal pain after this surgery. Its presentation is variable and difficult to treat. The aim of our study was to investigate the impact of chronic anal pain after SH and whether tailored therapy was likely to achieve a favorable outcome. METHODS: We retrospectively analyzed 31 consecutive patients with chronic anal pain who had undergone SH in other hospitals and were referred to our institutions. Depending on the type of pain, unrelated (at rest) or related to defecation, two groups of patients were identified. Moreover, the mean distance of the staple line from the anal verge was calculated in both groups. Treatments included: topical nifedipine, local anesthetic and steroid infiltration, removal of retained staples, anal dilation, and scar excision with mucosal suturing. A visual analog scale (VAS) was used to compare pain at baseline, postoperatively, and in the follow-up. This mean difference of the VAS score between stages was always used as the main outcome measure, depending on the type of presentation, type of pain, and type of treatment. Treatment response was defined as a 50 % decrease of VAS from baseline. RESULTS: There were 22 males and 9 females. The overall median age was 43 years (range 21-62 years). On digital examination and proctoscopy, 15 (48 %) patients had inflammatory changes, 19 (61 %) patients had staple retention, 8 (26 %) patients had anorectal stenosis, and 30 (97 %) patients had scar tissue. All patients had one or more of the following treatments listed from the least to most invasive: topical nifedipine in 12 (39 %) patients, anal dilation in 6 (19 %) patients, anesthetic and steroid infiltration in 18 (58 %) patients, removal of staples in 10 (32 %) patients, and scar excision in 18 (58 %) patients. The mean VAS score at baseline was 6.100, ± 1.953 SD, which dropped significantly after treatment to 1.733, ± 1.658 SD (p < 0.001) and remained low at follow-up (1.741 ± SD 1.251; p < 0.743). In patients with pain at rest (n = 20, 65 %), the symptoms improved in 19 (95 %) patients, while the VAS score decreased from 5.552 ± 2.115 SD to 1.457 ± 1.440 SD (95 % CI 3.217-4.964; p < 0.001). In patients with post-evacuation pain (n = 11, 35 %), the symptoms improved in 11 (100 %) patients, while the VAS score decreased from 6.429 ± 1.835 SD to 1.891 ± 1.792 SD (95 % CI 3.784-5.269; p < 0.001). Rating of response based on presentation was 90.0 % (0.9/10) after treatment of staple retention, which led to a significant decrease in the mean VAS score from 6.304 ± 1.845 SD to 1.782 ± 1.731 SD (95 % CI 3.859-5.185; p < 0.001). Anal stenosis was successfully treated in 100.0 % (n = 8/8) of cases with the mean VAS score dropping from 6.500 ± 1.309 SD to 2.125 ± 1.808 SD (95 % CI 2.831-5.919; p < 0.001). Anal inflammation improved in 60.0 % (n = 9/15) of patients and the mean VAS score dropped from 6.006 ± 2.138 SD to 1.542 ± 1.457 SD (95 % CI 3.217-4.964; p < 0.001). The response after scar tissue treatment was 94 % (n = 17/18) of patients with a mean VAS decreasing from 6.117 ± 2.006 SD to 1.712 ± 1.697 SD (95 % CI 3.812-4.974; p < 0.001). Success for topical nifedipine was between 13 and 25 % of patients depending on the clinical presentation. Anal dilation was successful in 75 % of patients, while Anesthetic and steroid infiltration in 23-54 % of patients depending on the clinical presentation. Staple removal was successful in 77 % of patients, and scar excision with mucosal suturing in 94 % of patients. CONCLUSIONS: Our retrospective study suggests that most patients with chronic anal pain after SH may be cured with treatment by applying a stepwise approach from the least to the most invasive treatment.", "provenance": [ { "field": "n", "quote": "We retrospectively analyzed 31 consecutive patients with chronic anal pain who had undergone SH" }, { "field": "population", "quote": "patients with chronic anal pain who had undergone SH in other hospitals and were referred to our institutions" }, { "field": "intervention", "quote": "Treatments included: topical nifedipine, local anesthetic and steroid infiltration, removal of retained staples, anal dilation, and scar excision with mucosal suturing." }, { "field": "comparator", "quote": "A visual analog scale (VAS) was used to compare pain at baseline, postoperatively, and in the follow-up." }, { "field": "primaryOutcome", "quote": "This mean difference of the VAS score between stages was always used as the main outcome measure" }, { "field": "result", "quote": "The mean VAS score at baseline was 6.100, ± 1.953 SD, which dropped significantly after treatment to 1.733, ± 1.658 SD (p < 0.001) and remained low at follow-up" }, { "field": "result", "quote": "Success for topical nifedipine was between 13 and 25 % of patients depending on the clinical presentation." }, { "field": "result", "quote": "scar excision with mucosal suturing in 94 % of patients" } ] }, { "id": "pmid:26813541", "pmid": "26813541", "doi": "10.1007/s00268-016-3419-z", "nctId": null, "pmcid": null, "title": "Milligan-Morgan (Open) Versus Ferguson Haemorrhoidectomy (Closed): A Systematic Review and Meta-Analysis of Published Randomized, Controlled Trials", "firstAuthor": "Bhatti", "multipleAuthors": true, "journal": "World J Surg", "year": 2016, "design": "meta-analysis", "n": 1326, "nField": "reported", "population": "patients having surgery to remove hemorrhoids", "intervention": "closed (Ferguson) hemorrhoid removal surgery", "comparator": "open (Milligan-Morgan) hemorrhoid removal surgery", "primaryOutcome": "pain after surgery, including pain with bowel movements, bleeding, and wound healing", "result": "Closed surgery caused less overall post-op pain, less bleeding, and faster healing, but pain specifically during bowel movements was not significantly different between the two methods", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "It pools several randomized trials but the studies differed a lot from each other, which makes the combined results less certain.", "directness": "indirect", "limitations": "Significant heterogeneity among included trials was noted by the authors.", "followUp": "", "plainFinding": "Surgery type didn't change pain when pooping.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26813541/", "sourceText": "OBJECTIVE: The purpose of this article is to systematically analyse the randomized, controlled trials (RCTs) comparing Ferguson or closed haemorrhoidectomy (CH) versus open haemorrhoidectomy (OH) or Milligan-Morgan haemorrhoidectomy in the management of haemorrhoidal disease (HD). METHODS: RCTs on the effectiveness of CH and OH in the management of HD were analysed systematically using RevMan(®), and combined outcome was expressed as odds ratio (OR) and standardized mean difference. RESULTS: Eleven CRTs encompassing 1326 patients were analysed systematically. There was significant heterogeneity among included trials. Therefore, in the random effects model, CH was associated with a reduced post-operative pain (SMD, -0.36; 95 % CI, -0.64, -0.07; z = 2.45; p = 0.01), faster wound healing (OR, 0.08; 95 % CI, 0.02, 0.24; z = 4.33; p < 0.0001), lesser risk of post-operative bleeding (OR, 0.50; 95 % CI, 0.27, 0.91; z = 2.27; p < 0.02) and prolonged duration of operation (SMD, 6.10; 95 % CI, 3.21, 8.98; z = 4.13; p < 0.0001). But the variables such as pain on defecation (SMD, -0.33; 95 % CI, -0.68, 0.03; z = 1.82; p = 0.07), length of hospital stay, post-operative complications, HD recurrence and risk of surgical site infection were similar in both groups. CONCLUSION: CH has clinically measurable advantages over OH in terms of reduced post-operative pain, lower risk of post-operative bleeding and faster wound healing.", "provenance": [ { "field": "n", "quote": "Eleven CRTs encompassing 1326 patients were analysed systematically." }, { "field": "population", "quote": "the management of haemorrhoidal disease (HD)" }, { "field": "intervention", "quote": "Ferguson or closed haemorrhoidectomy (CH)" }, { "field": "comparator", "quote": "open haemorrhoidectomy (OH) or Milligan-Morgan haemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "pain on defecation" }, { "field": "result", "quote": "pain on defecation (SMD, -0.33; 95 % CI, -0.68, 0.03; z = 1.82; p = 0.07), length of hospital stay, post-operative complications, HD recurrence and risk of surgical site infection were similar in both groups" }, { "field": "limitations", "quote": "There was significant heterogeneity among included trials." } ] }, { "id": "pmid:26704004", "pmid": "26704004", "doi": null, "nctId": null, "pmcid": null, "title": "[Meta-analysis of randomized controlled trials comparing procedure for prolapse and hemorrhoids with Milligan-Morgan hemorrhoidectomy in the treatment of prolapsed hemorrhoids]", "firstAuthor": "He", "multipleAuthors": true, "journal": "Zhonghua Wei Chang Wai Ke Za Zhi", "year": 2015, "design": "meta-analysis", "n": 1411, "nField": "reported", "population": "patients with prolapsed hemorrhoids undergoing surgery", "intervention": "stapled hemorrhoidopexy (procedure for prolapse and hemorrhoids, PPH)", "comparator": "traditional hemorrhoid removal surgery (Milligan-Morgan hemorrhoidectomy, MMH)", "primaryOutcome": "pain, recovery time, complications and recurrence after surgery", "result": "PPH caused less pain after surgery and during the first bowel movement, faster recovery, but higher chance of hemorrhoids coming back after a year", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "it combines many randomized trials which strengthens the findings, but the individual trials may vary in quality and this is about surgical patients, not general post-bowel-movement pain.", "directness": "indirect", "limitations": "The abstract does not describe the quality of individual trials in detail or discuss publication bias.", "followUp": "1 year", "plainFinding": "Less pain short-term, but more recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26704004/", "sourceText": "OBJECTIVE: To compare the safety and efficacy of procedure for prolapse and hemorrhoids (PPH) with Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of prolapsed hemorrhoids. METHODS: All the randomized controlled trials (RCT) comparing PPH with MMH in the treatment of prolapsed hemorrhoids published between January 1998 and January 2015 were retrieved from PubMed, Embase, Cochrane Library, CBM, CNKI, Wangfang, VIP databases. Hand search was applied in Chinese Journal of Gastrointestinal Surgery, Chinese Journal of Coloproctology and Journal of Colorectal and Anal Surgery from the library of Chengdu University of Traditional Chinese Medicine. Associated reference documents in enrolled trials were reviewed. The methodological quality of enrolled trials was evaluated according to the Cochrane handbook for systematic reviews of interventions. Meta-analysis was performed using RevMan 5.3 software. RESULT: Sixteen RCTs recruiting 1411 patients were identified. Among them, 702 patients underwent PPH, and other 709 patients MMH. Meta-analysis showed that as compared to MMH, PPH had shorter operating time(WMD=-12.34, 95% CI:-17.87 to -6.80, P=0.000], shorter hospital stay (WMD=-1.48, 95% CI: -1.81 to -1.14, P=0.000) and shorter time to recover normal activity (WMD=-14.11, 95% CI: -24.51 to -3.70, P=0.008). Patients in PPH group experienced less pain at postoperative 24 h, postoperative 1 week and the first postoperative bowel movement (all P<0.01). PPH was more ascendant in terms of the requirement for analgesics(P<0.01). PPH group had higher ratio of wound-healing 2 weeks after surgery (RR=0.19, 95% CI: 0.07 to 0.51, P=0.001), lower ratio of postoperative anal stenosis (RR=0.39, 95% CI: 0.15 to 0.99, P=0.050) and lower ratio of anal incontinence (RR=0.62, 95% CI: 0.38 to 1.01, P=0.050), but higher ratio of recurrent disease after 1 year (RR=2.54, 95% CI: 1.21 to 5.31, P=0.010). No significant differences in ratios of postoperative bleeding, urinary retention, and postoperative morbidity of complication were found(all P>0.05). Satisfaction degree of patients in PPH group was better than that in MMH group (OR=2.36, 95% CI:1.36 to 4.07, P=0.002). CONCLUSION: Procedure for prolapse and hemorrhoids offers some short-term benefits over Milligan-Morgan hemorrhoidectomy, but is associated with a higher rate of recurrent disease.", "provenance": [ { "field": "n", "quote": "Sixteen RCTs recruiting 1411 patients were identified." }, { "field": "population", "quote": "the treatment of prolapsed hemorrhoids" }, { "field": "intervention", "quote": "procedure for prolapse and hemorrhoids (PPH)" }, { "field": "comparator", "quote": "Milligan-Morgan hemorrhoidectomy (MMH)" }, { "field": "primaryOutcome", "quote": "To compare the safety and efficacy of procedure for prolapse and hemorrhoids (PPH) with Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of prolapsed hemorrhoids." }, { "field": "result", "quote": "Patients in PPH group experienced less pain at postoperative 24 h, postoperative 1 week and the first postoperative bowel movement (all P<0.01)." }, { "field": "result", "quote": "higher ratio of recurrent disease after 1 year (RR=2.54, 95% CI: 1.21 to 5.31, P=0.010)" } ] }, { "id": "pmid:26456162", "pmid": "26456162", "doi": "10.1111/codi.13147", "nctId": null, "pmcid": null, "title": "Comparison of captopril (0.5%) cream with diltiazem (2%) cream for chronic anal fissure: a prospective randomized double-blind two-centre clinical trial", "firstAuthor": "Ala", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2016, "design": "rct", "n": 50, "nField": "reported", "population": "patients aged 15-75 with chronic anal fissure", "intervention": "topical captopril cream (0.5%) applied twice daily", "comparator": "topical diltiazem cream (2%) applied twice daily", "primaryOutcome": "pain intensity during bowel movements, measured over 8 weeks", "result": "diltiazem gave lower pain scores early on (days 20-30), but by day 40 both creams gave similar pain relief; captopril caused much more itching", "resultDirection": "mixed", "quality": "low", "qualityWhy": "small trial of only 50 patients, so results may not be reliable or generalizable.", "directness": "direct", "limitations": "small sample size", "followUp": "8 weeks", "plainFinding": "Similar pain relief, but captopril caused more itching.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26456162/", "sourceText": "AIM: This study compared the efficacy of topical captopril with topical diltiazem in the treatment of chronic anal fissure (CAF). METHOD: Fifty patients aged between 15 and 75 years with CAF were included in a prospective randomized, double-blind clinical trial. They were randomly allocated to either captopril (0.5%) cream or diltiazem (2%) cream in a dose of 2 cm of cream on the perianal skin every 12 h for 8 weeks. The intensity of pain upon defaecation was evaluated every 10 days using a visual analogue scale. Bleeding on defaecation, pruritus and the presence of perianal irritation were also recorded before and during the trial. RESULTS: The average pain scores were lower in the diltiazem group on the 20th and 30th days. From day 40 to the end of the trial the average pain scores of the two groups did not differ significantly. There were no significant differences in bleeding or perianal irritation between the groups, but the incidence of pruritus was considerably higher in the captopril group, and at the end of the trial 45.8% of the patients in this group still suffered from pruritus. CONCLUSION: Topical captopril and diltiazem were found to be equally effective in the management of pain, bleeding and perianal irritation due to CAF, but due to the high incidence of pruritus observed with topical captopril this medication is not recommended for the treatment of CAF.", "provenance": [ { "field": "n", "quote": "Fifty patients aged between 15 and 75 years with CAF were included" }, { "field": "population", "quote": "patients aged between 15 and 75 years with CAF" }, { "field": "intervention", "quote": "They were randomly allocated to either captopril (0.5%) cream or diltiazem (2%) cream in a dose of 2 cm of cream on the perianal skin every 12 h for 8 weeks." }, { "field": "comparator", "quote": "They were randomly allocated to either captopril (0.5%) cream or diltiazem (2%) cream in a dose of 2 cm of cream on the perianal skin every 12 h for 8 weeks." }, { "field": "primaryOutcome", "quote": "The intensity of pain upon defaecation was evaluated every 10 days using a visual analogue scale." }, { "field": "result", "quote": "The average pain scores were lower in the diltiazem group on the 20th and 30th days. From day 40 to the end of the trial the average pain scores of the two groups did not differ significantly." }, { "field": "result", "quote": "the incidence of pruritus was considerably higher in the captopril group, and at the end of the trial 45.8% of the patients in this group still suffered from pruritus" } ] }, { "id": "pmid:26420725", "pmid": "26420725", "doi": "10.1002/bjs.9913", "nctId": null, "pmcid": null, "title": "Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids", "firstAuthor": "Simillis", "multipleAuthors": true, "journal": "Br J Surg", "year": 2015, "design": "meta-analysis", "n": 7827, "nField": "reported", "population": "adults with grade III and IV haemorrhoids having surgery", "intervention": "different surgical techniques for removing haemorrhoids (open, closed, stapled, THD, LigaSure, Harmonic, radiofrequency)", "comparator": "the other surgical techniques compared against each other", "primaryOutcome": "pain, complications, recovery time and haemorrhoid recurrence after surgery", "result": "newer techniques like THD, stapled, LigaSure and Harmonic caused less pain and faster recovery but more haemorrhoids came back, while open and closed surgery caused more pain and complications but fewer recurrences", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "it pooled many randomized trials with thousands of patients, but combining 11 different surgeries indirectly makes the comparisons less certain.", "directness": "indirect", "limitations": "Network meta-analysis combines indirect comparisons across many different trials and surgical techniques, which can introduce uncertainty; findings apply only to surgical patients with grade III/IV haemorrhoids, not general anal pain after bowel movements.", "followUp": "", "plainFinding": "Surgery type trades less pain for more recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26420725/", "sourceText": "BACKGROUND: The aim was to compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids. METHODS: Randomized clinical trials were identified by means of a systematic review. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS. RESULTS: Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed, stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled, LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than after open and closed procedures. THD provided the earliest time to first bowel movement. The stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified between treatments for anal stenosis, incontinence and perianal skin tags. CONCLUSION: Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The advantages and disadvantages of each surgical treatment should be discussed with the patient before surgery to allow an informed decision to be made.", "provenance": [ { "field": "n", "quote": "Ninety-eight trials were included with 7827 participants" }, { "field": "population", "quote": "11 surgical treatments for grade III and IV haemorrhoids" }, { "field": "intervention", "quote": "Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies" }, { "field": "comparator", "quote": "THD had significantly less postoperative bleeding than open and stapled procedures" }, { "field": "primaryOutcome", "quote": "compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids" }, { "field": "result", "quote": "Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates." } ] }, { "id": "pmid:28239267", "pmid": "28239267", "doi": null, "nctId": null, "pmcid": "PMC5295740", "title": "A Double-Blind Randomized Trial Comparing the Effectiveness and Safety of Nifedipine and Isosorbide Dinitrate in Chronic Anal Fissure", "firstAuthor": "Khaledifar", "multipleAuthors": true, "journal": "Malays J Med Sci", "year": 2015, "design": "rct", "n": 70, "nField": "reported", "population": "adults aged 20-60 with chronic anal fissure", "intervention": "nifedipine 0.3% cream applied three times daily", "comparator": "isosorbide dinitrate 0.2% cream applied three times daily", "primaryOutcome": "healing of fissure and pain levels after 21 days", "result": "more patients healed and less pain with nifedipine than ISDN", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small trial with borderline statistical significance for the main healing outcome and no mention of blinding success or loss to follow-up.", "directness": "direct", "limitations": "small sample size; healing difference only borderline significant (P = 0.05)", "followUp": "21 days", "plainFinding": "Nifedipine healed fissures better, less pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28239267/", "sourceText": "BACKGROUND: Chronic anal fissure is a common disease that is accompanied with pain and bleeding during defecation. Various surgical and non-surgical methods have been offered for the treatment of this condition. The aim of this randomised clinical study was to compare the effectiveness and safety of nifedipine and isosorbide dinitrate (ISDN) in the treatment of chronic anal fissure. METHODS: This double-blind clinical trial study was performed on patients aged 20 to 60 years old in 2012 to 2013. The samples with a primary diagnosis of chronic anal fissure were enrolled from the patients admitted to public treatment at the educational Imam Ali Clinic, Shahrekord, Iran by researchers and general surgery specialists. The patients were randomised into two groups: nifedipine 0.3% (n = 35) or ISDN 0.2% (n = 35) applied three times a day for three weeks. The patients were examined on the 7th, 14th, and 21st days of treatment, and the symptoms including bleeding, pain, and healing status, as well as the side effects of the drugs, were assessed. Pain was evaluated using a visual analogue scale (VAS). RESULTS: After 21 days of follow-up, complete healing was achieved in 77.1% (n = 27) of patients in the nifedipine group and 51.4% (n = 18) in the ISDN group (P = 0.05). The mean VAS of the pain on day 21 was 0.91 (SD 0.01) in the ISDN group and 0.45±0.78 in the nifedipine group, with a statistically significant difference (P = 0.038). The bleeding was similar in the two groups (P = 0.498). CONCLUSION: In view of the findings on healing status and pain in the patients, nifedipine may be significantly more effective in the treatment of chronic anal fissure than ISDN.", "provenance": [ { "field": "n", "quote": "nifedipine 0.3% (n = 35) or ISDN 0.2% (n = 35)" }, { "field": "population", "quote": "patients aged 20 to 60 years old" }, { "field": "population", "quote": "a primary diagnosis of chronic anal fissure" }, { "field": "intervention", "quote": "nifedipine 0.3% (n = 35)" }, { "field": "comparator", "quote": "ISDN 0.2% (n = 35)" }, { "field": "primaryOutcome", "quote": "symptoms including bleeding, pain, and healing status" }, { "field": "result", "quote": "complete healing was achieved in 77.1% (n = 27) of patients in the nifedipine group and 51.4% (n = 18) in the ISDN group (P = 0.05)" }, { "field": "result", "quote": "The mean VAS of the pain on day 21 was 0.91 (SD 0.01) in the ISDN group and 0.45±0.78 in the nifedipine group, with a statistically significant difference (P = 0.038)" } ] }, { "id": "pmid:26309351", "pmid": "26309351", "doi": "10.3748/wjg.v21.i31.9245", "nctId": null, "pmcid": "PMC4541377", "title": "Treatment of hemorrhoids: A coloproctologist's view", "firstAuthor": "Lohsiriwat", "multipleAuthors": false, "journal": "World J Gastroenterol", "year": 2015, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids", "intervention": "various hemorrhoid treatments (medication, rubber band ligation, injection, surgery)", "comparator": "different treatment options compared to each other", "primaryOutcome": "management and outcomes of hemorrhoids", "result": "not a study result; this is an overview of treatment approaches for hemorrhoids", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is an editorial/review summarizing general knowledge and opinion, not a study with data on this specific question.", "directness": "indirect", "limitations": "This is a general review article, not a study testing a specific treatment or measuring post-defecation pain; it does not address why pain occurs after pooping specifically.", "followUp": "", "plainFinding": "Review of hemorrhoid treatments, not pain cause", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26309351/", "sourceText": "Hemorrhoids is recognized as one of the most common medical conditions in general population. It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue. Generally, hemorrhoids can be divided into two types: internal hemorrhoid and external hemorrhoid. External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort. Meanwhile, low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy). Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred. Although excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids, several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices in order to avoid post-hemorrhiodectomy pain. This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist - which includes the management of hemorrhoids in complicated situations such as hemorrhoids in pregnancy, hemorrhoids in immunocompromised patients, hemorrhoids in patients with cirrhosis or portal hypertension, hemorrhoids in patients having antithrombotic agents, and acutely thrombosed or strangulated hemorrhoids. Future perspectives in the treatment of hemorrhoids are also discussed.", "provenance": [ { "field": "population", "quote": "Hemorrhoids is recognized as one of the most common medical conditions in general population." }, { "field": "intervention", "quote": "several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices in order to avoid post-hemorrhiodectomy pain" }, { "field": "comparator", "quote": "low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy)" }, { "field": "primaryOutcome", "quote": "This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist" }, { "field": "result", "quote": "Future perspectives in the treatment of hemorrhoids are also discussed." } ] }, { "id": "pmid:26185392", "pmid": "26185392", "doi": "10.3748/wjg.v21.i26.8178", "nctId": null, "pmcid": "PMC4499363", "title": "Procedure for prolapse and hemorrhoids vs traditional surgery for outlet obstructive constipation", "firstAuthor": "Lu", "multipleAuthors": true, "journal": "World J Gastroenterol", "year": 2015, "design": "rct", "n": 108, "nField": "reported", "population": "patients having surgery for constipation caused by internal rectal prolapse with circumferential hemorrhoids", "intervention": "procedure for prolapse and hemorrhoids (PPH) surgery", "comparator": "conventional (traditional) surgery", "primaryOutcome": "pain after surgery, measured at 24 hours, at first bowel movement, and one week later", "result": "Pain scores were lower with PPH surgery than with traditional surgery at 24 hours, at first defecation, and one week after surgery, and complications like perianal swelling and reduced anal sensation were also less common", "resultDirection": "benefit", "quality": "low", "qualityWhy": "it is a randomized trial but from a single hospital with a small, specific surgical population, so it may not apply to general anal pain after pooping", "directness": "indirect", "limitations": "Single-center study in patients with a specific surgical condition (rectal prolapse with hemorrhoids), not general anal pain after bowel movements; short study period (2012-2013).", "followUp": "", "plainFinding": "Less pain after hemorrhoid-prolapse surgery with PPH.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26185392/", "sourceText": "AIM: To compare the clinical efficacies of two surgical procedures for hemorrhoid rectal prolapse with outlet obstruction-induced constipation. METHODS: One hundred eight inpatients who underwent surgery for outlet obstructive constipation caused by internal rectal prolapse and circumferential hemorrhoids at the First Affiliated Hospital of Xinjiang Medical University from June 2012 to June 2013 were prospectively included in the study. The patients with rectal prolapse hemorrhoids with outlet obstruction-induced constipation were randomly divided into two groups to undergo either a procedure for prolapse and hemorrhoids (PPH) (n = 54) or conventional surgery (n = 54; control group). Short-term (operative time, postoperative hospital stay, postoperative urinary retention, postoperative perianal edema, and postoperative pain) and long-term (postoperative anal stenosis, postoperative sensory anal incontinence, postoperative recurrence, and postoperative difficulty in defecation) clinical effects were compared between the two groups. The short- and long-term efficacies of the two procedures were determined. RESULTS: In terms of short-term clinical effects, operative time and postoperative hospital stay were significantly shorter in the PPH group than in the control group (24.36 ± 5.16 min vs 44.27 ± 6.57 min, 2.1 ± 1.4 d vs 3.6 ± 2.3 d, both P < 0.01). The incidence of postoperative urinary retention was higher in the PPH group than in the control group, but the difference was not statistically significant (48.15% vs 37.04%). The incidence of perianal edema was significantly lower in the PPH group (11.11% vs 42.60%, P < 0.05). The visual analogue scale scores at 24 h after surgery, first defecation, and one week after surgery were significantly lower in the PPH group (2.9 ± 0.9 vs 8.3 ± 1.1, 2.0 ± 0.5 vs 6.5 ± 0.8, and 1.7 ± 0.5 vs 5.0 ± 0.7, respectively, all P < 0.01). With regard to long-term clinical effects, the incidence of anal stenosis was lower in the PPH group than in the control group, but the difference was not significant (1.85% vs 5.56%). The incidence of sensory anal incontinence was significantly lower in the PPH group (3.70% vs 12.96%, P < 0.05). The incidences of recurrent internal rectal prolapse and difficulty in defecation were lower in the PPH group than in the control group, but the differences were not significant (11.11% vs 16.67% and 12.96% vs 24.07%, respectively). CONCLUSION: PPH is superior to the traditional surgery in the management of outlet obstructive constipation caused by internal rectal prolapse with circumferential hemorrhoids.", "provenance": [ { "field": "n", "quote": "One hundred eight inpatients who underwent surgery for outlet obstructive constipation caused by internal rectal prolapse and circumferential hemorrhoids" }, { "field": "population", "quote": "patients with rectal prolapse hemorrhoids with outlet obstruction-induced constipation" }, { "field": "intervention", "quote": "procedure for prolapse and hemorrhoids (PPH) (n = 54)" }, { "field": "comparator", "quote": "conventional surgery (n = 54; control group)" }, { "field": "primaryOutcome", "quote": "The visual analogue scale scores at 24 h after surgery, first defecation, and one week after surgery" }, { "field": "result", "quote": "The visual analogue scale scores at 24 h after surgery, first defecation, and one week after surgery were significantly lower in the PPH group (2.9 ± 0.9 vs 8.3 ± 1.1, 2.0 ± 0.5 vs 6.5 ± 0.8, and 1.7 ± 0.5 vs 5.0 ± 0.7, respectively, all P < 0.01)" } ] }, { "id": "pmid:26021422", "pmid": "26021422", "doi": null, "nctId": null, "pmcid": null, "title": "Injection of a sclerosing agent as first line treatment in anal fissure", "firstAuthor": "Dessily", "multipleAuthors": true, "journal": "Acta Chir Belg", "year": 2014, "design": "case-series", "n": 109, "nField": "reported", "population": "patients with anal fissure (tear near the anus)", "intervention": "injection of a sclerosing agent (phenol, menthol and peanut oil) under the fissure", "comparator": "none (single-group study, no comparison treatment)", "primaryOutcome": "whether the fissure healed", "result": "53 of 58 acute fissures (91.4%) and 40 of 51 chronic fissures (78.4%) healed after injection", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective study of one treatment with no comparison group, so it can't show if the injection worked better than other options.", "directness": "direct", "limitations": "Retrospective design, no control group, and some complications (necrosis, abscess) and continence problems occurred.", "followUp": "", "plainFinding": "High healing rates after fissure injection.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26021422/", "sourceText": "BACKGROUND: In our institution, the first line treatment in acute anal fissures (AAF) or chronic anal fissures (CAF) is the injection of a sclerosing agent consisting of phenol, menthol and peanut oil (Phenomen®, Sterop laboratory, Belgium) under the fissure after a local anaesthesia. This retrospective study presents the technique of injection, evaluates its efficacy and demonstrates the minimal occurrence of complications, continence problems and recurrences. METHODS: 129 patients with an anal fissure were treated between January 2010 and June 2011. 124 patients were reviewed retrospectively. 109 patients benefited from a sclerosis in our outpatient clinic. RESULTS: Of the 109 patients treated by a sclerosis, 58 had an AAF and 51 had a CAF. 53/58 AAF (91.4%) healed and 40/51 CAF (78.4%). Duration of pain after injection was 2 days or less in 55 cases (50.4%), 1 week or less in 35 cases (32.2%) and more than 1 week in 19 cases (17.4%). The complication rate was low (2.7%) : 2 necrosis of the skin and 1 abscess at the site of injection. The rate of troubles of continence was 2.7% : 2 cases of soiling and 1 case of incon-tinence for gas all resolving within a month. At the end of the study, a fissure had recurred in 17 patients (15.6%). CONCLUSIONS: The injection of a sclerosing agent under the fissure is performed in the practitioner's office. Healing rates are high, complications and recurrences are low. This therapeutic option may be a good alternative to classical treatments in case of anal fissures.", "provenance": [ { "field": "n", "quote": "109 patients benefited from a sclerosis in our outpatient clinic." }, { "field": "population", "quote": "129 patients with an anal fissure were treated between January 2010 and June 2011." }, { "field": "intervention", "quote": "the injection of a sclerosing agent consisting of phenol, menthol and peanut oil (Phenomen®, Sterop laboratory, Belgium) under the fissure after a local anaesthesia" }, { "field": "comparator", "quote": "Of the 109 patients treated by a sclerosis, 58 had an AAF and 51 had a CAF." }, { "field": "primaryOutcome", "quote": "evaluates its efficacy" }, { "field": "result", "quote": "53/58 AAF (91.4%) healed and 40/51 CAF (78.4%)." } ] }, { "id": "pmid:25979561", "pmid": "25979561", "doi": "10.1016/j.jss.2015.04.029", "nctId": null, "pmcid": null, "title": "The comparison of saline enema and bisacodyl in rectal preparation before anorectal surgery", "firstAuthor": "Amouzeshi", "multipleAuthors": true, "journal": "J Surg Res", "year": 2015, "design": "rct", "n": 79, "nField": "reported", "population": "patients hospitalized for anorectal surgery (hemorrhoids, fissure, fistula)", "intervention": "bowel preparation with bisacodyl tablets before surgery", "comparator": "bowel preparation with saline rectal enema before surgery", "primaryOutcome": "pain after the first bowel movement following surgery", "result": "bisacodyl group had less pain after the first postoperative defecation and fewer complications than the enema group", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small randomized trial with only 79 patients and unclear blinding of patients, so the pain difference may not be reliable.", "directness": "indirect", "limitations": "Abstract does not mention blinding of patients or surgeons, and sample size is small; this studies post-surgical anorectal pain, not pain after normal bowel movements without surgery.", "followUp": "1 mo", "plainFinding": "Less pain with bisacodyl prep.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25979561/", "sourceText": "BACKGROUND: Given the limited data on the need of mechanical bowel preparation application before anorectal surgeries and the preferred method for bowel preparation, we aimed to compare saline enema and bisacodyl in rectal preparation before anorectal surgery. MATERIALS AND METHODS: This is a randomized clinical trial study. Seventy-nine hospitalized patients for anorectal surgery (hemorrhoid, fissure, and fistula) were recruited by convenient sampling and then randomly allocated to receive 500 cc Saline by rectal enema or six bisacodyl tablets (Sobhan company) beginning from a day before the operation in order to prepare the bowel. After surgery, surgeons' satisfaction of the surgery and patients' satisfaction of the preparation process were evaluated in the ward using Likert score by a nurse blind to the study. Also, the patients were interviewed for pain after the first defecation, using numeric rating scale based on a 0-10 scores. All patients were actively followed-up after discharge for 1 mo concerning postoperative complications. The obtained data were analyzed by SPSS software (version 16), Mann-Whitney, chi-squared, and Fisher exact tests at the significant level of P < 0/0.5. RESULTS: A total of 79 patients participated in the study, 38 received 500-cc saline by rectal enema and 41 bisacodyl tablets. No significant differences were observed between the two groups in most variables except for pain after the first defecation (P = 0.032). CONCLUSIONS: According to the results, the bisacodyl approach results in less pain in the first postoperative defecation and fewer complications than the rectal enema. Thus, bisacodyl can be suggested as a superior counterpart for enema.", "provenance": [ { "field": "n", "quote": "A total of 79 patients participated in the study, 38 received 500-cc saline by rectal enema and 41 bisacodyl tablets." }, { "field": "population", "quote": "Seventy-nine hospitalized patients for anorectal surgery (hemorrhoid, fissure, and fistula)" }, { "field": "intervention", "quote": "six bisacodyl tablets (Sobhan company) beginning from a day before the operation in order to prepare the bowel" }, { "field": "comparator", "quote": "receive 500 cc Saline by rectal enema" }, { "field": "primaryOutcome", "quote": "the patients were interviewed for pain after the first defecation, using numeric rating scale based on a 0-10 scores" }, { "field": "result", "quote": "the bisacodyl approach results in less pain in the first postoperative defecation and fewer complications than the rectal enema" } ] }, { "id": "pmid:25960796", "pmid": "25960796", "doi": "10.5114/wiitm.2015.49672", "nctId": null, "pmcid": "PMC4414111", "title": "Assessment of patients' quality of life after haemorrhoidectomy using the LigaSure device", "firstAuthor": "Szyca", "multipleAuthors": true, "journal": "Wideochir Inne Tech Maloinwazyjne", "year": 2015, "design": "case-series", "n": 50, "nField": "reported", "population": "adults with hemorrhoids who had surgery to remove them", "intervention": "hemorrhoidectomy surgery using the LigaSure device (Ferguson method)", "comparator": "same patients' pain and quality of life before surgery", "primaryOutcome": "pain level and quality of life before and after surgery", "result": "pain was significantly lower by 3 months after surgery and remained lower at 1 year", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small group of 50 patients with no comparison group, just checking the same people before and after surgery.", "directness": "indirect", "limitations": "No control group, small sample, self-reported pain and quality of life measures", "followUp": "1 year", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25960796/", "sourceText": "INTRODUCTION: Haemorrhoids are small anatomical structures within the anal canal that are involved in the proper functioning of the lower gastrointestinal tract. Factors favouring the development of haemorrhoidal disease are insufficient physical activity, prolonged sitting and hence a shortage of physical activity, as well as poor diet which lacks adequate amounts of fibre. The main symptom of this disease is bleeding with bright red blood just after defecation. Haemorrhoidal disease occurs when the ligamentous apparatus comes loose and the internal haemorrhoidal plexus translocates down, whereas haemorrhoids enlarge and move out of the anal canal. Haemorrhoidal disease treatment includes conservative, instrumental and surgical therapy. AIM: To assess treatment and satisfaction in particular life domains after haemorrhoidectomy. MATERIAL AND METHODS: The research was undertaken in the General, Thoracic and Vascular Surgery Clinic of the 10(th) Military Clinical Hospital with Polyclinic in Bydgoszcz among 50 patients treated due to haemorrhoids and operated on in the period 2007-2008. The study evaluated quality of patients' life after haemorrhoidectomy by Ferguson's method using a LigaSure appliance. RESULTS: The study investigated whether patients perceived a difference before and after surgery. The research proved that patients can describe disease symptoms and know the risk factors for haemorrhoids. In the studied group patients are able to describe characteristic signs of haemorrhoidal disease and also indicate differences in everyday life before and after the surgery. They can also describe and classify the pain before and 1 year after the haemorrhoidectomy, which was statistically significantly lower already 3 months after the operation. CONCLUSIONS: Conducted examinations showed that sick people in the precise way were able to determine manifestations and know risk factors of the prevalence of disease hemorrhoidal. Operated sick people indicated the difference in quality of the life both before, as well as after the undergone treatment. After the operation of the haemorrhoids with method of Ferguson using LigaSure apparatus operated sick persons could distinguish and classify pain before the treatment as well as in a year after which was statistically characteristically lower already after three months from treatment.", "provenance": [ { "field": "n", "quote": "among 50 patients treated due to haemorrhoids" }, { "field": "population", "quote": "50 patients treated due to haemorrhoids and operated on in the period 2007-2008" }, { "field": "intervention", "quote": "quality of patients' life after haemorrhoidectomy by Ferguson's method using a LigaSure appliance" }, { "field": "comparator", "quote": "whether patients perceived a difference before and after surgery" }, { "field": "primaryOutcome", "quote": "describe and classify the pain before and 1 year after the haemorrhoidectomy" }, { "field": "result", "quote": "which was statistically significantly lower already 3 months after the operation" } ] }, { "id": "pmid:25925729", "pmid": "25925729", "doi": "10.1007/s12664-015-0559-2", "nctId": null, "pmcid": null, "title": "The effects of topical application of metronidazole for treatment of chronic anal fissure: A randomized, controlled pilot study", "firstAuthor": "Grekova", "multipleAuthors": true, "journal": "Indian J Gastroenterol", "year": 2015, "design": "rct", "n": 47, "nField": "reported", "population": "patients with chronic anal fissures and anaerobic bacteria found in fissure swabs", "intervention": "topical metronidazole (antibacterial cream) applied to the fissure", "comparator": "conventional treatment for anal fissure", "primaryOutcome": "fissure healing confirmed by anoscopy", "result": "more fissures healed with metronidazole (95.6%) than with conventional treatment (70.8%)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small pilot study of only 47 patients with a result just barely reaching statistical significance.", "directness": "direct", "limitations": "small pilot study; only included patients whose fissures tested positive for anaerobic bacteria, so may not apply to all anal fissures.", "followUp": "28 days", "plainFinding": "Faster fissure healing with antibacterial cream.