Pudendal Nerve Block in Hemorrhoid Surgery: A Systematic Review and Meta-analysis

Effectiveness of pudendal nerve block in the management of acute post-haemorrhoidectomy pain in Asian individuals using inverse probability of treatment weighting (IPTW)

BACKGROUND

Inadequate management of acute post-haemorrhoidectomy pain is a major concern. Optimal pain management is necessary to reduce acute postoperative pain and improve care quality. Therefore, we investigated the efficacy of postoperative pudendal nerve block (PNB) in reducing acute post-haemorrhoidectomy pain in Asian individuals.

METHODS

This retrospective cohort study analysed 108 adult patients with grade 3 haemorrhoids. Patients with anorectal cancer were excluded from this study. Among the 108 patients, 79 and 29 received spinal anaesthesia (SA) with PNB (SAPNB) and SA alone, respectively. Propensity score matching and inverse probability of treatment weighting were performed to adjust for the effects of confounders.

RESULTS

Patients receiving SAPNB had significantly lower postoperative pain scores 6, 12, and 18 h after haemorrhoidectomy but significantly higher postoperative pain scores 24 and 48 h after haemorrhoidectomy than did patients receiving SA alone. PNB, older age, female sex, reduced operation time, and absence of cardiovascular disease reduced the risk of moderate to severe postoperative pain. Only the addition of PNB was consistently associated with a reduced risk of moderate to severe pain 6, 12, and 18 h after haemorrhoidectomy. Patients receiving SAPNB had significantly lower risks of perianal swelling and urinary retention but a significantly higher risk of nausea than did those receiving SA alone. The two groups exhibited similarity in their rates of postoperative readmission because of poor pain management and their lengths of stay upon readmission.

CONCLUSION

The addition of PNB to SA may effectively reduce acute post-haemorrhoidectomy pain.

Does the addition of perineal block enhance pain control after a haemorrhoidectomy? A prospective randomized, double-blind placebo-controlled study

BACKGROUND

Haemorrhoidectomy is associated with severe postoperative pain, a long rehabilitation, and QoL worsening for months. Most patients experience mild-to-moderate postoperative pain. We aimed to evaluate the intraoperative perineal block role for patients undergoing haemorrhoidectomy.

METHODS

In this prospective randomized, double-blind, placebo-controlled study, eligible patients with III-IV stage haemorrhoids were randomized to the experimental group (EG) with intraoperative perineal block and spinal anaesthesia and the control one (CG) only with spinal anaesthesia. During the postoperative period, the opioid consumption rate was evaluated as a primary endpoint, and the postoperative pain level according to VAS, systemic analgesics consumption, readmission, and complication rate, the timing of returning to work, patients' QoL, and overall satisfaction according to SF-36 were evaluated as secondary endpoints.

RESULTS

One hundred patients completed the study (48 in EG and 52 in CG). Patients of the EG had less postoperative pain intensity (P < 0.0001), required less opioid analgesia (P = 0.03), and had longer pain-free postoperative periods (P = 0.0002). 90% of patients in the CG required additional NSAID injections for adequate analgesia compared with only 58% in the EG. The average hospital stays, complication rate, and average operation duration didn't reach clinical significance. General health evaluation according to the SF-36 score and the median satisfaction rate was better in the EG (P < 0.001 and P = 0.012, respectively).

CONCLUSIONS

The administration of the perianal block is safe and effective and should be administered to appropriate patients undergoing anorectal surgery.

Management of Hemorrhoids and Anal Fissures

Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.

Protocol of a clinical trial on the effectiveness of pudendal nerve block with and without neurostimulation in reducing posthemorroidectomy pain

INTRODUCTION

Hemorrhoidal pathology is the most frequent proctological problem with a prevalence of 44% of the adult population. The most effective treatment is surgery but it also has the highest postoperative pain rate with moderate to severe pain rates of 30-40% during the first 24-48 hours. Here lies the importance of seeking measures to improve this situation, such as the pudendal nerve block with local anesthetic. However, the variability of the pudendal nerve sometimes makes its blockade ineffective and for this reason nerve location methods are sought to achieve a higher rate of success. The main aim of the study is to compare pain in the immediate postoperative period (24 h) after hemorrhoidectomy in patients with pudendal nerve block guided by anatomical references and guided by neurostimulation.

METHODS

The present project proposes the performance of a single-center, triple-blind, randomized clinical trial of efficacy, carried out under conditions of routine clinical practice. Patients over 18 years old with hemorrhoids refractory to medical treatment, symptomatic grade III-IV and grade II hemorrhoids that do not respond to conservative procedures in a third level hospital in Spain and that are subsidiaries of surgery in major ambulatory surgery will be included. Demographic variables, variables on hemorrhoidal pathology, details of surgery, verbal numeric pain scale in the preoperative period and surgical complications will be collected.

