Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Application for ESRA Abstract Prizes: I apply as a Trainee/Resident/Fellow (no age limit)

Background and Aims Haemorrhoidectomy is associated with moderate-to-severe postoperative pain. The aim of this systematic review was to assess the available literature and update previous PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) recommendations for optimal pain management after haemorrhoidectomy.

Methods A systematic review utilizing PROSPECT methodology was undertaken. Randomized controlled trials published in the English language from January 1, 2016 to February 2, 2022 assessing postoperative pain using analgesic, anaesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Database.

Results Of the 371 RCTs identified, 84 RCTs and 19 systematic reviews, meta-analyses met our inclusion criteria (total: 103 publications). Interventions that improved postoperative pain relief included: paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, systemic steroids, pudendal nerve block, topical metronidazole, topical diltiazem, topical sucralfate or topical glyceryl trinitrate, and intramuscular injection of botulinum toxin.

Conclusions This review has updated the previous recommendations written by our group. Important changes reside in abandoning oral metronidazole and recommending topical metronidazole, topical diltiazem, topical sucralfate, topical glyceryl trinitrate. Botulinum toxin can also be administered. Contemporary publications confirm the analgesic effect of bilateral pudendal nerve block but invalidate recommendations on perianal infiltration. The choice of the surgery is mostly left to the discretion of the surgeon based on his experience, expertise, type of haemorrhoids, and risk of relapse. That said, excisional surgery is more painful than other procedures.