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25925729/", "sourceText": "BACKGROUND: Chronic anal fissures (CAFs) rarely heal with conservative management. Because they are associated with strong anal sphincter tone, most treatment aim to reduce anal pressure. Although infections can cause fissures, as can traumatic injury to the anal canal, antimicrobial treatment is not recommended. In a previous study, we reported identifying a wide spectrum of pathogenic microorganisms in the bases of CAFs, anaerobic bacteria being present in half the cases. We postulated that microbial colonization delays healing of CAF and aimed to determine whether decreasing the bacterial load with topical antibacterial treatment accelerates fissure healing. METHODS: We cultured fecal samples and swabs from the bases of CAFs in 103 patients. Patients in whose samples anaerobic bacteria were identified (47 patients) were then invited to participate in a prospective randomized clinical trial comparing topical metronidazole with conventional treatment. The primary endpoint was fissure healing confirmed on anoscopy. Secondary endpoints of maximum pain on defecation assessed by visual analog scale, maximum anal resting pressure, and rectal pH were recorded on entry and at 10, 21, and 28 days. RESULTS: The CAFs were colonized by mixtures of gram-positive/gram-negative anaerobic bacteria or gram-negative aerobic monocultures. Patients with anaerobic bacteria in their swabs who received topical metronidazole treatment experienced rapid relief of pain and anal sphincter spasm along with enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048). CONCLUSION: Topical antimicrobial treatment can be effective in patients with CAF provided the relevant microorganisms are correctly identified.", "provenance": [ { "field": "n", "quote": "Patients in whose samples anaerobic bacteria were identified (47 patients) were then invited to participate" }, { "field": "population", "quote": "Patients with anaerobic bacteria in their swabs" }, { "field": "intervention", "quote": "topical metronidazole" }, { "field": "comparator", "quote": "comparing topical metronidazole with conventional treatment" }, { "field": "primaryOutcome", "quote": "The primary endpoint was fissure healing confirmed on anoscopy." }, { "field": "result", "quote": "enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048)" } ] }, { "id": "pmid:25748875", "pmid": "25748875", "doi": null, "nctId": null, "pmcid": null, "title": "Faecal retention: a common cause in functional bowel disorders, appendicitis and haemorrhoids--with medical and surgical therapy", "firstAuthor": "Raahave", "multipleAuthors": false, "journal": "Dan Med J", "year": 2015, "design": "case-series", "n": null, "nField": "not-reported", "population": "people with long-term bowel problems such as constipation, irritable bowel symptoms and haemorrhoids", "intervention": "a bowel-stimulation program (high-fibre diet, fluids, exercise and a bowel-stimulant drug), and in some patients surgery for haemorrhoids (stapled haemorrhoidopexy)", "comparator": "", "primaryOutcome": "anal pain after bowel movements (proctalgia) and related bowel symptoms such as bloating and difficult defecation", "result": "After the bowel-stimulation treatment, pain and bloating were significantly reduced and proctalgia and flu-like episodes were significantly reduced; after stapled haemorrhoid surgery, post-operative pain was described as low", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a mix of uncontrolled before-and-after studies and surgical case series without randomization or blinding, so the improvement could be due to other factors.", "directness": "indirect", "limitations": "No randomization or control group for the bowel-stimulation intervention; surgical series without comparison group; multiple different patient groups combined (constipation, appendicitis, haemorrhoids) making it hard to isolate the cause of anal pain after defecation.", "followUp": "5 years", "plainFinding": "Treating constipation reduced anal pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25748875/", "sourceText": "The present studies explored whether faecal retention in the colon is a causative factor in functional bowel disease, appendicitis, and haemorrhoids. Faecal retention was characterized by colon transit time (CTT) after radio-opaque marker ingestion and estimation of faecal loading on abdominal radiographs at 48 h and 96 h. Specific hypotheses were tested in patients (n = 251 plus 281) and in healthy random controls (n = 44). A questionnaire was completed for each patient, covering abdominal and anorectal symptoms and without a priori grouping. Patients with functional bowel disorders, predominantly women, had a significantly increased CTT and faecal load compared to controls. The CTT was significantly and positively correlated with segmental and total faecal loading. The faecal load was equal at 48 h and 96 h, mirroring the presence of permanent faecal reservoirs. In these first clinical studies to correlate bowel symptoms with CTT and colon faecal loading, abdominal bloating was significantly correlated with faecal loading in the right colon, total faecal load, and CTT. Abdominal pain was significantly and positively correlated to distal faecal loading and significantly associated with bloating. A new phenomenon with a high faecal load and a normal CTT was observed in a subset of patients (n = 90), proving faecal retention as hidden constipation. The CTT and faecal load were significantly higher in the right-side compared to the left and distal segments. Within the control group of healthy persons, the right-sided faecal load was significantly greater than the left and distal load. The CTT and faecal load significantly positively correlated with a palpable mass in the left iliac fossa and meteorism. Cluster analysis revealed that CTT and faecal load positively correlated with a symptom factor consisting of bloating, proctalgia and infrequent defecation of solid faeces. On the other hand, CTT and faecal load negatively correlated with a symptom factor comprising frequent easy defecations, repetitiveness, and incompleteness with solid or liquid faeces. The majority of patients with a heavy faecal load but normal CTT had repetitive daily defecation, mostly with ease and with altering faecal consistence. Flue-like episodes co-existed in symptom factors with abdominal pain and meteorism, and these symptoms together with a palpable right iliac fossa mass and tenderness, and in other factors with seldom and difficult defecation, and with epigastric discomfort and halitosis. Patients with seldom and difficult defecation of solid faeces experienced abdominal pain significantly more often and presented a palpable mass in the right iliac fossa with tenderness and meteorism. The CTT was significantly prolonged and faecal load significantly increased. In patients with a normal CTT and increased faecal load, only patients with abdominal pain had a significant correlation between faecal loading and bloating. CTT and faecal load were shown for the first time to increase significantly with the number of colonic redundancies (colon length), which also resulted in significantly increased bloating and pain. Intervention with a bowel stimulation regimen combining a fibre-rich diet, fluid, physical activity, and a prokinetic drug was essential to proving that abdominal symptoms and defecation disorders are caused by faecal retention, with or without a prolonged CTT. The CTT was significantly reduced, as was faecal load. Bloating and pain were reduced significantly. The defecation became easy with solid faeces, towards one per day and with significant reductions in incompleteness and repetitiveness. Proctalgia and flue-like episodes were significantly reduced. The intervention significantly reduced the presence of a tender palpable mass in the right fossa and rectal constipation. In patients with a normal CTT but increased faecal load, the intervention did not significantly change the CTT or load, but bloating and pain were significantly reduced, just as defecation improved overall. The novel knowledge of faecal retention in the patients does not explain why faecal retention occurs. However, it may be inferred from the present results that a constipated or irritable bowel may belong to the same underlying disease dimension, where faecal retention is a common factor. Thus, measuring CTT and faecal load is suggested as a guide to a positive functional diagnosis of bowel disorders compared to the constellation of symptoms alone. Thirty-five patients underwent surgery after being refractory to the conservative treatment for constipation. They had a significantly prolonged CTT and heavy faecal loading, which was responsible for the aggravated abdominal and defaecatory symptoms. The operated patients presented with a redundant colon (dolichocolon) significantly more often. These patients also had an extremely high rate of previous appendectomy. Twenty-one patients underwent hemicolectomy, and 11 patients had a subtotal colectomy with an ileosigmoidal anastomosis; three patients received a stoma. However, some patients had to have the initial segmental colectomy converted to a final subtotal colectomy because of persisting symptoms. Six more subtotal colectomies have been performed and the leakage rate of all colectomies is then 4.9 % (one patient died). After a mean follow-up of 5 years, the vast majority of patients were without abdominal pain and bloating, having two to four defecations daily with control and their quality of life had increased considerably. A faecalith is often located in the appendix, the occlusion of which is responsible for many cases of acute appendicitis, which is infrequent in all except white populations. An effort to trace the origin of the faecalith to faecal retention in the colon was made in a case control study (56 patients and 44 random controls). The CTT was longer and faecal load greater in patients with appendicitis compared to controls, though the difference was not significant. Power calculations showed that more patients were needed to reach statistical significance for these parameters. The presence of a faecalith was most often associated with a gangrenous or perforated appendix. No significant differences were found between the CTT and faecal load of patients who had or did not have a faecalith. However, the right-sided faecal load was significantly higher than the left and distal load. Haemorrhoids are often a consequence of constipation and defaecatory disorders and were found in every second patient with functional bowel disorders. The present studies are the first Danish reports of a novel operation to cure this disease, stapled haemorrhoidopexy (n = 40 and 258 patients). The majority of patients had prolapsed haemorrhoids, and the durability of procedure was confirmed with a follow-up of up to 5 years, meaning a normal anus. The operation time was short, post-operative pain was low, and recovery was rapid. No incontinence was observed, and patient satisfaction was high and significantly correlated with the appearance of a normal anus without prolapse. The cumulative risk of re-operation was greatest in the first 2 years after the stapled haemorrhoidopexy. Patients with persisting haemorrhoidal prolapse had the procedure repeated with results as good as those obtained in the rest of the patients. It was shown in a statistical model that the preoperative severity of haemorrhoidal disease and the immediate postoperative result contributed significantly to predicting the outcome that is the durability of the operation. The most frequent post-operative complication was bleeding requiring surgical haemostasis. One serious complication occurred after an anastomotic leak from a highly placed anastomosis, resulting in retro rectal, retro- and intra-peritoneal, and mediastinal gas. The patient recovered after conservative treatment and without surgical intervention. The stapling technique now used has revolutionized the surgical treatment of prolapsing haemorrhoids. Finally, a common cause may be suspected for diseases constantly associated with one another. Epidemiological evidence has recognized that constipation, diverticulosis and IBS increase the risk of colon cancer (and adenomas), diseases exceedingly rare in communities exempt from appendicitis. Haemorrhoids are a colonic co-morbidity as well. Notably, the patients with a functional bowel disorder had a much higher rate of a previous appendectomy than the background population. In addition, the patients who had previously had an appendectomy had a significantly longer CTT compared to patients, who had not. The data points to the involvement of faecal retention in the origin of faecaliths and, thus, acute appendicitis. Faecal reservoirs were shown in the right and left colon segments in both patients and controls, which are the same areas bearing the highest incidences of adenomateous polyps and malignancies. Familial colorectal cancer occurred significantly more often in patients who had a higher faecal load than the controls. Four malignancies and 25 adenomas were identified. An increased faecal load in the colon with or without delayed transit will increase bacterial counts and create a chronic inflammation of the colonic mucosa, which is a risk factor for cancer onset. A functional bowel disorder is then likely to occur with gradually transition from a primary functional disease into specific organic diseases. A diet rich in fibre and regular physical activity have a therapeutic and preventive effect on colorectal diseases associated with faecal retention. A “common cause” was earlier proposed for constipation, colon diverticula, cancer, appendicitis, and haemorrhoids. The actual results of the present studies support this unifying theory for these diet-related diseases, in which the functional retention of faeces maybe the common cause.", "provenance": [ { "field": "population", "quote": "Patients with functional bowel disorders, predominantly women, had a significantly increased CTT and faecal load compared to controls." }, { "field": "intervention", "quote": "Intervention with a bowel stimulation regimen combining a fibre-rich diet, fluid, physical activity, and a prokinetic drug was essential to proving that abdominal symptoms and defecation disorders are caused by faecal retention, with or without a prolonged CTT." }, { "field": "intervention", "quote": "a novel operation to cure this disease, stapled haemorrhoidopexy (n = 40 and 258 patients)" }, { "field": "primaryOutcome", "quote": "Proctalgia and flue-like episodes were significantly reduced." }, { "field": "result", "quote": "Bloating and pain were reduced significantly." }, { "field": "result", "quote": "The operation time was short, post-operative pain was low, and recovery was rapid." }, { "field": "followUp", "quote": "the durability of procedure was confirmed with a follow-up of up to 5 years" } ] }, { "id": "pmid:25741159", "pmid": "25741159", "doi": "10.3748/wjg.v21.i8.2490", "nctId": null, "pmcid": "PMC4342928", "title": "Clinical observations on the treatment of prolapsing hemorrhoids with tissue selecting therapy", "firstAuthor": "Wang", "multipleAuthors": true, "journal": "World J Gastroenterol", "year": 2015, "design": "rct", "n": 480, "nField": "reported", "population": "adults with severe hemorrhoids that bulge out (prolapsing hemorrhoids) having surgery", "intervention": "tissue selecting therapy (TST) stapler hemorrhoid surgery", "comparator": "Milligan-Morgan hemorrhoidectomy (traditional surgical removal)", "primaryOutcome": "pain levels and complications after hemorrhoid surgery, including pain with first bowel movement", "result": "TST patients had less pain at 12 hours, at first dressing change, and at first bowel movement than M-M patients, plus fewer complications", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial with a large number of patients, but it only looked at people having surgery for severe hemorrhoids, not general pain after pooping, and it was done at one hospital.", "directness": "indirect", "limitations": "Single-center study limited to patients undergoing surgery for severe prolapsing hemorrhoids; doesn't address non-surgical causes of pain after defecation.", "followUp": "one year after the operation", "plainFinding": "Less pain after bowel movements with TST surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25741159/", "sourceText": "AIM: To compare the effects and postoperative complications between tissue selecting therapy stapler (TST) and Milligan-Morgan hemorrhoidectomy (M-M). METHODS: Four hundred and eighty patients with severe prolapsing hemorrhoids, who were admitted to the Shenyang Coloproctology Hospital between 2009 and 2012, were randomly divided into observation (n=240) and control (n=240) groups. Hemorrhoidectomies were performed with TST in the observation group and with the M-M technique in the control group. The therapeutic effects, operation security, and postoperative complications in the two groups were compared. The immediate and long-term complications were assessed according to corresponding criteria. Pain was assessed on a visual analogue scale. The efficacy was assessed by specialized criteria. The follow-up was conducted one year after the operation. RESULTS: The total effective rates of the observation and control groups were 99.5% (217/218) and 98.6% (218/221) respectively; the difference was not statistically significant (P=0.322). Their were significant differences between observation and control groups in intraoperative blood loss (5.07±1.14 vs 2.45±0.57, P=0.000), pain (12 h after the surgery: 5.08±1.62 vs 7.19±2.01, P=0.000; at first dressing change: 2.64±0.87 vs 4.34±1.15, P=0.000; first defecation: 3.91±1.47 vs 5.63±1.98, P=0.001), urine retention (n=22 vs n=47, P=0.001), anal pendant expansion after the surgery (2.35±0.56 vs 5.16±1.42, P=0.000), operation time (18.3±5.6 min vs 29.5±8.2 min, P=0.000), and the length of hospital stay (5.3±0.6 d vs 11.4±1.8 d, P=0.000). Moreover TST showed significant reductions compared to M-M in the rates of long-term complications such as fecal incontinence (n=3 vs n=16, P=0.003), difficult bowel movement (n=1 vs n=9, P=0.011), intractable pain (n=2 vs n=12, P=0.007), and anal discharge (n=3 vs n=23, P=0.000). CONCLUSION: TST for severe prolapsing hemorrhoids is a satisfactory technique for more rapid recovery, lower complication rates, and higher operation security.", "provenance": [ { "field": "n", "quote": "Four hundred and eighty patients with severe prolapsing hemorrhoids, who were admitted to the Shenyang Coloproctology Hospital between 2009 and 2012, were randomly divided into observation (n=240) and control (n=240) groups." }, { "field": "population", "quote": "Four hundred and eighty patients with severe prolapsing hemorrhoids" }, { "field": "intervention", "quote": "Hemorrhoidectomies were performed with TST in the observation group" }, { "field": "comparator", "quote": "with the M-M technique in the control group" }, { "field": "primaryOutcome", "quote": "Pain was assessed on a visual analogue scale." }, { "field": "result", "quote": "first defecation: 3.91±1.47 vs 5.63±1.98, P=0.001" } ] }, { "id": "pmid:25642882", "pmid": "25642882", "doi": null, "nctId": null, "pmcid": null, "title": "The effect of early warm plastic bag application on postoperative pain after hemorrhoidectomy: a prospective randomized controlled trial", "firstAuthor": "Balta", "multipleAuthors": true, "journal": "Am Surg", "year": 2015, "design": "rct", "n": null, "nField": "not-reported", "population": "people who had surgery to remove hemorrhoids", "intervention": "warm plastic bag applied after surgery", "comparator": "no warm bag treatment", "primaryOutcome": "pain levels after surgery, including pain during bowel movements", "result": "lower pain scores at rest on days 1 and 3, and lower pain during defecation on day 3, with less need for extra pain medicine", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a small single trial about a specific surgical pain-relief method, not about everyday pain after a normal bowel movement", "directness": "indirect", "limitations": "abstract does not report number of participants, blinding, or how pain was measured beyond VAS scores", "followUp": "", "plainFinding": "Warm compress eased post-surgery pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25642882/", "sourceText": "Hemorrhoidectomy is used for the surgical treatment of high-grade hemorrhoids. The most prominent complaint after hemorrhoidectomy is pain. Postoperative pain management is still a big problem after surgery in patients with hemorrhoidectomy. The aim of the study was to assess the effect of early application of warm bag on postoperative pain after hemorrhoidectomy. All patients were randomly divided into warm plastic bag and control groups by using sealed envelopes, which were prepared preoperatively. After standard spinal anesthesia, all patients underwent standard Milligan-Morgan hemorrhoidectomy using Ligasure™. Although the study group received the warm bag application, the control group did not receive such a treatment. Two separate visual analog scale (VAS) measurements were performed for postoperative pain assessments on postoperative days, one during the resting state and the other one during the straining phase after the onset of peristaltic bowel movement. Postoperative VAS scores were significantly lower among the warm plastic bag group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for defecation. Additionally, a significant difference existed between the two groups in terms of the need for additional anesthesia. Local thermal application appears to be a safe and effective method for pain relief after hemorrhoidectomy.", "provenance": [ { "field": "population", "quote": "All patients were randomly divided into warm plastic bag and control groups" }, { "field": "intervention", "quote": "the study group received the warm bag application" }, { "field": "comparator", "quote": "the control group did not receive such a treatment" }, { "field": "primaryOutcome", "quote": "Two separate visual analog scale (VAS) measurements were performed for postoperative pain assessments on postoperative days, one during the resting state and the other one during the straining phase after the onset of peristaltic bowel movement." }, { "field": "result", "quote": "Postoperative VAS scores were significantly lower among the warm plastic bag group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for defecation." } ] }, { "id": "pmid:25642874", "pmid": "25642874", "doi": null, "nctId": null, "pmcid": null, "title": "Dermal flap advancement combined with conservative sphincterotomy in the treatment of chronic anal fissure", "firstAuthor": "Theodoropoulos", "multipleAuthors": true, "journal": "Am Surg", "year": 2015, "design": "retrospective", "n": 62, "nField": "reported", "population": "adults with chronic anal fissure needing surgery", "intervention": "lateral internal sphincterotomy plus dermal flap advancement after fissure removal", "comparator": "conventional lateral internal sphincterotomy alone", "primaryOutcome": "pain after surgery and during bowel movements, and how fast the wound healed", "result": "the flap technique caused less pain, needed fewer painkillers, and healed faster with less soiling", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this compared two surgical groups from different time periods rather than randomly assigning patients, so other differences between the groups could explain the results", "directness": "indirect", "limitations": "not randomized, compared a new group to a previously treated group, no mention of blinding, long-term outcomes unclear", "followUp": "", "plainFinding": "Faster healing, less post-surgery pain", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25642874/", "sourceText": "Lateral internal sphincterotomy (LIS) is considered the surgical treatment of choice for chronic anal fissure (CAF). Flap techniques for fissure coverage have the advantage of primary wound healing, potentially providing better functional results and faster pain relief. The standard surgical strategy for CAF consisting of conventional LIS (CLIS) up to the dentate line was modified by \"tailoring\" the LIS to the apex of the CAF, but never greater than 1 cm, and by advancing a dermal flap for coverage of the CAF (LIS + flap) after fissurectomy. Thirty consecutive patients who underwent \"LIS + flap\" were compared with 32 patients who had been previously treated by CLIS. A modified, trapezoid-like Y-V flap from perianal skin was advanced into the CAF base. Pain at the first postoperative day, pain at defecation during the first week, postoperative use of analgesics, and time for patients' pain relief were significantly less at the \"LIS + flap\" group (P < 0.01). Objective healing was achieved faster (P < 0.01) and soiling episodes were less (P < 0.05) after \"LIS + flap.