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Hemorrhoids and perianal pain 233
Furthermore, RCT evidence found that for patients with acute anal fissures
who were taking psyllium fiber laxatives there was no pain improvement from
adding sitz baths for 10 min (once post-defecation in the morning, and once at
night). 2 Patients randomized to sitz baths do have significantly higher satisfaction,
however, and adverse events from sitz baths are both uncommon and
mild (mostly perianal rash). 2 The findings regarding sitz bath use for anal
fissures – marginal pain improvement yet significant increase in patient
satisfaction – are also reported for use of sitz baths post-hemorrhoidectomy. 3
Laxatives are the initial therapy for perianal pain from a variety of conditions.
Cochrane review of seven RCTs found that the evidence, although of
suboptimal quality, consistently indicated a significant and persistent pain
relief advantage from use of fiber-containing (e.g. psyllium) laxatives. 4 Use
of the fiber-containing laxatives halves the chances of continuing hemorrhoid
pain. 4 Given the low side effect rate and frequent symptomatic relief, a
trial of laxatives is appropriate for most patients with perianal pain.
In addition to sitz baths and laxatives, many ED patients are candidates
for astringents such as witch hazel (Hamamelis). 5 These over-the-counter
topical preparations do provide some pain relief, particularly for mild discomfort,
and can be tried if they have not already been used prior to ED
presentation. 6
Given the influence of internal anal sphincter hypertonia on perianal pain,
pharmacologic measures to relieve sphincter tone form the mainstay of drug
therapy for most patients with perianal disorders. The general approaches
most often discussed in the literature are nitroglycerin (glyceryl trinitrate)
and calcium channel blockers. In both cases, the drugs are best administered
locally (i.e. topically) to minimize systemic side effects. Nitroglycerin, the
more traditional therapy, will be discussed first.
Topically applied nitroglycerin (0.2–0.5% ointment) is widely recommended
for pain caused by either anal fissures or thrombosed external hemorrhoids.
7–9 The topical preparation is worth trying even in patients with
advanced external hemorrhoidal disease; response may still occur and nitroglycerin
use can occasionally obviate surgical excision. 10
Compared with the surgical options of excision (not in the ED armamentarium)
and incision, topical nitroglycerin prescription gives the ED provider