Analgesics around the clock is better than the on-demand modality for pain treatment after hemorrhoid surgery

Abstract Background: This study aims to investigate the best pharmacological treatment for postoperative pain after hemorrhoidectomy. Material and Methods: This prospective non-randomized study included 5335 patients who underwent hemorrhoidectomy from July 2016 to December 2020, divided into two groups: "around-the-clock" analgesic treatment (ACAT) with 3,767 participants, and "on-demand" analgesic treatment (ODAT) with 1568 participants. Results: The mean age was 47.47 years old, 59.98% male. Postoperatively, severe pain was reported by 14.13% of the patients, moderate pain in 36.49%, mild pain in 34.28%, and no pain in 15.09%. In the ACAT group, the mean for maximum pain was 3.04 on the Visual Analogue Scale (VAS) and 4.95 for the ODAT group. The average pain in the ACAT group was 0.79 VAS and for the ODAT group 1.45 VAS. The pain at the time of discharge was 0.42 (SD±0.730) VAS for the ACAT group and 0.63 (SD±0.799) VAS for the ODAT group. Comparing the three modalities of pain measurement, the ACAT group reported significantly less pain (p<.001). Having a higher BMI and being younger were risk factors for pain (p=.049, and p<.001, respectively). The ACAT group used significantly fewer opioids, which decreased the use of meperidine by 68.38% less; morphine by 43.57%, tramadol by 46.82%; 38.74% oxycodone; and codeine by 53.40% less. The need for non-opioid analgesics was also lower in the ACAT group, between 16-59% less than in the ODAT group. Conclusion: Hemorrhoidectomy induces moderate postoperative pain and only 14% of the patients suffer severe pain. A fixed schedule multimodal pain regime diminishes pain from moderate to mild after hemorrhoidectomy, independent of procedure and anesthesia type, thereby reducing the doses of opioids needed from between 38 to 68%, and reducing the dosage of non-opiates as well. Higher BMI and youngest age were recognized as risk factors for higher postoperative pain. Trial registration clinicaltrials.gov (NCT04953182). Available at: https://clinicaltrials.gov/ct2/show/NCT04953182