RESULTS

Not avaliable until the end of the study.

CONCLUSIONS

The pudendal nerve block guided by anatomical landmarks has been shown to be useful in postoperative pain control after hemorrhoidectomy although the use of the neurostimulator has not been well studied and we believe it may improve outcom.

Pudendal nerve block decreases narcotic requirements and time spent in post-anesthesia care units in patients undergoing primary inflatable penile prosthesis implantation

Efforts to minimize narcotic usage following inflatable penile prosthesis (IPP) implantation are vital, considering the current opioid epidemic in the United States. We aimed to determine whether pudendal nerve block (PNB) utilization in a multiethnic population undergoing primary IPP implantation can decrease rates of post-operative opiate usage. A single-institution, retrospective study was conducted on patients who underwent primary IPP implantation between December 2015 and June 2022. PNB usage and intra- and post-operative outcomes were analyzed using multivariate binary logistic regression. 449 patients were included, with 373 (83.1%) in the PNB group. Median time (minutes) spent in the post-anesthesia care unit (PACU) (1499 [119-198] vs. 235 [169-322], p < 0.001) was significantly lower in the PNB group. There were no significant differences in intra-operative and PACU morphine milligram equivalents or post-operative safety outcomes between groups. However, fewer patients in the PNB group called for pain medications post-operatively (10.2% vs 19.7%, p = 0.019). Multivariate analysis revealed a significantly decreased operative time (B -6.23; 95%CI -11.28, -1.17; p = 0.016) and decreased time in recovery (B: -81.62; 95%CI: -106.49, -56.76, p < 0.001) in the PNB group. PNB decreases post-operative opioid analgesic requirements and time spent in PACU in patients undergoing a primary IPP implantation and thus may represent an attractive, non-opioid adjunct.

Use of pudendal nerve blocks in rubber band ligation of haemorrhoids: an Australia-wide cross-sectional analysis

BACKGROUND

Surgeons vary in their approach to preventing pain post rubber band ligation (RBL) of haemorrhoids, with pudendal nerve blocks (PNB) being one analgesic strategy. No data exists on how commonly PNBs are used in RBL in Australia, and whether use varies by year and patient and hospital characteristics.

METHODS

Aggregate data from the National Hospital Morbidity Database was obtained for all admissions for RBL in Australia from 2012 to 2021, with and without a PNB, overall and in relation to sex, age group, hospital remoteness, hospital sector, and year of procedure. Adjusted relative risks (adj. RR) of PNB were estimated using Poisson regression, mutually adjusting for all variables.

RESULTS

Of the 346 542 admissions for RBL, 14013 (4.04%) involved a PNB. The proportion of patients receiving a PNB increased between 2012-2013 and 2020-2021, from 1.62% to 6.63% (adj. RR 3.99, CI 3.64-4.36). Patients most likely to receive a PNB were female (adj. RR 1.10; CI 1.07-1.14) aged 25-34 years (adj. RR 1.13; CI 1.01-1.26); in major-city (adj. RR 1.25 CI 1.20-1.30) and private hospitals (adj. RR 3.28 CI 3.13-3.45).

CONCLUSION

This is the first published analysis of the use of PNB in RBL. Pudendal nerve block use has increased over time, with substantial variation in practice. Blocks were more than three times as likely to be used in private compared to public hospitals. If evidence supporting PNB use is established, equitable access to the procedure should be pursued.

Analgesic effect of local anaesthetic in haemorrhoid banding: systematic review and meta-analysis

PURPOSE

Rubber band ligation of haemorrhoids can be,painful and there is no consensus regarding the optimal analgesic strategy. This study aims to determine whether there is a difference in post-procedural pain in adults undergoing haemorrhoid banding who have received local anaesthetic, a pudendal nerve block or no regional or local analgesia.

METHODS

MEDLINE, Embase, Google Scholar and clinical trial registries were searched for randomised trials of local anaesthetic or pudendal nerve block use in banding. Primary outcomes were patient-reported pain scores. The quality of the evidence was assessed using the GRADE approach.

