Topical versus oral metronidazole for post-haemorrhoidectomy pain: A systematic review and meta-analysis of...

Excisional haemorrhoidectomy is often associated with intense post-operative pain and delayed recovery. Bacterial colonization may contribute to this discomfort, and metronidazole has been proposed as an analgesic adjunct. This study compared the analgesic efficacy of topical metronidazole with oral metronidazole.

A systematic search was conducted in PubMed, Scopus, and the Cochrane Central Register through May 2025. Randomized controlled trials comparing topical metronidazole with oral metronidazole for post-operative pain after haemorrhoidectomy were included. Visual analogue scale (VAS) scores on post-operative days 1, 3, and 7 were pooled. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed with the I² statistic. Risk of bias (RoB 2) and certainty of evidence (GRADE) were evaluated.

Four RCTs involving 439 patients (218 topical, 221 oral) met inclusion criteria. No significant differences were found between topical and oral metronidazole at day 1 (MD -0.1; 95% CI -0.3 to 0.2; I² = 25%), day 3 (MD -0.4; 95% CI -1.3 to 0.6; I² = 94%), or day 7 (MD -0.2; 95% CI -1.0 to 0.5; I² = 90%).

Topical and oral metronidazole showed similar short-term analgesic efficacy after haemorrhoidectomy.