\" The addition of a dermal flap after \"conservative\" LIS resulted in better healing and significantly less postoperative discomfort than the isolated application of CLIS.", "provenance": [ { "field": "population", "quote": "chronic anal fissure" }, { "field": "intervention", "quote": "\"tailoring\" the LIS to the apex of the CAF, but never greater than 1 cm, and by advancing a dermal flap for coverage of the CAF (LIS + flap) after fissurectomy" }, { "field": "comparator", "quote": "32 patients who had been previously treated by CLIS" }, { "field": "primaryOutcome", "quote": "Pain at the first postoperative day, pain at defecation during the first week, postoperative use of analgesics, and time for patients' pain relief" }, { "field": "result", "quote": "Pain at the first postoperative day, pain at defecation during the first week, postoperative use of analgesics, and time for patients' pain relief were significantly less at the \"LIS + flap\" group (P < 0.01)." }, { "field": "n", "quote": "Thirty consecutive patients who underwent \"LIS + flap\" were compared with 32 patients who had been previously treated by CLIS." } ] }, { "id": "pmid:25628851", "pmid": "25628851", "doi": null, "nctId": null, "pmcid": "PMC4293798", "title": "Clinical Manifestations among Children with Chronic Functional Constipation", "firstAuthor": "Dehghani", "multipleAuthors": true, "journal": "Middle East J Dig Dis", "year": 2015, "design": "case-series", "n": 222, "nField": "reported", "population": "children under 18 with long-term constipation seen at a pediatric gastroenterology clinic", "intervention": "no treatment was tested; researchers just recorded symptoms", "comparator": "not applicable - no treatment comparison was made", "primaryOutcome": "how often different constipation-related symptoms occurred, including painful pooping and anal fissures", "result": "anal fissures and fresh rectal bleeding were the least common symptoms, while painful defecation occurred in most children", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this was just a descriptive look at symptoms in kids with constipation, with no comparison group and no test of any treatment, so it can't tell us what causes anal pain after pooping in general.", "directness": "indirect", "limitations": "cross-sectional design with no control group, limited to children with chronic functional constipation, based on history and physical exam rather than objective testing", "followUp": "", "plainFinding": "Painful pooping tied to hard stool, fissures in kids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25628851/", "sourceText": "BACKGROUND Constipation is one of the most frequent cause of patient visits to pediatric gastroenterology clinics. Early diagnosis and treatment is important. There are few studies about clinical manifestations of constipation in children. We aimed to find the relative frequency of gastrointestinal manifestations of constipation among constipated children. METHODS This cross-sectional study was carried out on children aged < 18 years old with chronic functional constipation referred to Imam Reza Clinic of Shiraz University of Medical Sciences. Children with organic causes of chronic constipation were excluded from study. Rome III criteria were used for defining constipation. The duration of study was 1 year starting from September 2010. Abdominal pain, fecal mass, rectal bleeding, anorexia, fecal soiling, retentive posture, withholding behavior, anal fissure, and peri-anal erythema were recorded for each case based on history and physical examination. Data were analyzed using SPSS software, version 13.0 (Chicago, IL, USA). RESULTS Of 222 children with functional constipation, 124(55.9%) were girls and 98 (44.1%) were boys with a mean ± SD age of 5±3.12 years. The mean ± SD duration of constipation was 2.2±1.9 years. Large and hard stool was present in 93.7% of the patients. Painful defecation and withholding behavior were seen in 92.3% and 91.9% of the patients, respectively. Fecal impaction was more frequent among boys compared with girls (p<0.01). Fecal soiling was present in 40.8% of the boys and 28.2% of the girls (p=0.04). CONCLUSION Large and hard stool, painful defecation and withholding behavior were the most frequent signs or symptoms among children with chronic functional constipation. Fresh rectal bleeding and anal fissure were the least frequent signs and symptoms in this group.", "provenance": [ { "field": "n", "quote": "Of 222 children with functional constipation" }, { "field": "population", "quote": "children aged < 18 years old with chronic functional constipation referred to Imam Reza Clinic of Shiraz University of Medical Sciences" }, { "field": "intervention", "quote": "This cross-sectional study was carried out on children" }, { "field": "comparator", "quote": "Abdominal pain, fecal mass, rectal bleeding, anorexia, fecal soiling, retentive posture, withholding behavior, anal fissure, and peri-anal erythema were recorded for each case based on history and physical examination." }, { "field": "primaryOutcome", "quote": "We aimed to find the relative frequency of gastrointestinal manifestations of constipation among constipated children." }, { "field": "result", "quote": "Fresh rectal bleeding and anal fissure were the least frequent signs and symptoms in this group." } ] }, { "id": "pmid:25421703", "pmid": "25421703", "doi": "10.1007/s10151-014-1235-8", "nctId": null, "pmcid": null, "title": "Ligation anopexy versus hemorrhoidectomy in the treatment of second- and third-degree hemorrhoids", "firstAuthor": "Elshazly", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2015, "design": "rct", "n": 200, "nField": "reported", "population": "patients with grade II and III hemorrhoids undergoing surgery", "intervention": "ligation anopexy (LA) surgery for hemorrhoids", "comparator": "conventional hemorrhoidectomy (CH)", "primaryOutcome": "pain, complications, recovery time after hemorrhoid surgery", "result": "LA had shorter operative times, earlier bowel movement, earlier return to work, and lower pain scores on days 1,3,7,14 after surgery, with no difference in complications", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "It was a randomized trial comparing two surgeries with 200 patients, but it doesn't address general causes of pain after bowel movements, only post-surgical recovery.", "directness": "indirect", "limitations": "Abstract does not mention blinding, long-term follow-up beyond 14 days, or how pain was measured in detail.", "followUp": "14 days", "plainFinding": "Less pain after newer hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25421703/", "sourceText": "BACKGROUND: The aim of the study was to compare ligation anopexy (LA) and conventional hemorrhoidectomy (CH) in treatment of second- and third-degree hemorrhoids. METHODS: A prospective controlled randomized clinical trial included 100 patients who underwent CH (CH group) and 100 patients who underwent LA (LA group). A detailed history was taken from all the patients. The effectiveness, safety, postoperative complications, operative time, length of hospital stay, time until first bowel movement, time until return to work, and postoperative pain score were assessed. RESULTS: There was no significant difference between groups regarding age, sex, and preoperative symptoms. The LA group had significantly shorter operative times, earlier first bowel movement, and an earlier return to work/activities. The postoperative pain score in the LA group was significantly lower than that in the CH group on days 1, 3, 7, and 14 after surgery. There was no significant difference between groups as regards postoperative complications. CONCLUSIONS: LA is safe, and as effective as CH in the treatment of grade II and grade III hemorrhoids, with shorter operative times, earlier mobilization, and lower postoperative pain scores.", "provenance": [ { "field": "n", "quote": "100 patients who underwent CH (CH group) and 100 patients who underwent LA (LA group)" }, { "field": "population", "quote": "treatment of second- and third-degree hemorrhoids" }, { "field": "intervention", "quote": "ligation anopexy (LA)" }, { "field": "comparator", "quote": "conventional hemorrhoidectomy (CH)" }, { "field": "primaryOutcome", "quote": "effectiveness, safety, postoperative complications, operative time, length of hospital stay, time until first bowel movement, time until return to work, and postoperative pain score were assessed" }, { "field": "result", "quote": "The LA group had significantly shorter operative times, earlier first bowel movement, and an earlier return to work/activities. The postoperative pain score in the LA group was significantly lower than that in the CH group on days 1, 3, 7, and 14 after surgery." } ] }, { "id": "pmid:25398818", "pmid": "25398818", "doi": null, "nctId": null, "pmcid": null, "title": "Long-term outcome of stapled transanal rectal resection (STARR) versus stapled hemorrhoidopexys (STH) for grade III-IV hemorrhoids: preliminary results", "firstAuthor": "Zanella", "multipleAuthors": true, "journal": "In Vivo", "year": 2014, "design": "retrospective", "n": 320, "nField": "reported", "population": "patients with grade III or IV hemorrhoids", "intervention": "stapled transanal rectal resection (STARR) surgery", "comparator": "stapled hemorrhoidopexy (STH) surgery", "primaryOutcome": "postoperative bleeding, pain, recurrence and complications after hemorrhoid surgery", "result": "STARR had less bleeding and lower recurrence, but pain, soiling, incontinence and urgency were the same between groups", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a non-randomized comparison of two surgeries with small numbers in one group, described by the authors themselves as preliminary.", "directness": "indirect", "limitations": "Not randomized, unequal group sizes (281 vs 39), authors call results preliminary.", "followUp": "three years", "plainFinding": "No difference in pain after surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25398818/", "sourceText": "Circular stapled transanal hemorrhoidopexy (STH) was first introduced by A. Longo for the correction of internal mucosal prolapse and obstructed defecation and in 1998, was proposed as alternative to conventional excisional hemorrhoidectomy. More recently, stapled transanal rectal resection (STARR) has gradually gained popularity, as the Longo procedure, in the treatment of hemorrhoids. The aim of our study was to evaluate the usefulness of STARR as alternative to STH in patients with grade III (n=218, 68.1%) and IV (n=102, 31.9%) hemorrhoids. A group of 320 consecutive patients (median age=51 years; range=16-85) underwent STH (n=281) or STARR (n=39) procedure. The rate of postoperative bleeding (53.8% vs. 74.4%, p<0.01) was significantly reduced in patients who underwent STARR procedure, which required a longer (45 ± 22 vs. 26 ± 11 min, p<0.01) operative time. There were no differences between groups with regard to use of painkillers, postoperative pain intensity, short- (three months) and long-term (one and three years) residual pain, soiling, incontinence and urgency. Patients treated with the STARR procedure had lower recurrence rate of hemorrhoids and a lower incidence of prolapse, both at one year (none vs. 1.4%, p=0.593 and 2.6% vs. 5.3%, p=0.396, respectively) and at two years (none vs. 6.8%, p=0.078 and none vs. 13.2%, p=0.012, respectively). The one-year (9.0 ± 1.8 vs. 9.4 ± 0.7, p=0.171) and two-year (9.6 ± 0.8 vs. 9.1 ± 1.7, p=0.072) general satisfaction was similar but higher in STARR patients than in the STH group. In conclusion, according to our preliminary results, the STARR procedure leads to a lower incidence of complications and recurrences and should be considered for patients with grade III or IV hemorrhoids previously selected for stapled hemorrhoidectomy, as a promising alternative to STH.", "provenance": [ { "field": "n", "quote": "A group of 320 consecutive patients (median age=51 years; range=16-85) underwent STH (n=281) or STARR (n=39) procedure." }, { "field": "population", "quote": "patients with grade III (n=218, 68.1%) and IV (n=102, 31.9%) hemorrhoids" }, { "field": "intervention", "quote": "stapled transanal rectal resection (STARR)" }, { "field": "comparator", "quote": "Circular stapled transanal hemorrhoidopexy (STH)" }, { "field": "primaryOutcome", "quote": "The rate of postoperative bleeding (53.8% vs. 74.4%, p<0.01) was significantly reduced in patients who underwent STARR procedure" }, { "field": "result", "quote": "There were no differences between groups with regard to use of painkillers, postoperative pain intensity, short- (three months) and long-term (one and three years) residual pain, soiling, incontinence and urgency." } ] }, { "id": "pmid:25391392", "pmid": "25391392", "doi": null, "nctId": null, "pmcid": "PMC4229958", "title": "Anal fissure (chronic)", "firstAuthor": "Nelson", "multipleAuthors": false, "journal": "BMJ Clin Evid", "year": 2014, "design": "systematic-review", "n": null, "nField": "not-reported", "population": "people with chronic anal fissures causing anal pain after pooping", "intervention": "surgical treatments (anal advancement flap, anal stretch/dilation, internal anal sphincterotomy)", "comparator": "different surgical options compared with each other", "primaryOutcome": "effectiveness and safety of surgical treatments for chronic anal fissure", "result": "The abstract lists the interventions reviewed but does not state which worked better or by how much", "resultDirection": "unclear", "quality": "low", "qualityWhy": "The abstract doesn't report actual results, numbers, or effect sizes, just which treatments were reviewed.", "directness": "direct", "limitations": "No outcome data, effect sizes, or comparative results are given in this abstract; only the topics covered are listed.", "followUp": "", "plainFinding": "Anal fissures cause pain; surgery options reviewed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25391392/", "sourceText": "INTRODUCTION: Anal fissures are a common cause of anal pain during, and for 1 to 2 hours after, defecation. The cause is not fully understood, but low intake of dietary fibre may be a risk factor. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of surgical treatments for chronic anal fissure? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found nine studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: anal advancement flap, anal stretch/dilation, and internal anal sphincterotomy.", "provenance": [ { "field": "population", "quote": "Anal fissures are a common cause of anal pain during, and for 1 to 2 hours after, defecation." }, { "field": "intervention", "quote": "anal advancement flap, anal stretch/dilation, and internal anal sphincterotomy" }, { "field": "primaryOutcome", "quote": "we present information relating to the effectiveness and safety of the following interventions" }, { "field": "result", "quote": "In this systematic review, we present information relating to the effectiveness and safety of the following interventions: anal advancement flap, anal stretch/dilation, and internal anal sphincterotomy." }, { "field": "comparator", "quote": "What are the effects of surgical treatments for chronic anal fissure?" } ] }, { "id": "pmid:24985040", "pmid": "24985040", "doi": "10.1007/s10067-014-2732-x", "nctId": null, "pmcid": null, "title": "Evaluation of the incidence of haemorrhoidal disease in patients with ankylosing spondylitis", "firstAuthor": "Caglayan", "multipleAuthors": true, "journal": "Clin Rheumatol", "year": 2015, "design": "case-control", "n": 221, "nField": "reported", "population": "people with ankylosing spondylitis, compared to those with chronic low back pain and healthy people", "intervention": "having ankylosing spondylitis", "comparator": "chronic low back pain patients and healthy control subjects", "primaryOutcome": "presence of haemorrhoidal disease", "result": "haemorrhoids were much more common in ankylosing spondylitis patients than in the other two groups", "resultDirection": "harm", "quality": "low", "qualityWhy": "this is a small observational comparison that cannot prove ankylosing spondylitis causes haemorrhoids, only that they occur together more often.", "directness": "indirect", "limitations": "The abstract does not report controlling for other factors like diet, or the study design details beyond a three-group comparison.", "followUp": "", "plainFinding": "More haemorrhoids with ankylosing spondylitis.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24985040/", "sourceText": "Haemorrhoidal disease (HD) is one of the most common diseases encountered by the clinicians of general surgery. Chronic constipation, pushing during defecation and increased abdominal pressure play an important role in development of haemorrhoidal disease. Patients with ankylosing spondylitis (AS) frequently use the Valsalva manoeuvre in their daily lives, which may increase the abdominal pressure, leading to formation of haemorrhoids. The purpose of this study was to evaluate the incidence of haemorrhoidal disease in patients with AS. A total of 221 individuals were included in this study in three groups as follows: 72 patients with ankylosing spondylitis (AS), 75 patients with chronic low back pain (LBP) and 74 healthy control subjects. Patients were examined both physically and anoscopically, and their histories were taken. The incidence of HD was 45.8% in patients with AS, 16% in patients with chronic LBP and 9.5% in healthy control subjects. The incidence of HD was significantly higher in patients with AS compared to the other groups. Patients with AS have a high incidence of HD, which should be taken into consideration by clinicians during routine examination of these patients.", "provenance": [ { "field": "n", "quote": "A total of 221 individuals were included in this study in three groups" }, { "field": "population", "quote": "72 patients with ankylosing spondylitis (AS), 75 patients with chronic low back pain (LBP) and 74 healthy control subjects" }, { "field": "intervention", "quote": "Patients with ankylosing spondylitis (AS) frequently use the Valsalva manoeuvre in their daily lives, which may increase the abdominal pressure, leading to formation of haemorrhoids." }, { "field": "comparator", "quote": "75 patients with chronic low back pain (LBP) and 74 healthy control subjects" }, { "field": "primaryOutcome", "quote": "The purpose of this study was to evaluate the incidence of haemorrhoidal disease in patients with AS." }, { "field": "result", "quote": "The incidence of HD was significantly higher in patients with AS compared to the other groups." } ] }, { "id": "pmid:24953368", "pmid": "24953368", "doi": null, "nctId": null, "pmcid": null, "title": "[Clinical study of tissue-selecting therapy in the treatment of mixed hemorrhoids: a single-blind randomized controlled trail]", "firstAuthor": "He", "multipleAuthors": true, "journal": "Zhonghua Wei Chang Wai Ke Za Zhi", "year": 2014, "design": "rct", "n": 120, "nField": "reported", "population": "adults with mixed hemorrhoids undergoing surgery", "intervention": "tissue-selecting therapy (TST) hemorrhoid surgery", "comparator": "procedure for prolapse and hemorrhoids (PPH) surgery", "primaryOutcome": "surgical outcomes and complications after hemorrhoid surgery, including pain with first bowel movement", "result": "TST had a shorter operation time, lower rectal urgency scores, shorter hospital stay, and no anastomotic stricture (vs 18.3% with PPH); there was no significant difference between the two surgeries in effective rate or pain score at first bowel movement", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It is a small, single-blind surgical trial comparing two hemorrhoid operations, not a study of the general cause of pain after a bowel movement.", "directness": "indirect", "limitations": "Single-blind design, small sample of only surgical hemorrhoid patients, and no mention of blinding for pain assessment or