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Hemorrhoids and perianal pain 237
addition of minoxidil (0.5%). 29 Another study found that addition of nifedi-
pine (0.3%) to lidocaine (1.5%) significantly improved pain relief provided by
topical application of the local anesthetic. 30 The combination of calcium
channel blocker and local anesthetic is anecdotally of utility in post-
hemorrhoidectomy pain, especially if the operative procedure included
sphincterotomy. Case report evidence suggests utility in topical application
of eutectic mixture of local anesthetics (EMLA) for external hemorrhoid pain. 31
However, RCT data have shown no benefit to EMLA application when used to
reduce pain of infiltration anesthesia for hemorrhoidectomy. 32 Consequently,
it seems premature to endorse EMLA or any other local anesthetic for regular
use in ED therapy of perianal pain.
Some approaches for perianal pain from hemorrhoids or fissures may
provide a degree of symptom relief, but ED recommendation awaits further
study. A nonblinded study showed significant relief of both resting and
movement pain from application of a paste comprising heparin and trypsin/
chymotrypsin. 33 The ED utility of this approach is rendered unlikely by the
need to compound the paste.
Another therapy with limited high-grade evidence is use of carraghenates.
Suppository or cream formulations both seem to provide some relief, but
data are insufficient to endorse ED use. 34
Given the uncertainties surrounding absorption of topically applied agents
during pregnancy, the ED provider considering follow-up for gravida with
painful hemorrhoids can feel comfortable recommending consultative referral
for surgical therapy, which is both safe and effective in pregnancy. 35
Complete prolapse of the anal ring of hemorrhoids may occur in late pregnancy.
This condition usually resolves postpartum, so surgical therapy is not
required. An astringent such as witch hazel may be used to temporize, with
consideration of addition of a calcium channel blocker if pain relief is
incomplete.
The remainder of this chapter addresses diagnoses or therapeutic
approaches that are unlikely to be in the purview of ED providers. The first
such entity is Crohn’s disease. Thalidomide has been found useful in a recent
trial of patients with perianal pain from Crohn’s disease (or HIV), but this
approach is limited by side effects. 27,36,37 Another therapy for perianal