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Hemorrhoids and perianal pain 235
Second, healthcare providers should be aware of the significant diversity in
actual concentrations of nitroglycerin in ointments, which are often prepared
by compounding pharmacies. A recent study of two dozen pharmacies
indicated that nearly half of the nitroglycerin ointments failed to meet US
Pharmacopoeia specifications for potency or content uniformity. 7 Attention
to proper preparation can at least assure clinicians what concentration a
patient is getting, and thus further decision-making can progress on correct
assumptions about what has already been tried. Finally, a trial examining the
use of an applicator that directs (into the anus) a TID dose of nitroglycerin
(0.75 ml of 0.3% nitroglycerin ointment, providing 2.25 mg nitroglycerin)
demonstrated reduced headache incidence (with no reduction in efficacy)
compared with gloved-finger application of the same nitroglycerin dose. 18
In at least one group, those with post-hemorrhoidectomy pain, RCT data
suggest that topical nitroglycerin (0.2%, applied BID) provides minimal pain
relief when given in the first four to six weeks after the operation. 15 Therefore,
for post-hemorrhoidectomy (especially those patients who have failed nitroglycerin
therapy), ED recommended therapy includes PO NSAIDs (e.g. indomethacin)
with rescue opioids (e.g. oxycodone) only if necessary. 19 Use of
topical calcium channel blockers is also recommended (see below).
The utility of NSAIDs in post-hemorrhoidectomy pain is further demonstrated
by trials of perioperative administration of agents such as ketorolac
and diflunisal. 20,21 A Belgian RCT found that diclofenac provided some posthemorrhoidectomy
pain relief, but that the NSAID was outperformed by
betamethasone in terms of opioid-sparing effect. 22 The conclusion based
upon available data and clinical experience (e.g. taking into account the
unhelpful constipating effects of opioids)isthatNSAIDs constitute the optimal
systemic approach to perianal pain when local therapy fails. Opioids can then
be used as rescue therapy. Any opioid-sparing effect accrued with NSAIDs is
particularly important in post-hemorrhoidectomy pain, given the importance
of avoiding constipation and straining (which increases risk of postoperative
hemorrhage).
For patients with chronic anal fissure or painful external hemorrhoids who
fail nitroglycerin therapy, or who have intolerable side effects to the drug,
calcium channel blockers have been recommended as an alternative means