long-term follow-up.", "followUp": "", "plainFinding": "Similar post-poop pain, fewer surgery complications", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24953368/", "sourceText": "OBJECTIVE: To evaluate the clinical efficacy and safety of tissue-selecting therapy (TST) in treatment of mixed hemorrhoids. METHODS: A single-blind randomized study was carried out. A total of 120 patients with mixed hemorrhoids from January to December 2012 were prospectively enrolled in the study and equally divided into two groups, TST group and procedure for prolapse and hemorrhoids(PPH) group. Surgical data, efficacy and postoperative complications were compared between the two groups. RESULTS: As compared to PPH group, patients in TST group had shorter operation time [(15.9±5.18) min vs. (22.6±7.1) min, P<0.05], lower scores of rectal urgency (0.5±0.2 vs. 1.5±1.4, P<0.05), and shorter hospital stay [(11.2±3.7) d vs. (14.8±3.7) d, P<0.05]. No anastomotic stricture case was found in TST group, while 11 cases(18.3%) developed anastomotic stricture in PPH group. There were no significant differences in effective rate and pain score of first defecation between the two groups. CONCLUSION: TST is reliable and safe for mixed hemorrhoids with the advantage of simple, rapid recovery and less complications.", "provenance": [ { "field": "n", "quote": "A total of 120 patients with mixed hemorrhoids from January to December 2012 were prospectively enrolled in the study and equally divided into two groups" }, { "field": "population", "quote": "patients with mixed hemorrhoids" }, { "field": "intervention", "quote": "tissue-selecting therapy (TST)" }, { "field": "comparator", "quote": "procedure for prolapse and hemorrhoids(PPH)" }, { "field": "primaryOutcome", "quote": "Surgical data, efficacy and postoperative complications were compared between the two groups." }, { "field": "result", "quote": "There were no significant differences in effective rate and pain score of first defecation between the two groups." }, { "field": "result", "quote": "No anastomotic stricture case was found in TST group, while 11 cases(18.3%) developed anastomotic stricture in PPH group." } ] }, { "id": "pmid:24952734", "pmid": "24952734", "doi": "10.1007/s10151-014-1187-z", "nctId": null, "pmcid": null, "title": "The tissue selecting technique (TST) versus the Milligan-Morgan hemorrhoidectomy for prolapsing hemorrhoids: a retrospective case-control study", "firstAuthor": "Lin", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2014, "design": "retrospective", "n": 195, "nField": "reported", "population": "patients with advanced (grade III-IV) prolapsing hemorrhoids needing surgery", "intervention": "tissue selecting technique (TST), a stapled hemorrhoid surgery", "comparator": "Milligan-Morgan hemorrhoidectomy (traditional hemorrhoid removal surgery)", "primaryOutcome": "pain after bowel movements and recurrence of hemorrhoids after surgery", "result": "TST caused less pain than MMH after surgery and at first bowel movement, with similar 1-year recurrence rates", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective study comparing two surgery groups without randomization, so other differences between patients could affect the results.", "directness": "indirect", "limitations": "Retrospective design, not randomized, so groups may differ in ways that affect pain and outcomes.", "followUp": "1-year", "plainFinding": "Less pain with TST surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24952734/", "sourceText": "BACKGROUND: Milligan-Morgan hemorrhoidectomy (MMH) is the procedure of choice in the management of hemorrhoidal disease. However, this procedure is associated with significant postoperative pain. Tissue selecting technique (TST) is a segmental stapled hemorrhoidopexy, which aims to reduce the postoperative pain, rectovaginal fistula (RVF) and rectal stenosis. The aim of the present study was to compare the clinical outcomes between TST and MMH. METHODS: A case-control study was undertaken to investigate the difference in clinical characteristics between the patients treated with TST and those treated with MMH. Intraoperative and postoperative parameters in both groups were collected and compared. RESULTS: One hundred and ninety-five eligible patients underwent either TST (n = 121) or MMH (n = 74). The pain score was significantly less in the TST group than that in the MMH group at the first defecation and at 12 h, day 3 and day 7 postoperatively (P = 0.001). Further analysis revealed that, at the time point of 12 h, day 3, day 7 and during first defecation, the pain score in the TST group and TST + STE group was less than that in the MMH group (P = 0.001). No patient in either group developed postoperative rectal stenosis. Furthermore, no case of RVF was identified in the TST group. The 1-year recurrence rate was 3.3 % (4/121) and 2.7 % (2/74), respectively, in TST and MMH groups (P = 1.0). CONCLUSIONS: The 1-year recurrence rate after TST and MMH for the treatment of patients with grade III-IV hemorrhoids is similar. It is encouraging that TST is associated with less postoperative pain and no RVF or rectal stenosis.", "provenance": [ { "field": "n", "quote": "One hundred and ninety-five eligible patients underwent either TST (n = 121) or MMH (n = 74)." }, { "field": "population", "quote": "patients with grade III-IV hemorrhoids" }, { "field": "intervention", "quote": "Tissue selecting technique (TST) is a segmental stapled hemorrhoidopexy" }, { "field": "comparator", "quote": "Milligan-Morgan hemorrhoidectomy (MMH) is the procedure of choice in the management of hemorrhoidal disease" }, { "field": "primaryOutcome", "quote": "The pain score was significantly less in the TST group than that in the MMH group at the first defecation and at 12 h, day 3 and day 7 postoperatively" }, { "field": "result", "quote": "The pain score was significantly less in the TST group than that in the MMH group at the first defecation and at 12 h, day 3 and day 7 postoperatively (P = 0.001)." }, { "field": "result", "quote": "The 1-year recurrence rate was 3.3 % (4/121) and 2.7 % (2/74), respectively, in TST and MMH groups (P = 1.0)." } ] }, { "id": "pmid:24918721", "pmid": "24918721", "doi": "10.1590/s0100-69912014000200004", "nctId": null, "pmcid": null, "title": "Postoperative topical analgesia of hemorrhoidectomy with policresulen and cinchocaine: a prospective and controlled study", "firstAuthor": "Froehner Junior", "multipleAuthors": true, "journal": "Rev Col Bras Cir", "year": 2014, "design": "rct", "n": 43, "nField": "reported", "population": "patients who had hemorrhoid surgery (hemorrhoidectomy)", "intervention": "topical ointment with policresulen and cinchocaine applied after surgery", "comparator": "placebo ointment or usual care with oral medications alone", "primaryOutcome": "pain intensity after surgery, measured on a pain scale", "result": "no difference in pain between groups at any time point, including at first bowel movement", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "very small number of patients split into small groups makes it hard to trust the result.", "directness": "indirect", "limitations": "small sample size split across three groups, studied pain after surgical hemorrhoid removal rather than ordinary pain after a bowel movement", "followUp": "day 15", "plainFinding": "No benefit over placebo", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24918721/", "sourceText": "OBJECTIVE: To evaluate the effects of topical policresulen and cinchocaine in the postoperative pain behavior of open hemorrhoidectomy. METHODS: We conducted a prospective, double-blinded, controlled study. The control group received the usual guidelines with oral medications. The topical treatment group received, in addition, the application of the ointment and was comprised of two subgroups (policresulen + cinchocaine, and placebo). Pain intensity was recorded with the visual analogue scale. RESULTS: 43 patients were operated on: control group - n = 13, one excluded; placebo - n = 15; and policresulen + cinchocaine - n = 15. The mean age was 45.98 years and 37.2% were men. The average pain intensity was 4.09 (immediate postoperative), 3.22 (hospital discharge), 5.73 (day 1) , 5.77 (day 2), 5.74 (day 3), 5.65 (day 7), 5.11 (day 10), 2.75 (day 15) and 7.70 (first bowel movement), with no difference between groups in all periods. CONCLUSION: This study showed no reduction in pain after hemorrhoidectomy with the use of topical policresulen and cinchocaine.", "provenance": [ { "field": "n", "quote": "43 patients were operated on: control group - n = 13, one excluded; placebo - n = 15; and policresulen + cinchocaine - n = 15." }, { "field": "population", "quote": "postoperative pain behavior of open hemorrhoidectomy" }, { "field": "intervention", "quote": "topical policresulen and cinchocaine" }, { "field": "comparator", "quote": "The topical treatment group received, in addition, the application of the ointment and was comprised of two subgroups (policresulen + cinchocaine, and placebo)." }, { "field": "primaryOutcome", "quote": "Pain intensity was recorded with the visual analogue scale." }, { "field": "result", "quote": "with no difference between groups in all periods" }, { "field": "result", "quote": "This study showed no reduction in pain after hemorrhoidectomy with the use of topical policresulen and cinchocaine." } ] }, { "id": "pmid:24906978", "pmid": "24906978", "doi": "10.1007/s10151-014-1170-8", "nctId": null, "pmcid": null, "title": "Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review", "firstAuthor": "Tsang", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2014, "design": "retrospective", "n": 77, "nField": "reported", "population": "adults with symptomatic hemorrhoids who had surgery", "intervention": "transanal hemorrhoidal dearterialisation (THD) surgery", "comparator": "stapled hemorrhoidopexy (PPH) surgery", "primaryOutcome": "pain level after surgery, plus bleeding, prolapse, complications and recurrence", "result": "THD patients had much lower pain scores than PPH patients and returned to normal activity sooner, with similar complication and recurrence rates", "resultDirection": "benefit", "quality": "low", "qualityWhy": "it compared one group of patients to historical records from a different time period rather than randomly assigning treatments, and the groups were small.", "directness": "indirect", "limitations": "Retrospective comparison with a historical control group, excluded thrombosed or external-only hemorrhoids, small sample size.", "followUp": "", "plainFinding": "Less pain with one hemorrhoid surgery technique", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24906978/", "sourceText": "BACKGROUND: The aim of this study was to evaluate and compare transanal haemorrhoidal dearterialisation (THD) and stapled haemorrhoidopexy [also called procedure for prolapsed haemorrhoids (PPH)] in the management of haemorrhoidal disease, in terms of short-term outcomes and efficacy. METHODS: Patients presenting with symptomatic haemorrhoids were treated with THD. Patient demographics, pre-operative data, post-operative pain scores, complications, recurrence, and patient satisfaction scores were evaluated and recorded. Patients with acute thrombosed haemorrhoids, external haemorrhoids only, or other concomitant anal diseases were excluded. These data were compared with the historical data of PPH. RESULTS: Forty consecutive patients underwent THD from February 2012 to July 2013 and were compared to 37 patients who underwent PPH taken from a medical records database. There were no significant differences in terms of demographic data, type of anaesthesia, operative time, and blood loss. Length of hospital stay, time to first post-operative bowel movement, and complications were similar between the two groups. The median pain score after THD and PPH was 1.71 and 5.00, respectively, on a scale of 0-10 (10 = worst possible pain) (p = 0.000). There was a significant improvement in bleeding and prolapse scores after THD. THD patients had an earlier return to normal daily activities (3.13 vs. 6.78 days, p = 0.001) when compared with the PPH group. Upon follow-up, patients in both groups had similar satisfaction scores, and complication and recurrence rates. CONCLUSIONS: Both THD and PPH appear to be safe procedures for haemorrhoidal disease, and they appear to have similar short-term outcomes. In particular, THD seems to be associated with a lower pain score than PPH, an earlier return to normal daily activities, and similar rates of complication and recurrence.", "provenance": [ { "field": "n", "quote": "Forty consecutive patients underwent THD from February 2012 to July 2013 and were compared to 37 patients who underwent PPH" }, { "field": "population", "quote": "Patients presenting with symptomatic haemorrhoids were treated with THD." }, { "field": "intervention", "quote": "transanal haemorrhoidal dearterialisation (THD)" }, { "field": "comparator", "quote": "stapled haemorrhoidopexy [also called procedure for prolapsed haemorrhoids (PPH)]" }, { "field": "primaryOutcome", "quote": "post-operative pain scores, complications, recurrence, and patient satisfaction scores were evaluated and recorded" }, { "field": "result", "quote": "The median pain score after THD and PPH was 1.71 and 5.00, respectively, on a scale of 0-10 (10 = worst possible pain) (p = 0.000)." }, { "field": "result", "quote": "THD patients had an earlier return to normal daily activities (3.13 vs. 6.78 days, p = 0.001) when compared with the PPH group." } ] }, { "id": "pmid:24860106", "pmid": "24860106", "doi": "10.1177/0009922814535659", "nctId": null, "pmcid": null, "title": "Fecal overflow often affects children with chronic constipation that appears after the age of 2 years", "firstAuthor": "Kammacher Guerreiro", "multipleAuthors": true, "journal": "Clin Pediatr (Phila)", "year": 2014, "design": "retrospective", "n": 270, "nField": "reported", "population": "children seen at a pediatric gastroenterology clinic with chronic constipation", "intervention": "not applicable (observational study of risk factors, no treatment tested)", "comparator": "children with chronic constipation without overflow incontinence (encopresis)", "primaryOutcome": "whether the child developed overflow incontinence (soiling) and related risk factors", "result": "pain at defecation or anal fissure was not linked to soiling; stool retention, scybala, later onset, longer disease duration, and male gender were linked to it", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a retrospective chart review without a control intervention, so it can show associations but not prove what causes pain after pooping.", "directness": "indirect", "limitations": "retrospective design, relies on clinic records from 1997-2012, no information on general population, does not directly address anal pain mechanism", "followUp": "", "plainFinding": "Pain not linked to soiling.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24860106/", "sourceText": "Chronic functional constipation with or without encopresis is a common problem in the pediatric population, and the prevalence of encopresis may be underestimated. The aim of this study was to assess the prevalence and risk factors for overflow incontinence in patients with chronic constipation seen at a pediatric gastroenterology consultation. A retrospective study of 270 files of patients seen between 1997 and 2012 was conducted, and a classification according to Rome III criteria was done. Among 145 (53.7%) boys and 125 (46.2%) girls, 117 had overflow incontinence (43.3%) - 41 (35%) girls and 76 (65%) boys. The first symptoms of chronic constipation appeared at a median age of 30 and 33 months in encopretic and 16 and 12 months in nonencopretic girls and boys, respectively. The first specialized consultation took place after a median disease duration of 26.5 and 24 months in encopretic and 16 and 9 months in nonencopretic girls and boys, respectively. A history of stool retention and the presence of scybala at examination, but not of pain at defecation or anal fissure, were associated with encopresis. The onset of chronic constipation after the age of 2 years, a longer disease duration, male gender, and a history of stool retention were seen as risk factors for the development of encopresis in patients with chronic functional constipation.", "provenance": [ { "field": "n", "quote": "A retrospective study of 270 files of patients seen between 1997 and 2012 was conducted" }, { "field": "population", "quote": "patients with chronic constipation seen at a pediatric gastroenterology consultation" }, { "field": "primaryOutcome", "quote": "assess the prevalence and risk factors for overflow incontinence in patients with chronic constipation" }, { "field": "result", "quote": "A history of stool retention and the presence of scybala at examination, but not of pain at defecation or anal fissure, were associated with encopresis." }, { "field": "comparator", "quote": "41 (35%) girls and 76 (65%) boys" }, { "field": "intervention", "quote": "The aim of this study was to assess the prevalence and risk factors for overflow incontinence in patients with chronic constipation seen at a pediatric gastroenterology consultation." } ] }, { "id": "pmid:24763890", "pmid": "24763890", "doi": null, "nctId": null, "pmcid": null, "title": "Effects of Aloe vera cream on chronic anal fissure pain, wound healing and hemorrhaging upon defection: a prospective double blind clinical trial", "firstAuthor": "Rahmani", "multipleAuthors": true, "journal": "Eur Rev Med Pharmacol Sci", "year": 2014, "design": "rct", "n": null, "nField": "not-reported", "population": "people with chronic anal fissures (small tears/cracks in the anus causing pain)", "intervention": "Aloe vera cream applied to the wound 3 times a day for 6 weeks", "comparator": "control group (not specified what they received)", "primaryOutcome": "pain, bleeding after pooping, and wound healing", "result": "significant improvement in pain, bleeding, and healing from the first week onward compared to control group", "resultDirection": "benefit", "quality": "low", "qualityWhy": "the abstract does not report how many patients were studied or what the control group received, making it hard to judge how reliable the results are.", "directness": "direct", "limitations": "number of participants not reported; details of control treatment not described; abstract does not specify randomization or blinding methods in detail despite being called double-blind", "followUp": "6 weeks", "plainFinding": "Less pain, faster healing with aloe cream.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24763890/", "sourceText": "Aloe vera is a medicinal plant that promotes wound healing in burn injuries. A prospective clinical trial was conducted to evaluate the effects of a topical cream containing 0.5% Aloe vera juice powder in the treatment of chronic anal fissures. The aloe cream was applied by the patients to the wound site 3 times per day for 6 weeks following the instructions of a physician. Pain was assessed with a visual analog scale before treatment and at the end of each week of treatment. Wound healing and the amount and severity of bleeding were examined and evaluated before and at the end of each week of treatment. There were statistically significant differences in chronic anal fissure pain, hemorrhaging upon defection and wound healing before and at the end of the first week of treatment also in comparison with control group (p < 0.0001). In this study, a topical cream containing aloe vera juice was an effective treatment for chronic anal fissures. This is a promising result indicating that further comparative studies are justified.", "provenance": [ { "field": "population", "quote": "topical cream containing 0.5% Aloe vera juice powder in the treatment of chronic anal fissures" }, { "field": "intervention", "quote": "The aloe cream was applied by the patients to the wound site 3 times per day for 6 weeks" }, { "field": "comparator", "quote": "in comparison with control group" }, { "field": "primaryOutcome", "quote": "Pain was assessed with a visual analog scale before treatment and at the end of each week of treatment. Wound healing and the amount and severity of bleeding were examined and evaluated" }, { "field": "result", "quote": "There were statistically significant differences in chronic anal fissure pain, hemorrhaging upon defection and wound healing before and at the end of the first week of treatment also in comparison with control group (p < 0.0001)." } ] }, { "id": "pmid:24732739", "pmid": "24732739", "doi": "10.1097/SLE.0000000000000009", "nctId": null, "pmcid": null, "title": "Ligasure versus stapled hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials", "firstAuthor": "Chen", "multipleAuthors": true, "journal": "Surg Laparosc Endosc Percutan Tech", "year": 2014, "design": "meta-analysis", "n": 397, "nField": "reported", "population": "patients with prolapsed hemorrhoids undergoing surgery", "intervention": "Ligasure hemorrhoidectomy (a sealing device used to remove hemorrhoids)", "comparator": "stapled hemorrhoidectomy", "primaryOutcome": "surgical outcomes including operative time, recurrence, and postoperative pain", "result": "Ligasure had shorter operative time and lower recurrence than stapling, but no significant difference in postoperative pain or other complications", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "It pools five randomized trials with a reasonable total number of patients, but it only covers people having hemorrhoid surgery, not general pain after bowel movements.", "directness": "indirect", "limitations": "Abstract does not mention blinding, heterogeneity between trials, or quality assessment of included studies.", "followUp": "", "plainFinding": "No difference in pain between surgery types.