Management of intractable pain in patients treated with hemorrhoidectomy for mixed hemorrhoids

Post-hemorrhoidectomy pain is common, usually temporary, and responsive to analgesics. However, some patients experience prolonged, intractable anal pain, which is refractory to conventional analgesics and adversely effects quality of life. We aimed to evaluate the efficacy of a combination injection containing local anesthesia and steroids for the treatment of intractable post-hemorrhoidectomy anal pain.

This study included five patients with intractable post-hemorrhoidectomy anal pain who presented between July 2015 and November 2018. Milligan-Morgan hemorrhoidectomy (M-M) with a sclerosant injection had been performed in three patients and stapled hemorrhoidectomy (SH) along with external hemorrhoidectomy in two. For the purpose of this study, all patients received local combination injections containing ropivacaine and triamcinolone acetonide. The primary outcome was the visual analogue scale (VAS) score, and secondary outcomes included the Pittsburgh Sleep Quality Index (PSQI) score, adverse reactions, and recurrence.

Prior to treatment, the VAS score was 8 in one patient and 5-7 in four, and the PSQI score was ≥16 in all patients. The injection was administered once (n=4) or twice (n=1). Rapid pain resolution was achieved on the day of treatment (VAS scores 0-3), and patients reported undisturbed sleep the same night. VAS scores were 0-2 (n=4) and 1-3 (n=1), and the PQSI scores were 0-6 (n=4) and 11-15 (n=1) at the 6-month follow-up. No patient reported significant pain or adverse reaction.

Intractable post-hemorrhoidectomy anal pain is rare but significantly effects quality of life. While conventional analgesia may be ineffective, the local injection of anti-inflammatory and analgesic drugs may be a useful treatment strategy.