RESULTS

Seven studies were included in the final review. No articles were identified that studied pudendal nerve blocks. The difference in numerical pain scores between treatment groups favoured the local anaesthetic group at all timepoints. The mean difference in scores on a 10-point scale was at 1 h,-1.43 (95% CI-2.30 to-0.56, p < 0.01, n = 342 (175 in treatment group)); 6 h,-0.52 (95% CI-1.04 to 0.01, p = 0.05, n = 250 (130 in treatment group)); and 24 h,-0.31 (95% CI-0.82 to 0.19, p = 0.86, n = 247 (127 in treatment group)). Of reported safety outcomes, vasovagal symptoms proceeded to meta-analysis, with a risk ratio of 1.01 (95% CI 0.64-1.60). The quality of the evidence was rated down to 'low' due to inconsistency and imprecision.

CONCLUSION

This review supports the use of LA for reducing early post-procedural pain following haemorrhoid banding. The evidence was limited by small sample sizes and substantial heterogeneity across studies.

REGISTRATION

PROSPERO (ID CRD42022322234).

The role of pudendal nerve block in hemorrhoid surgery: a systematic review and meta-analysis of double-blind randomized controlled trials

Background

Pudendal nerve block (PNB) is a commonly used anesthesia method that has been widely used in postoperative analgesia for hemorrhoids in recent years. Therefore, we conducted a systematic review and meta-analysis of double-blind randomized controlled trials (RCTs) to analyze the effectiveness of PNB in postoperative analgesia for hemorrhoids.

Methods

Relevant data and studies published from inception until August 14, 2023, were retrieved from PubMed, Embase, and Web of Science to evaluate the beneficial effects of PNB for analgesia following hemorrhoidectomy.

Results

This meta-analysis included 6 double-blind RCTs comprising 501 patients. We evaluated the function of PNB in improving outcomes of postoperative analgesia of hemorrhoids. Visual analogue scale (VAS) scores on postoperative within 6 h (MD, -3.04; 95% CI, -4.13 to -1.95; P < 0.0001), 12 h (MD, -3.14; 95% CI, -3.87 to -2.40; P < 0.0001), and 24 h (MD, -2.25; 95% CI, -2.95 to -1.55; P < 0.0001) were enhanced by the application of PNB, but not in 48 h (MD, -2.54; 95% CI, -5.29 to 0.20; P = 0.07).

Conclusion

Pudendal nerve block (PNB) could effectively relieve postoperative pain of hemorrhoids. However, our results still need to be confirmed by multi-center clinical studies.

Laparoscopic-Assisted Transversus Abdominis Plane (TAP) Block Versus Port-Site Infiltration with Local Anesthetics in Bariatric Surgery: a Double-Blind Randomized Controlled Trial

BACKGROUND

The transversus abdominis plane (TAP) block has shown great potential usefulness in the management of postoperative pain; however, there is lacking evidence regarding its use in bariatric surgery. This randomized double-blind trial was aimed at comparing the effectiveness of the TAP block and port-site infiltration (PSI) in patients undergoing bariatric surgery.

METHODS

We included patients ≥ 18 years old undergoing bariatric surgery. From July 2020 to July 2021, all eligible patients were randomized to receive either laparoscopic-assisted TAP block or PSI. Demographic and clinical data were collected and analyzed.

RESULTS

During the study period, we included 113 patients. Fifty-one were allocated to the TAP block group and 62 to the PSI group. The mean age was 47.9 ± 11.2 years, 88 (77.9%) patients were female, and mean BMI was 40.5 ± 5.9 kg/m2. Operative time was 110 ± 42 min vs. 114 ± 41 min in the TAP block and PSI groups (p = 0.658). At 24 h after surgery, pain on the VAS was 2.5 ± 2.6 vs. 2.3 ± 2.1 (p = 0.661). No significant difference between the groups was noted at 3, 6, 12, and 18 h. Also, opioid and antiemetic consumption, the length of stay (3.4 ± 1.5 days vs. 3.2 ± 1.1 days, p = 0.392), and satisfaction score (154 ± 10 pts vs. 154 ± 16 pts, p = 0.828) were similar in the two groups.

CONCLUSIONS

Patients undergoing bariatric surgery and receiving either the TAP block or the PSI had similar postoperative pain, nausea, length of stay, and satisfaction. As PSI is technically easier and more reproducible, it might be the first choice for postoperative multimodal analgesia in bariatric surgery.

Local anaesthetic infiltration in rubber band ligation of rectal haemorrhoids: study protocol for a three-arm, double-blind randomised controlled trial (PLATIPUS trial)

INTRODUCTION

Rubber band ligation ('banding') is a common approach for the management of symptomatic haemorrhoids. However, up to 90% of patients experience postprocedural pain, and there is no consensus regarding the optimal analgesic strategy. In practice, patients may receive submucosal local anaesthetic, pudendal nerve block or routine periprocedural analgesia. The aim of this study is to compare the efficacy of submucosal local anaesthetic, pudendal nerve block and routine analgesia for postprocedural pain in patients undergoing haemorrhoid banding.