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24732739/", "sourceText": "The aim of this meta-analysis was to compare the outcomes of Ligasure hemorrhoidectomy and stapled hemorrhoidectomy for prolapsed hemorrhoids. Original studies in any language were searched from MEDLINE database, PubMed, Web of science and the Cochrane Library database, and Wangfang database. Randomized control trials that compared Ligasure hemorrhoidectomy with stapled hemorrhoidectomy were identified. Data were extracted independently for each study, and a meta-analysis was performed using fixed and random-effects models. Five trials including 397 patients met the inclusion criteria. Patients treated with Ligasure had a significantly shorter operative time compared with patients who underwent stapler techniques. The recurrence rate was higher in patients who underwent stapled hemorrhoidectomy. No statistically significant differences were observed in postoperative bleeding, urinary retention, difficult defecating, anal fissure, anal stenosis, incontinence, postoperative pain, return to normal activities, and hospital stay. Our meta-analysis shows that Ligasure is an effective instrument for hemorrhoidectomy, which results in shorter operation time and lower recurrence rate.", "provenance": [ { "field": "population", "quote": "to compare the outcomes of Ligasure hemorrhoidectomy and stapled hemorrhoidectomy for prolapsed hemorrhoids" }, { "field": "intervention", "quote": "Ligasure hemorrhoidectomy" }, { "field": "comparator", "quote": "stapled hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "No statistically significant differences were observed in postoperative bleeding, urinary retention, difficult defecating, anal fissure, anal stenosis, incontinence, postoperative pain, return to normal activities, and hospital stay." }, { "field": "result", "quote": "Patients treated with Ligasure had a significantly shorter operative time compared with patients who underwent stapler techniques. The recurrence rate was higher in patients who underwent stapled hemorrhoidectomy. No statistically significant differences were observed in postoperative bleeding, urinary retention, difficult defecating, anal fissure, anal stenosis, incontinence, postoperative pain, return to normal activities, and hospital stay." }, { "field": "n", "quote": "Five trials including 397 patients met the inclusion criteria." } ] }, { "id": "pmid:24682584", "pmid": "24682584", "doi": "10.1007/s00595-014-0885-5", "nctId": null, "pmcid": null, "title": "Comparison of the early results of transanal hemorrhoidal dearterialization and hemorrhoidectomy using an ultrasonic scalpel", "firstAuthor": "Tsunoda", "multipleAuthors": true, "journal": "Surg Today", "year": 2015, "design": "retrospective", "n": 66, "nField": "reported", "population": "patients with grade III or IV hemorrhoids undergoing surgery", "intervention": "Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (THD surgery)", "comparator": "hemorrhoidectomy using an ultrasonic scalpel (US surgery)", "primaryOutcome": "postoperative pain scores and analgesic use", "result": "THD patients had significantly lower pain scores on days 6 and 7 and used fewer analgesic tablets, though blood loss was greater; complications were similar between groups", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This compared one group of patients to a separate group from a past study rather than randomizing everyone together, which makes the comparison less reliable.", "directness": "indirect", "limitations": "Compared a new cohort of THD patients against a historical cohort from a previous randomized trial rather than a concurrent randomized comparison; small sample size.", "followUp": "first postoperative week", "plainFinding": "Less pain than other hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24682584/", "sourceText": "PURPOSE: Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (THD surgery) is a new approach for treating hemorrhoids. The early results of the procedure are presented and compared with those of hemorrhoidectomy using an ultrasonic scalpel (US surgery). METHODS: Thirty-six patients with grade III hemorrhoids underwent the THD surgery and were compared with a cohort of 30 patients with grade III or IV hemorrhoids who were assigned to US surgery in a previous randomized trial. RESULTS: The pain scores were significantly lower in the THD patients on days 6 and 7 after the operation. The number of analgesic tablets consumed during the first postoperative week in the THD patients was significantly lower than that in the US patients. The blood loss was significantly greater in the THD patients. The hospital stay and length of time until the first defecation after surgery were both significantly shorter in the THD patients. The postoperative complications were comparable between the two groups of patients. CONCLUSION: The THD surgery was as effective as the US surgery for the treatment of hemorrhoids in the short term. THD surgery might be a preferred treatment because it is associated with a similar complication rate and short-term results, but results in lower postoperative pain and analgesic requirements compared with the US surgery.", "provenance": [ { "field": "n", "quote": "Thirty-six patients with grade III hemorrhoids underwent the THD surgery and were compared with a cohort of 30 patients with grade III or IV hemorrhoids who were assigned to US surgery in a previous randomized trial." }, { "field": "population", "quote": "Thirty-six patients with grade III hemorrhoids underwent the THD surgery and were compared with a cohort of 30 patients with grade III or IV hemorrhoids who were assigned to US surgery in a previous randomized trial." }, { "field": "intervention", "quote": "Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (THD surgery) is a new approach for treating hemorrhoids." }, { "field": "comparator", "quote": "hemorrhoidectomy using an ultrasonic scalpel (US surgery)" }, { "field": "primaryOutcome", "quote": "The pain scores were significantly lower in the THD patients on days 6 and 7 after the operation." }, { "field": "result", "quote": "The pain scores were significantly lower in the THD patients on days 6 and 7 after the operation. The number of analgesic tablets consumed during the first postoperative week in the THD patients was significantly lower than that in the US patients. The blood loss was significantly greater in the THD patients." } ] }, { "id": "pmid:24637183", "pmid": "24637183", "doi": "10.1016/j.asjsur.2014.01.009", "nctId": null, "pmcid": null, "title": "Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: a prospective randomized study", "firstAuthor": "Gupta", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2014, "design": "rct", "n": 136, "nField": "reported", "population": "patients with chronic anal fissure", "intervention": "closed lateral internal anal sphincterotomy", "comparator": "open lateral sphincterotomy", "primaryOutcome": "postoperative pain, healing, and complications after surgery", "result": "closed technique had lower pain scores, shorter hospital stay, and fewer complications than open technique", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a surgical treatment study for an already-diagnosed fissure, not evidence about why pain happens after normal bowel movements.", "directness": "indirect", "limitations": "abstract does not report randomization method, blinding, or detailed statistics beyond pain score and complication rate", "followUp": "more than 1 year", "plainFinding": "Closed surgery less painful than open.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24637183/", "sourceText": "OBJECTIVE: Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral sphincterotomy has long been regarded as the gold standard of treatment. This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes. METHODS: A prospective, randomized comparative study was conducted between October 2010 and August 2012. A total of 136 patients were randomly assigned to each of two groups. Patients were followed up postoperatively for more than 1 year to assess any complications. The outcomes were compared among the two groups using the Chi-square test and Student t test. RESULTS: The mean age at presentation was 40.13 years. The male to female ratio was 1.47:1. The typical presentation was painful defecation. Fissures were most often located in the posterior midline and associated with a sentinel pile. Delayed postoperative healing was found in 4.4% of the group of patients undergoing open lateral sphincterotomy. The mean pain score and duration of hospital stay were lower with the closed technique. CONCLUSION: Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures as it is effective, safe, less expensive, and associated with a lower rate of complications than the open sphincterotomy technique.", "provenance": [ { "field": "n", "quote": "A total of 136 patients were randomly assigned to each of two groups." }, { "field": "population", "quote": "Chronic anal fissure is a benign disorder that is associated with considerable discomfort." }, { "field": "intervention", "quote": "Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures" }, { "field": "comparator", "quote": "group of patients undergoing open lateral sphincterotomy" }, { "field": "primaryOutcome", "quote": "This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes." }, { "field": "result", "quote": "The mean pain score and duration of hospital stay were lower with the closed technique." } ] }, { "id": "pmid:24569943", "pmid": "24569943", "doi": "10.1007/s00384-014-1845-7", "nctId": null, "pmcid": null, "title": "Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus", "firstAuthor": "Naldini", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2014, "design": "case-series", "n": 160, "nField": "reported", "population": "patients with advanced hemorrhoids or obstructed defecation with rectal prolapse", "intervention": "stapled transanal surgery using a new device (TST STARR Plus)", "comparator": "", "primaryOutcome": "safety, effectiveness and feasibility of the surgery, including complications", "result": "short operative time, low complication rate, no major complications, bleeding in 5% of patients", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a case series of one surgery type with no comparison group, so it can't show whether the surgery is better than other options.", "directness": "indirect", "limitations": "No control group, short follow-up, and focuses on surgical complications rather than everyday post-bowel-movement pain.", "followUp": "30 days", "plainFinding": "New stapler surgery mostly safe.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24569943/", "sourceText": "OBJECTIVE: The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery. METHODS: All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded. RESULTS: From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm(3), the mean hospital stay was 2.2 days. In 88 patients (55%), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5%). Urgency after 30 days was reported in one patient. No major complication occurred. CONCLUSIONS: The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.", "provenance": [ { "field": "n", "quote": "160 consecutive patients (96 females) were enrolled in the study" }, { "field": "population", "quote": "All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception" }, { "field": "intervention", "quote": "underwent stapled transanal resection with TST STARR plus" }, { "field": "primaryOutcome", "quote": "The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery." }, { "field": "result", "quote": "The mean duration of the procedure was 25 min." }, { "field": "result", "quote": "Bleeding was reported in seven patients (5%)." }, { "field": "result", "quote": "Urgency after 30 days was reported in one patient." }, { "field": "result", "quote": "No major complication occurred." } ] }, { "id": "pmid:24507943", "pmid": "24507943", "doi": "10.1016/j.amjsurg.2013.10.020", "nctId": null, "pmcid": null, "title": "Hemorrhoidal laser procedure: short- and long-term results from a prospective study", "firstAuthor": "Crea", "multipleAuthors": true, "journal": "Am J Surg", "year": 2014, "design": "case-series", "n": 97, "nField": "reported", "population": "adults with symptomatic grade 2-3 hemorrhoids with mild to moderate internal prolapse", "intervention": "hemorrhoidal laser procedure (HeLP)", "comparator": "none (single-arm study, no comparison group)", "primaryOutcome": "pain, bleeding, itching and hemorrhoid grade after laser treatment", "result": "symptoms (bleeding, pain, itching, hemorrhoidal acute syndrome) decreased by 76% to 79%, hemorrhoid grade was significantly reduced, and disease recurred in 5% of patients at 2 years", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a single-arm study with no comparison group, so it can't show whether the laser worked better than no treatment or another method.", "directness": "indirect", "limitations": "no control or comparator group was used, and the study only reports outcomes in people already diagnosed with hemorrhoids undergoing a specific laser procedure.", "followUp": "15 months", "plainFinding": "Laser hemorrhoid treatment reduced symptoms, little pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24507943/", "sourceText": "BACKGROUND: We report the results of 2-year regular use of the hemorrhoidal laser procedure (HeLP) in 97 patients with symptomatic second- to third-grade hemorrhoids with minimal or moderate internal mucosal prolapse. METHODS: Data on duration of the procedure, perioperative complications, postoperative pain, downgrading of hemorrhoids, resolution or persistency, and recurrence of hemorrhoidal disease (HD) were prospectively collected. RESULTS: No significant intraoperative complications occurred. The median follow-up was 15 months. Postoperative pain was null in most patients. There were no cases of rectal tenesmus or alteration of defecation habits. Symptoms and HD downgrading reached a \"plateau\" at 3 to 6 months after the HeLP. At this evaluation, frequency of bleeding, pain, itching, and hemorrhoidal acute syndrome decreased by 76% to 79%. HD grade showed a significant reduction. HD recurrence rate was 5% at 2 years. CONCLUSIONS: Our study demonstrates that the HeLP is a safe, effective, and painless technique for the treatment of symptomatic second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse, ideally suitable as ambulatory treatment.", "provenance": [ { "field": "population", "quote": "97 patients with symptomatic second- to third-grade hemorrhoids with minimal or moderate internal mucosal prolapse" }, { "field": "intervention", "quote": "hemorrhoidal laser procedure (HeLP)" }, { "field": "comparator", "quote": "Data on duration of the procedure, perioperative complications, postoperative pain, downgrading of hemorrhoids, resolution or persistency, and recurrence of hemorrhoidal disease (HD) were prospectively collected." }, { "field": "primaryOutcome", "quote": "postoperative pain, downgrading of hemorrhoids, resolution or persistency, and recurrence of hemorrhoidal disease" }, { "field": "result", "quote": "frequency of bleeding, pain, itching, and hemorrhoidal acute syndrome decreased by 76% to 79%. HD grade showed a significant reduction. HD recurrence rate was 5% at 2 years." }, { "field": "n", "quote": "97 patients with symptomatic second- to third-grade hemorrhoids" }, { "field": "followUp", "quote": "The median follow-up was 15 months." } ] }, { "id": "pmid:24310680", "pmid": "24310680", "doi": "10.1590/S0080-623420130000400010", "nctId": null, "pmcid": null, "title": "[Constipation in patients with quadriplegic cerebral palsy: intestinal reeducation using massage and a laxative diet]", "firstAuthor": "Faleiros-Castro", "multipleAuthors": true, "journal": "Rev Esc Enferm USP", "year": 2013, "design": "prospective-cohort", "n": 50, "nField": "reported", "population": "Patients with severe cerebral palsy (quadriplegic) who had constipation", "intervention": "Daily laxative foods, vegetable oils, increased fluids, and intestinal massage", "comparator": "No separate control group; symptoms compared before and after the intervention", "primaryOutcome": "Relief of constipation and related symptoms including pain during bowel movements", "result": "90% of patients had full or partial relief of constipation, with fewer anal fissures, less rectal bleeding, and less pain on defecation", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This was a small, uncontrolled study in a very specific population of children with cerebral palsy, so it says little about anal pain after pooping in general.", "directness": "indirect", "limitations": "No control group, specific and unusual patient population, and no mention of blinding or randomization", "followUp": "", "plainFinding": "Diet and massage eased painful constipation", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24310680/", "sourceText": "Constipation affects 74% of individuals with cerebral palsy. This study aimed to evaluate the results of nursing interventions for treating intestinal constipation associated with cerebral palsy. This quantitative, prospective, comparative study included 50 patients with quadriplegic cerebral palsy and constipation. The main conservative measures included daily consumption of laxative foods and vegetable oils, increase in fluid intake, and daily intestinal massage. Total or partial constipation relief was observed in 90% of the patients, with improvement in quality-of-life aspects such as sleep, appetite, and irritability, and a significant decrease in rectal bleeding, anal fissure, voluntary retention of stools, crying, and pain on defecation. Only 10% of the patients required laxative medications. It is recommended that conservative measures be used for treating cerebral palsy-related constipation and medications be used solely as adjuvants, if needed.", "provenance": [ { "field": "population", "quote": "50 patients with quadriplegic cerebral palsy and constipation" }, { "field": "intervention", "quote": "daily consumption of laxative foods and vegetable oils, increase in fluid intake, and daily intestinal massage" }, { "field": "comparator", "quote": "quantitative, prospective, comparative study" }, { "field": "primaryOutcome", "quote": "evaluate the results of nursing interventions for treating intestinal constipation associated with cerebral palsy" }, { "field": "result", "quote": "Total or partial constipation relief was observed in 90% of the patients, with improvement in quality-of-life aspects such as sleep, appetite, and irritability, and a significant decrease in rectal bleeding, anal fissure, voluntary retention of stools, crying, and pain on defecation." }, { "field": "n", "quote": "included 50 patients with quadriplegic cerebral palsy and constipation" } ] }, { "id": "pmid:24054756", "pmid": "24054756", "doi": "10.1016/j.asjsur.2013.01.010", "nctId": null, "pmcid": null, "title": "Comparison of topical isosorbide mononitrate, topical diltiazem, and their combination in the treatment of chronic anal fissure", "firstAuthor": "Bulus", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2013, "design": "rct", "n": 55, "nField": "reported", "population": "people with chronic anal fissure (a tear in the anus causing pain, often with pooping)", "intervention": "topical isosorbide mononitrate, topical diltiazem, or a combination cream applied to the anus", "comparator": "the three creams compared against each other", "primaryOutcome": "pain level (on a visual pain scale) and straining during bowel movements, before and after treatment", "result": "pain and straining both decreased significantly in all three groups after treatment, but none of the creams worked significantly better than the others", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it was a randomized trial but very small, had no placebo group to compare against, and did not describe blinding.", "directness": "direct", "limitations": "small sample size (55 patients total split into three groups), no placebo comparison group, and the abstract does not describe blinding or length of follow-up", "followUp": "", "plainFinding": "All three creams eased fissure pain equally.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24054756/", "sourceText": "BACKGROUND/OBJECTIVE: Chronic anal fissure is a painful condition that is associated with an increase in internal anal sphincter pressure. The main aim of this study is to evaluate the efficacy and adverse effects of topical isosorbide 5 mononitrate and topical diltiazem, when administered either as single agents or in combination, in the treatment of anal fissure. METHODS: Patients with chronic anal fissure were enrolled in the study. They were randomized into three groups: Group A (0.2% isosorbide 5 mononitrate users), Group B (2% diltiazem users), and Group C (2%diltiazem + 0.2% isosorbide 5 mononitrate users). Pain was evaluated using a visual analog scale (VAS). Level of strain during defecation was graded on a 4-point scale. RESULTS: A total of 55 patients were enrolled in the study. The average ages of patients in Groups A, B, and C were 37.94 ± 16.19, 42.83 ± 13.21, 40 ± 13.58 years, respectively. After treatment, pain completely abated in 55.6% of patients in Group A, 27.8% (n = 5) in Group B, and 42.1% (n = 8) in Group C. The decreases in average VAS values prior to and after treatment in Groups A, B, and C were statistically significant (p values 0.0001, 0.001, and 0.0001, respectively). Average strain scores prior to and after treatment were 2.11/0.72 for Group A, 2.17/0.94 for Group B, and 1.95/0.47 for Group C. Strain during defecation prior to and after treatment in Groups A, B, and C was statistically significant (p values 0.001, 0.001, and 0.003, respectively). CONCLUSION: Topical diltiazem and a combination of nitrate and diltiazem can be used in the treatment of anal fissure. However, the agents are not significantly superior each other.", "provenance": [ { "field": "population", "quote": "Patients with chronic anal fissure were enrolled in the study." }, { "field": "intervention", "quote": "Group A (0.2% isosorbide 5 mononitrate users), Group B (2% diltiazem users), and Group C (2%diltiazem + 0.2% isosorbide 5 mononitrate users)" }, { "field": "comparator", "quote": "They were randomized into three groups" }, { "field": "primaryOutcome", "quote": "Pain was evaluated using a visual analog scale (VAS). Level of strain during defecation was graded on a 4-point scale." }, { "field": "result", "quote": "The decreases in average VAS values prior to and after treatment in Groups A, B, and C were statistically significant (p values 0.0001, 0.001, and 0.0001, respectively)." }, { "field": "result", "quote": "the agents are not significantly superior each other." }, { "field": "n", "quote": "A total of 55 patients were enrolled in the study." } ] }, { "id": "pmid:24030967", "pmid": "24030967", "doi": "10.1136/dtb.2013.9.0202", "nctId": null, "pmcid": null, "title": "Non-surgical treatments for anal fissure in adults", "firstAuthor": null, "multipleAuthors": false, "journal": "Drug Ther Bull", "year": 2013, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "adults with anal fissure (a tear in the anal lining causing pain after pooping)", "intervention": "non-surgical treatments for anal fissure", "comparator": "", "primaryOutcome": "how well treatments work and their safety", "result": "the abstract does not state a specific result, only that it reviews the evidence", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a narrative review summarizing background information without presenting specific trial results or data in the abstract.", "directness": "direct", "limitations": "the abstract gives background information on anal fissure but does not report the actual findings or data comparing treatments", "followUp": "", "plainFinding": "Explains fissure pain, no results given.