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236 Hemorrhoids and perianal pain
to reduce anal tone and relieve symptoms. In fact, evidence shows this class
may be preferable to nitroglycerin for prescription from the ED. One study
found that nifedipine ointment relieves fissure pain at least as well as topical
nitroglycerin, and is associated with significantly fewer side effects. 23 Another
trial found that the calcium channel blocker diltiazem (2% topically) actually
relieved anal fissure pain better than did topical nitroglycerin (0.2%). 24
Further evidence of the calcium channel blockers’ superiority over nitroglycerin
is found in a study assessing care of patients with nitroglycerin-refractory
external hemorrhoid pain. This study’s data show that BID topical diltiazem
gel (700 mg of a 2% preparation) relieves pain and related symptoms effectively
after failure of nitroglycerin therapy. 25 Even in the post-hemorrhoidectomy
population, in whom perianal pain relief can be particularly challenging, RCT
data demonstrate topical diltiazem (2%) is efficacious. 26 Therefore, we conclude
that the calcium channel blockers are a reasonable choice for first-line
therapy in patients with perianal pain from either hemorrhoids or anal fissures.
The local anesthetics are the next class of agents occasionally recommended
for perianal pain. These drugs may be administered by injection or
topical application, as monotherapy or in conjunction with other agents.
Other than for use as procedural anesthesia (i.e. for incision of hemorrhoids
or abscesses), there is little ED role for perianal injection of local
anesthetics. There is essentially no evidence on ED use of (non-procedural)
local anesthetic injection therapy for perianal pain, and the data from the
perioperative setting are not suggestive of utility. When injected at the close
of hemorrhoidectomy, agents such as bupivacaine provide only a little
analgesic benefit, and no significant opioid-sparing effect. 27,28 There is anecdotal
evidence of use of injected local anesthetics (e.g. bupivacaine 0.25%)
into acute (but not chronic) anal fissures, with further relief of pain achieved
by incision into the sphincter. No high-level evidence can be found addressing
use of this technique in the ED, but experience is consistent with some
success and little risk.
There may be a role for topical application of local anesthetics for improving
perianal pain, but most trials find that other therapies provide faster
healing and better pain relief. One RCT suggested that the modest pain relief
from topical application of lidocaine (5%) ointment can be augmented by