METHODS AND ANALYSIS

This is a multicentre, prospective, three-arm, double-blind randomised controlled trial of adults booked for haemorrhoid banding. Participants will be randomised to one of three groups in a 1:1:1 ratio: (1)submucosal bupivacaine injection; (2) pudendal nerve ropivacaine injection and (3) no local anaesthetic. The primary outcome is patient reported postprocedural pain (scored 0-10) from 30 min to 2 weeks. Secondary outcomes include postprocedural analgesia use, time to discharge, patient satisfaction, time to return to work and complications. A sample size of 120 patients is required to achieve statistical significance.

ETHICS AND DISSEMINATION

This study received Human Research Ethics Approval from the Austin Health Human Research Ethics Committee (March 2022). Trial results will be submitted to a peer-reviewed journal, and presented at academic meetings. A summary of the trial results will be made available to study participants on request.

TRIAL REGISTRATION NUMBER

ACTRN12622000006741p.

The role of the Rafaelo procedure in the management of hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to summarize the current evidence regarding the role of the Rafaelo procedure in the management of hemorrhoidal disease (HD).

METHODS

This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was performed (Medline, Scopus, CENTRAL, and Web of Science) from inception to 25/09/2022. Grey literature databases were also reviewed. The primary endpoint was the pooled complications rate of the Rafaelo procedure in patients with HD. Secondary endpoints included short- (bleeding, pain, thrombosis, necrosis, urinary retention, fever, oedema, anal fissure, and readmission) and long-term (stenosis, meteorism, constipation, anal tags, anal hyposensibility, reoperation, and recurrence) postoperative complication rates. Both prospective and retrospective studies were considered. Quality evaluation was performed via the ROBINS-I tool. Certainty of Evidence was based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

Overall, 6 non-randomized studies and 327 patients were included. The overall complication rate was 17.6% (95% CI 8.8-26.3%). Short-term complications were bleeding (7.5%, 95% CI 2.5-12.5%), thrombosis (2.2%, 95% CI 0.4-4.8%), and pain (1.6%, 95% CI 0.2-3.3%). Reoperation and recurrence rates were 1.8% (95% CI 0.3-3.4%) and 4.8% (95% CI 1.2-8.4%), respectively. A significant improvement in the presenting symptoms was noted. Method approval and patient satisfaction rates were 89.1% (95% CI 81.7-96.6%) and 95% (95% CI 89.8-100%), correspondingly. Overall CoE was "Very Low".

CONCLUSIONS

Further randomized controlled trials are required to delineate the exact role of the Rafaelo procedure in HD.

Preparation and In Vivo Evaluation of a Lidocaine Self-Nanoemulsifying Ointment with Glycerol Monostearate for Local Delivery

Lidocaine, a commonly used local anesthetic, has recently been developed into a number of ointment products to treat hemorrhoids. This study examined its efficient delivery to the dermis through the pharmaceutical improvement of hemorrhoid treatment ointments. We attempted to increase the amount of skin deposition of lidocaine by forming a nanoemulsion through the self-nanoemulsifying effect that occurs when glycerol monostearate (GMS) is saturated with water. Using Raman mapping, the depth of penetration of lidocaine was visualized and confirmed, and the local anesthetic effect was evaluated via an in vivo tail-flick test. Evaluation of the physicochemical properties confirmed that lidocaine was amorphous and evenly dispersed in the ointment. The in vitro dissolution test confirmed that the nanoemulsifying effect of GMS accelerated the release of the drug from the ointment. At a specific concentration of GMS, lidocaine penetrated deeper into the dermis; the in vitro permeation test showed similar results. When compared with reference product A in the tail-flick test, the L5 and L6 compounds containing GMS had a significantly higher anesthetic effect. Altogether, the self-nanoemulsifying effect of GMS accelerated the release of lidocaine from the ointment. The compound with 5% GMS, the lowest concentration that saturated the dermis, was deemed most appropriate.

Ultrasound-Guided Pudendal Nerve Block in Patients Undergoing Open Hemorrhoidectomy: A Post-Hoc Cost-Effectiveness Analysis from a Double-Blind Randomized Controlled Trial

Background

Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy.

Methods

From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed.

Results

Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482±386 vs 613±543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606±816 vs 2769±1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of −243 ± 881 EUR/pain unit on the VAS.

Conclusion

Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.