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24030967/", "sourceText": "An anal fissure is defined as a linear tear or ulcer of the anal mucosa. Patients typically describe a sharp pain 'like passing broken glass' on defaecation, followed by a burning pain in the anus lasting a few hours. Pain and bleeding during and after the passage of stool are the usual presenting features. Fissures are most common in young to middle-aged adults and are also commonly seen in pregnant and postpartum women. The lifetime incidence of anal fissure is around 11%. Here, we review the evidence on the efficacy and safety of non-surgical treatments for anal fissure.", "provenance": [ { "field": "population", "quote": "Fissures are most common in young to middle-aged adults and are also commonly seen in pregnant and postpartum women." }, { "field": "intervention", "quote": "Here, we review the evidence on the efficacy and safety of non-surgical treatments for anal fissure." }, { "field": "primaryOutcome", "quote": "Here, we review the evidence on the efficacy and safety of non-surgical treatments for anal fissure." }, { "field": "result", "quote": "Here, we review the evidence on the efficacy and safety of non-surgical treatments for anal fissure." } ] }, { "id": "pmid:23967636", "pmid": "23967636", "doi": null, "nctId": null, "pmcid": null, "title": "[Influence of acupuncture and moxibustion on defecation in postoperative patients of anal fissure: a randomized controlled trial]", "firstAuthor": "Huang", "multipleAuthors": true, "journal": "Zhongguo Zhen Jiu", "year": 2013, "design": "rct", "n": 200, "nField": "reported", "population": "patients who had surgery for anal fissure", "intervention": "acupuncture and moxibustion plus standard post-surgery care", "comparator": "laxative medication (forlax) plus standard post-surgery care", "primaryOutcome": "pain, willingness to defecate, difficulty, and stool texture after bowel movements following surgery", "result": "From day 3, acupuncture group had less pain and more willingness to defecate than medication group; no difference in defecation difficulty or stool texture", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small single trial in a very specific post-surgical population, with unclear blinding, so it may not generalize to typical anal pain after pooping.", "directness": "indirect", "limitations": "Abstract does not describe blinding, randomization method, or dropout rates; population is specifically post-surgical anal fissure patients, not general anal pain sufferers.", "followUp": "", "plainFinding": "Less pain with acupuncture after fissure surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23967636/", "sourceText": "OBJECTIVE: To verify the clinical efficacy of acupuncture and moxibustion on defecating and pain symptoms in postoperative patient of anal fissure. METHODS: Two hundred cases of postoperation of anal fissure were randomly divided into an acupuncture-moxibustion group and a medication group, 100 cases in each one. The basic treatment after the surgery was the same in two groups, besides, acupuncture was applied at Zhongliao (BL 33) and Xialiao (BL 34) in the morning of first 5 days of postoperative 24 h in the acupuncture-moxibustion group, and suspended moxibusiton was applied at Changqiang (GV 1) within 5 to 10 min after defecation; while two bags of forlax was orally administrated in the morning of first 5 days of postoperative 24 h in the medication group. The pain intensity, defecation willingness, defecation difficulty and stool texture during postoperative defecation were observed. RESULTS: The defecation pain on the first two days after the treatment was not statistically significant between two groups (both P > 0.05). From the third day of treatment, the improvements of defecation pain in acupuncture-moxibustion group were more obvious than those in the medication group (all P < 0.05). The patients in the acupuncture-moxibustion group had more positive defecation willingness than those in the medication group (all P < 0.05). The differences of defecation difficulty and stool properties in two groups had no statistical significance (both P > 0.05). CONCLUSION: The intervention treatment of acupuncture and moxibustion has clinical significance on relieving pain symptoms and improving defecation willingness in postoperative patient of anal fissure.", "provenance": [ { "field": "n", "quote": "Two hundred cases of postoperation of anal fissure were randomly divided into an acupuncture-moxibustion group and a medication group, 100 cases in each one." }, { "field": "population", "quote": "postoperative patient of anal fissure" }, { "field": "intervention", "quote": "acupuncture was applied at Zhongliao (BL 33) and Xialiao (BL 34) in the morning of first 5 days of postoperative 24 h in the acupuncture-moxibustion group, and suspended moxibusiton was applied at Changqiang (GV 1) within 5 to 10 min after defecation" }, { "field": "comparator", "quote": "two bags of forlax was orally administrated in the morning of first 5 days of postoperative 24 h in the medication group" }, { "field": "primaryOutcome", "quote": "The pain intensity, defecation willingness, defecation difficulty and stool texture during postoperative defecation were observed." }, { "field": "result", "quote": "From the third day of treatment, the improvements of defecation pain in acupuncture-moxibustion group were more obvious than those in the medication group (all P < 0.05). The patients in the acupuncture-moxibustion group had more positive defecation willingness than those in the medication group (all P < 0.05). The differences of defecation difficulty and stool properties in two groups had no statistical significance (both P > 0.05)." } ] }, { "id": "pmid:23943282", "pmid": "23943282", "doi": "10.1007/s00384-013-1758-x", "nctId": null, "pmcid": null, "title": "Role of 0.4 % glyceryl trinitrate ointment after stapled trans-anal rectal resection for obstructed defecation syndrome: a prospective, randomized trial", "firstAuthor": "Izzo", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2014, "design": "rct", "n": 104, "nField": "reported", "population": "patients who had surgery (STARR) for obstructed defecation syndrome", "intervention": "topical glyceryl trinitrate (GTN) ointment 0.4% applied every 12 hours for four weeks after surgery", "comparator": "no GTN ointment after surgery", "primaryOutcome": "anal spasm, anal fissure, and pain after the surgery", "result": "GTN group had less anal spasm (0% vs 14.6%), less anal fissure (0% vs 9.7%), and lower pain scores at 1 week and 1 month", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small randomized trial in a specific post-surgical population, so it may not apply to general after-pooping anal pain.", "directness": "indirect", "limitations": "Small sample size; studies a specific surgical population (after STARR for obstructed defecation syndrome), not general post-defecation anal pain.", "followUp": "1, 6, and 12 months", "plainFinding": "Less pain and fissures after surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23943282/", "sourceText": "PURPOSE: The anal fissure and spasm represent possible complications and causes of postoperative anal pain in patients that have undergone stapled trans-anal rectal resection (STARR). The etiology of these complications is still questioned such as the treatment modality. This study was designed to evaluate the effectiveness of topical glyceryl trinitrate (GTN) 0.4 % in determining decrease of incidence of postoperative anal spams and fissure and reduction of early postoperative pain. METHODS: From a total of 243 patients referred for obstructed defecation syndrome (ODS) 104 (42.7 %) underwent STARR and were randomized to receive (Group 1) or not (Group 2) topical 0.4 % GTN ointment every 12 h for four postoperative weeks. Postoperative evaluation was made at 1, 6, and 12 months. RESULTS: At 1 month follow-up, the incidence of anal spasm in Groups 1 and 2 was, respectively, 0 and 14.6 % (6/41) (p = 0.010; Fisher's exact test). The incidence of anal fissure was 4/41 (9.7 %) in Group 2 and 0/44 (0 %) in Group 1 (p = 0.05; Fisher's exact test). Significant differences in median visual analogue scale score between groups were found at 1 week and 1 month follow-up (1; 0-5 vs. 2; 0-7: p = 0.0104; Mann-Whitney U test). CONCLUSION: Anal spasm and fissure may represent a cause of early postoperative anal pain in patients that have undergone STARR procedure for ODS. The use of topical GTN 0.4 % ointment in the early postoperative course seems to reduce the incidence of anal spasm and fissure and to improve the associated early postoperative pain.", "provenance": [ { "field": "n", "quote": "104 (42.7 %) underwent STARR and were randomized" }, { "field": "population", "quote": "patients that have undergone stapled trans-anal rectal resection (STARR)" }, { "field": "intervention", "quote": "topical 0.4 % GTN ointment" }, { "field": "comparator", "quote": "104 (42.7 %) underwent STARR and were randomized to receive (Group 1) or not (Group 2) topical 0.4 % GTN ointment every 12 h for four postoperative weeks." }, { "field": "primaryOutcome", "quote": "evaluate the effectiveness of topical glyceryl trinitrate (GTN) 0.4 % in determining decrease of incidence of postoperative anal spams and fissure and reduction of early postoperative pain" }, { "field": "result", "quote": "the incidence of anal spasm in Groups 1 and 2 was, respectively, 0 and 14.6 % (6/41) (p = 0.010; Fisher's exact test)" }, { "field": "result", "quote": "The incidence of anal fissure was 4/41 (9.7 %) in Group 2 and 0/44 (0 %) in Group 1 (p = 0.05; Fisher's exact test)" }, { "field": "result", "quote": "Significant differences in median visual analogue scale score between groups were found at 1 week and 1 month follow-up (1; 0-5 vs. 2; 0-7: p = 0.0104; Mann-Whitney U test)." }, { "field": "followUp", "quote": "Postoperative evaluation was made at 1, 6, and 12 months." } ] }, { "id": "pmid:23898561", "pmid": "23898561", "doi": null, "nctId": null, "pmcid": null, "title": "Early quality of life outcomes following Doppler guided transanal haemorrhoidal dearterialisation: a prospective observational study", "firstAuthor": "Talha", "multipleAuthors": true, "journal": "Acta Gastroenterol Belg", "year": 2013, "design": "prospective-cohort", "n": 13, "nField": "reported", "population": "patients with hemorrhoid disease", "intervention": "Doppler guided transanal hemorrhoidal dearterialisation (THD) surgery", "comparator": "same patients before surgery", "primaryOutcome": "symptoms (including pain with pooping) and quality of life one month after surgery", "result": "pain with bowel movements and other symptoms significantly reduced one month after surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Very small study of only 13 people with no comparison group and short follow-up, so it can't rule out other explanations for improvement.", "directness": "direct", "limitations": "Small sample size, no control group, short follow-up of only one month.", "followUp": "1-month", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23898561/", "sourceText": "BACKGROUND AND AIMS: There are few studies examining the quality of life (QOL) of patients with haemorrhoidal disease. Transanal heamorrhoidal dearterialization (THD) is a treatment modality for heamorrhoidal disease in which a Doppler transducer is used to locate the supplying arteries that are subsequently ligated. The aim of this study was to assess symptoms and QOL changes following THD. PATIENTS AND METHODS: This was a prospective evaluation of QOL and symptom changes following THD. Patient symptoms, demographics and QOL were recorded preoperatively and 1-month post-operatively following THD using the medical outcomes study short-form-36 (SF-36). RESULTS: Thirteen patients undergoing THD were evaluated. One month following THD symptoms of haemorrhoid protrusion, bleeding, anal pain, painful defaecation, constipation and tenesmus, had all significantly reduced (P <0.05). Limitations in usual role activities because of physical health problems (53.8 +/- 10.5 Vs 90.4 +/-4.5, P = 0.004), vitality, energy and fatigue (45 +/- 6.9 Vs 73.5 +/- 5.0, P= 0.003), general mental health, psychologic distress and wellbeing (60.9 +/- 6.9 Vs 83.1 +/- 5.9, P= 0.023), limitations in social activities because of physical or emotional problems (58.7 +/- 8.8 Vs 84 +/- 5.9, P = 0.025), and physical pain (52.9 +/- 7.9 Vs 84.6 +/- 6.4, P= 0.005) scores had all improved 1-month following THD. CONCLUSIONS: THD significantly reduces symptoms of haemorrhoidal disease and improves specific aspects of QOL 1-month following surgery.", "provenance": [ { "field": "n", "quote": "Thirteen patients undergoing THD were evaluated." }, { "field": "population", "quote": "There are few studies examining the quality of life (QOL) of patients with haemorrhoidal disease." }, { "field": "intervention", "quote": "Transanal heamorrhoidal dearterialization (THD) is a treatment modality for heamorrhoidal disease in which a Doppler transducer is used to locate the supplying arteries that are subsequently ligated." }, { "field": "comparator", "quote": "Patient symptoms, demographics and QOL were recorded preoperatively and 1-month post-operatively following THD using the medical outcomes study short-form-36 (SF-36)." }, { "field": "primaryOutcome", "quote": "The aim of this study was to assess symptoms and QOL changes following THD." }, { "field": "result", "quote": "One month following THD symptoms of haemorrhoid protrusion, bleeding, anal pain, painful defaecation, constipation and tenesmus, had all significantly reduced (P <0.05)." }, { "field": "followUp", "quote": "1-month post-operatively following THD" } ] }, { "id": "pmid:23775515", "pmid": "23775515", "doi": "10.1007/s00268-013-2124-4", "nctId": null, "pmcid": null, "title": "A randomized, prospective, double-blind, placebo-controlled trial of the effect of diltiazem gel on pain after hemorrhoidectomy", "firstAuthor": "Sugimoto", "multipleAuthors": true, "journal": "World J Surg", "year": 2013, "design": "rct", "n": 62, "nField": "reported", "population": "Adults who had surgery to remove hemorrhoids", "intervention": "Diltiazem gel applied to the anal area after hemorrhoid surgery", "comparator": "Placebo gel", "primaryOutcome": "Pain level during bowel movements and amount of pain medication used", "result": "Pain during defecation and pain medication use were lower with diltiazem but the difference was not statistically significant", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "It was a well-designed blinded trial but small, and its main pain results did not reach statistical significance.", "directness": "indirect", "limitations": "Small sample size (62 patients), results for pain and medication use did not reach statistical significance, and total complications were higher in the treatment group.", "followUp": "14 days", "plainFinding": "No clear pain benefit after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23775515/", "sourceText": "BACKGROUND: Spasm of the internal anal sphincter is considered to be one of the causes of pain in anal diseases. We have evaluated the effects of topical diltiazem on postoperative pain after hemorrhoidectomy. METHODS: Sixty-two patients were randomly assigned to receive a 2 % diltiazem gel (n = 32) or a placebo gel (n = 30) after hemorrhoidectomy. Patients applied the gel to the anal region three times per day for 14 days. Pain both in the resting state and on defecation ranged from 0 to 10 on a numerical rating scale, and the number of prescribed loxoprofen tablets (Loxonin) were recorded and confirmed daily by telephone. Any morbidity during the follow-up period was recorded. RESULTS: Both pain scores during defecation and the number of analgesic tablets consumed tended to be lower in the diltiazem group, although they did not reach statistical significance (P = 0.09, P = 0.12, respectively). Total number of complications was significantly higher in the diltiazem group, but each incidence of complications, including itching sensation, headache, and dizziness was not statistically different. CONCLUSIONS: Perianal application of 2 % diltiazem gel after hemorrhoidectomy has the potential to reduce postoperative pain during defecation.", "provenance": [ { "field": "population", "quote": "Sixty-two patients were randomly assigned to receive a 2 % diltiazem gel (n = 32) or a placebo gel (n = 30) after hemorrhoidectomy." }, { "field": "intervention", "quote": "a 2 % diltiazem gel" }, { "field": "comparator", "quote": "a placebo gel" }, { "field": "primaryOutcome", "quote": "Pain both in the resting state and on defecation ranged from 0 to 10 on a numerical rating scale, and the number of prescribed loxoprofen tablets (Loxonin) were recorded" }, { "field": "result", "quote": "Both pain scores during defecation and the number of analgesic tablets consumed tended to be lower in the diltiazem group, although they did not reach statistical significance (P = 0.09, P = 0.12, respectively)." }, { "field": "n", "quote": "Sixty-two patients were randomly assigned to receive a 2 % diltiazem gel (n = 32) or a placebo gel (n = 30)" } ] }, { "id": "pmid:23737323", "pmid": "23737323", "doi": "10.1007/s13304-013-0217-0", "nctId": null, "pmcid": null, "title": "Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial", "firstAuthor": "de Rosa", "multipleAuthors": true, "journal": "Updates Surg", "year": 2013, "design": "rct", "n": 142, "nField": "reported", "population": "people with chronic anal fissure (tear in anal lining with painful bowel movements) lasting at least 2 months, with tight anal sphincter muscle", "intervention": "surgery to cut part of the internal anal sphincter muscle (lateral internal sphincterotomy)", "comparator": "topical nifedipine ointment applied with a warm anal dilator twice daily for 4 weeks", "primaryOutcome": "complete healing of the fissure at 8 weeks, and pain after bowel movements", "result": "more surgery patients healed by 8 weeks (88.2% vs 68.9%) and fewer reported pain after defecation, pain at 3 days, and pain at 7 days compared with the ointment group", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial comparing two treatments directly, but it did not include a placebo-only group and relied on patient-reported pain scales.", "directness": "direct", "limitations": "no mention of blinding; outcomes relied on self-reported pain scores; no long-term follow-up beyond 8 weeks reported", "followUp": "8 weeks", "plainFinding": "Surgery healed fissures faster, less pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23737323/", "sourceText": "Anal fissure is a tear in the lining of the anal canal distal to the dentate line, which most commonly occurs in the posterior midline. Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion. One hundred and forty-two consecutive patients with a chronic anal fissure with hypertonicity of internal sphincter on proctological examination were selected for this study from October 2008 to October 2010. Patients enrolled for the study were randomized to two groups by using a computer-generated list. Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia. Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks. Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure. All patients were required to record pain after the first defecation, on 3rd and 7th postoperative day on a self-administered VAS scale in cm (0-10). Sixty-eight patients were randomly assigned to LIS, 74 to the conservative approach. Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077. As regards post-operative pain, 43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless. In the topical nifedipine group 43 (58.1 %) after 3 days since treatment and 35 (47.3 %) after 7 days had pain. In the LIS group 22 (32.3 %) after 3 days and 9 (13.2 %) after 7 days referred pain. There was no statistical difference between LIS and topical nifedipine group concerning side effects. Lateral internal sphincterotomy is an effective, less painful, fast recovery treatment for chronic anal fissure. Incontinence rate is overestimated and often the fear of a continence disturbance, albeit with a low incidence following surgery, may obscure the need to relieve symptoms which may be so severe as to make the patient's life intolerable.", "provenance": [ { "field": "n", "quote": "One hundred and forty-two consecutive patients with a chronic anal fissure" }, { "field": "population", "quote": "Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion." }, { "field": "intervention", "quote": "Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia." }, { "field": "comparator", "quote": "Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks." }, { "field": "primaryOutcome", "quote": "Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure." }, { "field": "result", "quote": "Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077." }, { "field": "result", "quote": "43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless" } ] }, { "id": "pmid:23711288", "pmid": "23711288", "doi": "10.1111/codi.12303", "nctId": null, "pmcid": null, "title": "Dearterialization with mucopexy versus haemorrhoidectomy for grade III or IV haemorrhoids: short-term results of a double-blind randomized controlled trial", "firstAuthor": "Denoya", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2013, "design": "rct", "n": 40, "nField": "reported", "population": "adults with grade III or IV hemorrhoids (enlarged, prolapsing hemorrhoidal tissue)", "intervention": "a procedure called dearterialization with mucopexy (using Doppler guidance to tie off hemorrhoid blood vessels and lift tissue back into place)", "comparator": "standard hemorrhoidectomy (surgical removal of hemorrhoids)", "primaryOutcome": "pain after the procedure, measured with a pain inventory score", "result": "dearterialization caused less pain, shorter operative time, earlier first bowel movement, and less need for pain medication than hemorrhoidectomy, though symptom relief was similar by 3 months", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "this was a well-designed double-blind randomized trial, but it was small (40 patients) and from a single hospital, so results may not generalize widely.", "directness": "indirect", "limitations": "small sample size, single-center study, only short-term follow-up reported, and it compares two specific surgical techniques rather than addressing general post-bowel-movement anal pain", "followUp": "3 months", "plainFinding": "Less pain after hemorrhoid surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23711288/", "sourceText": "AIM: There is scepticism regarding anatomical rationale and Doppler guidance for ligation of haemorrhoidal arteries. The null hypothesis of this randomized controlled trial (RCT) was that there is no difference in pain following dearterialization or haemorrhoidectomy for grade III/IV internal haemorrhoids in a minimum of three quadrants. METHOD: This was a single-centre, double-blind RCT. Patients were allocated to dearterialization or haemorrhoidectomy. Included haemorrhoids were grade III, prolapsing but reducible; and grade IV, chronic non-incarcerated. The primary end-point was pain. Patients with external component, acute incarcerated grade IV or recurrent haemorrhoids were not included. The interventions were dearterialization (with Doppler guidance and mucopexy) or haemorrhoidectomy. The main outcome measure was the Brief Pain Inventory (BPI). RESULTS: Twenty dearterialization patients were comparable to 20 haemorrhoidectomy patients for age (P = 0.107), body mass index (P = 0.559), race (P = 0.437), American Society of Anesthesiology score (P = 0.569), comorbidities (P = 0.592), grade (P = 0.096), quadrants (P = 0.222), Fecal Incontinence Quality-of-Life Score (FIQOL; P = 0.388), coping (P = 0.532), depression (P = 0.505), embarrassment (P = 0.842), and Short Form Health Survey (SF-12) physical components (P = 0.337), SF-12 mental components (P = 0.396) and constipation (P = 0.628) scores. Dearterialization patients had shorter operative time (36 vs 54 min, P = 0.043) with less pain (P = 0.011) and urinary retention (P = 0.012). Dearterialization patients had first bowel movement earlier (1.3 vs 4.6 days, P = 0.001), less pain (P = 0.011) and lower pain intensity (P = 0.001). Narcotic requirements were reduced in dearterialization patients (25% vs 100%, P = 0.001), with less medication (4.9 vs 112 pills, P = 0.001) and shorter regimen (0 vs 7 days, P = 0.001). BPI did not differ on days 1, 3, 5, 7 and 14 except for less pain in dearterialization patients. At 3 months, symptomatic relief was the same with no differences in BPI, FIQOL or SF-12. CONCLUSION: Compared with haemorrhoidectomy, dearterialization led to less pain in grade III/IV haemorrhoids.", "provenance": [ { "field": "n", "quote": "Twenty dearterialization patients were comparable to 20 haemorrhoidectomy patients" }, { "field": "population", "quote": "Included haemorrhoids were grade III, prolapsing but reducible; and grade IV, chronic non-incarcerated." }, { "field": "intervention", "quote": "dearterialization (with Doppler guidance and mucopexy)" }, { "field": "comparator", "quote": "haemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "The primary end-point was pain." }, { "field": "result", "quote": "Dearterialization patients had shorter operative time (36 vs 54 min, P = 0.043) with less pain (P = 0.011) and urinary retention (P = 0.012)." }, { "field": "result", "quote": "At 3 months, symptomatic relief was the same with no differences in BPI, FIQOL or SF-12." } ] }, { "id": "pmid:23229850", "pmid": "23229850", "doi": "10.1007/s00268-012-1895-3", "nctId": null, "pmcid": null, "title": "Efficacy of cholestyramine ointment in reduction of postoperative pain and pain during defecation after open hemorrhoidectomy: results of a prospective, single-center, randomized, double-blind, placebo-controlled trial", "firstAuthor": "Ala", "multipleAuthors": true, "journal": "World J Surg", "year": 2013, "design": "rct", "n": 91, "nField": "reported", "population": "patients with third and fourth degree hemorrhoids undergoing open hemorrhoidectomy", "intervention": "cholestyramine ointment (15%) applied after surgery", "comparator": "placebo ointment given the same way after surgery", "primaryOutcome": "pain at rest and pain during pooping, and need for pain medication", "result": "cholestyramine reduced pain and pain during defecation, and reduced need for pain medication compared to placebo", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "this was a randomized, double-blind, placebo-controlled trial but with a modest number of patients from a single center.", "directness": "indirect", "limitations": "small single-center trial; applies specifically to pain after hemorrhoid surgery, not general pain after bowel movements in people without hemorrhoid surgery.", "followUp": "14 days", "plainFinding": "Less pain after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23229850/", "sourceText": "BACKGROUND: The aim of the present study was to evaluate the efficacy of cholestyramine ointment (15 %) in reducing postoperative pain at rest and during defecation after open hemorrhoidectomy. METHODS: A total of 91 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 cholestyramine ointment or placebo immediately after surgery, 12 h after surgery, and then every 8 h for 14 days. 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 tramadol consumption. RESULTS: The cholestyramine group had less postoperative pain than the placebo group at the 24th hour (1.84 ± 2.54 vs. 4.07 ± 3.35; P = 0.001) and 48th hour (0.18 ± 0.88 vs. 3.57 ± 3.45; P < 0.001) and less pain during defecation starting at the 48th hour (2.28 ± 2.96 vs. 4.77 ± 4.09; P = 0.001). Similarly, the average tramadol consumption at hours 24 and 48 was significantly lower for the cholestyramine group (5.32 ± 21.45 vs. 43.18 ± 61.56 mg at 24 h, and 4.48 ± 16.65 vs. 57.63 ± 65.47 mg at 48 h; P < 0.001). The only adverse event was pruritus, which had a lower frequency in the cholestyramine group but the difference was not significant until postoperative week 4 (P < 0.001). CONCLUSIONS: Compared with placebo, cholestyramine ointment (15%) reduced postoperative pain at rest and on defecation, and consequently lowered the analgesic requirement after open hemorrhoidectomy.", "provenance": [ { "field": "population", "quote": "A total of 91 patients with third and fourth degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial." }, { "field": "intervention", "quote": "The patients were randomly assigned to either cholestyramine ointment or placebo immediately after surgery, 12 h after surgery, and then every 8 h for 14 days." }, { "field": "comparator", "quote": "The patients were randomly assigned to either cholestyramine ointment or placebo immediately after surgery, 12 h after surgery, and then every 8 h for 14 days." }, { "field": "primaryOutcome", "quote": "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 tramadol consumption." }, { "field": "result", "quote": "The cholestyramine group had less postoperative pain than the placebo group at the 24th hour (1.84 ± 2.54 vs. 4.07 ± 3.35; P = 0.001) and 48th hour (0.18 ± 0.88 vs. 3.57 ± 3.45; P < 0.001) and less pain during defecation starting at the 48th hour (2.28 ± 2.96 vs. 4.77 ± 4.09; P = 0.001)" }, { "field": "n", "quote": "A total of 91 patients with third and fourth degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial." } ] }, { "id": "pmid:23140829", "pmid": "23140829", "doi": "10.1016/j.amjsurg.2012.01.014", "nctId": null, "pmcid": null, "title": "Long-term results and quality of life in patients treated with hemorrhoidectomy using two different techniques: Ligasure versus transanal hemorrhoidal dearterialization", "firstAuthor": "Zampieri", "multipleAuthors": true, "journal": "Am J Surg", "year": 2012, "design": "rct", "n": 114, "nField": "reported", "population": "adults having surgery to remove hemorrhoids", "intervention": "hemorrhoid removal surgery using a sealing device called Ligasure", "comparator": "hemorrhoid removal surgery using a technique called transanal hemorrhoidal dearterialization (THD)", "primaryOutcome": "quality of life, quality of bowel movements, and symptom improvement after surgery", "result": "THD patients had faster pain resolution, while Ligasure patients had more constipation after surgery", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small randomized study comparing two surgical techniques, not addressing typical post-bowel-movement anal pain in the general population.", "directness": "indirect", "limitations": "Small number of patients, and findings apply only to people who had surgical hemorrhoid removal, not to general anal pain after defecation.", "followUp": "1 year", "plainFinding": "Faster pain relief with one surgery type.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23140829/", "sourceText": "BACKGROUND: Hemorrhoids are the most frequent anal pathology. We evaluated the results of 2 techniques at 1 year after surgery. METHODS: The clinical charts and data of patients who underwent hemorrhoidectomy between January 2008 and June 2010 were considered and analyzed. Patients underwent surgery with 2 techniques: transanal hemorrhoidal dearterialization (THD) hemorrhoidectomy or LigaSure-vessel sealing system (Valleylab, Boulder, CO). Patients were chosen randomly to receive one technique or the other. The primary objectives were quality of life, quality of defecation, and regression of symptoms. RESULTS: Forty-six patients treated with THD and 68 patients treated with Ligasure were enrolled in the study. No significant differences were observed in the rate of postoperative surgical complications or readmissions. Short- and medium-term (1-6 mo) results showed that THD patients had a higher rate of pain resolution compared with Ligasure patients (P < .05). Functionally, all patients treated with Ligasure showed more postoperative constipation despite administration of laxatives than patients treated with THD. CONCLUSIONS: THD is an effective technique and is associated with the best short-term clinical and surgical outcomes if compared with Ligasure.", "provenance": [ { "field": "n", "quote": "Forty-six patients treated with THD and 68 patients treated with Ligasure were enrolled in the study." }, { "field": "population", "quote": "Patients who underwent hemorrhoidectomy between January 2008 and June 2010 were considered and analyzed." }, { "field": "intervention", "quote": "LigaSure-vessel sealing system (Valleylab, Boulder, CO)" }, { "field": "comparator", "quote": "transanal hemorrhoidal dearterialization (THD) hemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "The primary objectives were quality of life, quality of defecation, and regression of symptoms." }, { "field": "result", "quote": "THD patients had a higher rate of pain resolution compared with Ligasure patients (P < .05)." }, { "field": "result", "quote": "Functionally, all patients treated with Ligasure showed more postoperative constipation despite administration of laxatives than patients treated with THD." }, { "field": "followUp", "quote": "at 1 year after surgery" } ] }, { "id": "pmid:22983551", "pmid": "22983551", "doi": "10.1007/s10151-012-0894-6", "nctId": null, "pmcid": null, "title": "Ano-coccygeal support in the treatment of idiopathic chronic posterior anal fissure: a prospective non-randomised controlled pilot trial", "firstAuthor": "Gee", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2013, "design": "prospective-cohort", "n": 53, "nField": "reported", "population": "adults with long-lasting (chronic) anal fissures", "intervention": "a cushioned ano-coccygeal support device attached to the toilet seat", "comparator": "standard surgery (lateral internal sphincterotomy)", "primaryOutcome": "fissure healing, bleeding resolution and pain scores after treatment", "result": "both treatments healed all fissures with no significant difference in bleeding resolution, pain scores or time to healing", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "this was a small pilot study where patients chose their own treatment group rather than being randomly assigned, so the comparison is weak.", "directness": "direct", "limitations": "non-randomised design with patient self-selection into groups, small sample size, described by the authors as a pilot trial needing larger randomised trials", "followUp": "6 months", "plainFinding": "Comparable relief to surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22983551/", "sourceText": "BACKGROUND: Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure. METHODS: Fifty-three patients with confirmed chronic anal fissures were enrolled and assigned, based on their preference, to the test group and the control group. Each patient was reviewed after therapy, and follow-up was scheduled at 4, 6 and 8 weeks and at 6 months. RESULTS: The fissure healing rate was 100% in both groups. There were no statistically significant differences between the test group (n = 30, median age 42 years; range 20-71 years) and the control group (n = 22, median age 38 years; range 23-60 years) with regards to resolution of rectal bleeding at defaecation after 4 weeks (86.6 vs. 72.7%, p = 0.698), and by week 6, bleeding had resolved in 100% of patients in both groups. There was no statistically significant difference between the test group and the control group with regards to pain scores at 4, 6 and 8 weeks (4.30 ± 0.79, 2.03 ± 0.80, 0.43 ± 0.50 vs. 3.50 ± 0.74, 1.68 ± 0.56, 0.50 ± 0.51, p = 0.054) and to time until complete healing of fissures (5.60 ± 1.52 weeks vs. 5.91 ± 1.57 weeks, p = 0.479). After continuous use of the ano-coccygeal support over 6 months, no patients in the test group had recurrent fissures. No complications were observed during the trial. CONCLUSIONS: Results of both methods were comparable and demonstrated that the ano-coccygeal support is at least as effective as LIS, without any short-term complications. Larger and randomised trials on the use of ano-coccygeal support for chronic anal fissures are awaited.", "provenance": [ { "field": "n", "quote": "Fifty-three patients with confirmed chronic anal fissures were enrolled" }, { "field": "population", "quote": "Fifty-three patients with confirmed chronic anal fissures were enrolled" }, { "field": "intervention", "quote": "a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec)" }, { "field": "comparator", "quote": "the standard procedure of lateral internal sphincterotomy (LIS)" }, { "field": "primaryOutcome", "quote": "resolution of rectal bleeding at defaecation after 4 weeks" }, { "field": "primaryOutcome", "quote": "pain scores at 4, 6 and 8 weeks" }, { "field": "result", "quote": "The fissure healing rate was 100% in both groups." }, { "field": "result", "quote": "There was no statistically significant difference between the test group and the control group with regards to pain scores at 4, 6 and 8 weeks" }, { "field": "followUp", "quote": "follow-up was scheduled at 4, 6 and 8 weeks and at 6 months" } ] }, { "id": "pmid:22851840", "pmid": "22851840", "doi": "10.1007/s12262-011-0239-0", "nctId": null, "pmcid": "PMC3144351", "title": "Comparative study of glyceryl trinitrate ointment versus surgical management of chronic anal fissure", "firstAuthor": "Tauro", "multipleAuthors": true, "journal": "Indian J Surg", "year": 2011, "design": "prospective-cohort", "n": 90, "nField": "reported", "population": "adults with chronic anal fissure causing pain and bleeding during bowel movements", "intervention": "0.2% glyceryl trinitrate (GTN) ointment applied to the anus", "comparator": "surgical treatment (fissurectomy with lateral or posterior internal sphincterotomy)", "primaryOutcome": "relief of pain and bleeding during defecation and healing of the fissure", "result": "Both GTN ointment and surgical sphincterotomy relieved pain and healed fissures, but surgery was recommended for patients who did not respond to GTN, suggesting surgery may be more reliably effective while GTN serves as a good alternative for those avoiding surgery", "resultDirection": "mixed", "quality": "low", "qualityWhy": "small groups of only 30 patients each, not clearly randomized, and no statistical comparison data given between groups.", "directness": "direct", "limitations": "No randomization described, no statistical significance reported between treatment arms, and short follow-up of only 12 weeks.", "followUp": "12 weeks", "plainFinding": "Both GTN and surgery relieve pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22851840/", "sourceText": "Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.", "provenance": [ { "field": "n", "quote": "Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy" }, { "field": "population", "quote": "Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity." }, { "field": "intervention", "quote": "A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm." }, { "field": "comparator", "quote": "fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS)" }, { "field": "primaryOutcome", "quote": "regarding symptoms like pain and bleeding during defecation, healing of CAF" }, { "field": "result", "quote": "Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment." } ] } ], "faqs": [ { "q": "Why does it hurt to sit on my butt after pooping?", "a": "In these studies, sharp pain that lingers after a bowel movement was most often linked to an anal fissure, a small tear in the lining of the anus. Trials found that creams like diltiazem or nifedipine healed most of these within weeks." }, { "q": "Why does anal hurt but pooping doesn't?", "a": "One guideline in this review notes that hemorrhoids usually don't cause pain unless a clot has formed inside them, so ongoing pain not tied to the act of passing stool may point to something other than typical hemorrhoids. This wasn't tested in a formal trial, so it's not a sure answer." }, { "q": "What to do when your anus hurts while pooping?", "a": "Trials found that more fiber and fluids, warm water (sitz) baths, and over-the-counter or prescription creams eased pain and healed most fissures within weeks. See a doctor if the pain lasts more than a couple of weeks, or if there's a lump or bleeding, since rare but serious causes have been reported behind what looked like ordinary hemorrhoids." }, { "q": "Is it hemorrhoids or an anal fissure?", "a": "A guideline included here says fissures usually cause sharp pain during or right after passing stool, while hemorrhoids mostly cause pain only if a clot has formed. But a separate study found that symptoms often don't match what's actually found on examination, so this can't be reliably self-diagnosed." }, { "q": "Should I just treat it myself, or should I see a doctor instead?", "a": "Most cases in these trials improved with simple conservative care — fiber, sitz baths, and topical creams — so trying those first is reasonable. But see a doctor rather than continuing to self-treat if pain lasts more than a couple of weeks, there's a lump, or you notice bleeding, because case reports found rare but serious causes, including a cancer, mistaken for ordinary hemorrhoids." } ], "searchedAs": [ "why does it hurt to sit on my butt after pooping", "why does my anus hurt so bad after pooping", "why does my butt hurt when i poop", "why does my butthole hurt after pooping", "why does my anus hole hurt after i poop", "why does anal hurt but pooping doesnt", "what to do when your anus hurts while pooping", "why everytime i poop my anus hurts" ], "patientTakeaway": "In these studies, the most common reason for sharp pain after a bowel movement was an anal fissure, a small tear that often heals within weeks using fiber, warm water soaks, and prescription creams. Hemorrhoids themselves usually only cause ongoing pain if a clot has formed inside them. See a doctor if the pain lasts more than a couple of weeks, if there's a lump, or if you notice bleeding — rare but serious conditions have been found behind what looked like ordinary hemorrhoids.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Fissure in Ano\"[Mesh] OR \"Hemorrhoids\"[Mesh] OR anal fissure OR hemorrhoid*) AND (\"Defecation\"[Mesh] OR defecation OR bowel movement) AND (pain[Title/Abstract] OR \"Pain\"[Mesh])" }, "pubmedQueryTranslation": "(\"Fissure in Ano\"[MeSH Terms] OR \"Hemorrhoids\"[MeSH Terms] OR (\"Fissure in Ano\"[MeSH Terms] OR (\"fissure\"[All Fields] AND \"ano\"[All Fields]) OR \"Fissure in Ano\"[All Fields] OR (\"anal\"[All Fields] AND \"fissure\"[All Fields]) OR \"anal fissure\"[All Fields]) OR \"hemorrhoid*\"[All Fields]) AND (\"Defecation\"[MeSH Terms] OR (\"defaecate\"[All Fields] OR \"defaecated\"[All Fields] OR \"defaecating\"[All Fields] OR \"defaecation\"[All Fields] OR \"Defecation\"[MeSH Terms] OR \"Defecation\"[All Fields] OR \"defaecations\"[All Fields] OR \"defecate\"[All Fields] OR \"defecated\"[All Fields] OR \"defecates\"[All Fields] OR \"defecating\"[All Fields] OR \"defecations\"[All Fields] OR \"defecational\"[All Fields]) OR (\"Defecation\"[MeSH Terms] OR \"Defecation\"[All Fields] OR (\"bowel\"[All Fields] AND \"movement\"[All Fields]) OR \"bowel movement\"[All Fields])) AND (\"Pain\"[Title/Abstract] OR \"Pain\"[MeSH Terms])", "searchedOn": "2026-10-13", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. 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