International Journal of Colorectal Disease

, Volume 33, Issue 7, pp 895–899 | Cite as

A prospective randomized double-blind study of pain control by topical calcium channel blockers versus placebo after Milligan–Morgan hemorrhoidectomy

  • Sunandan Yadav
  • Radha Govind Khandelwal
  • Prabha Om
  • K. Ravindra
  • Kanhaiya Lal Choudhary
Original Article



Post-hemorrhoidectomy pain is significantly associated with a hypertonicity of the internal anal sphincter. We evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. Purpose of our study was to determine difference in extent of pain control by application of topical calcium channel blocker (diltiazem 2%) versus placebo ointment.


This was a prospective randomized double-blind clinical study conducted at Sawai Man Singh Hospital, Jaipur, from May 2016 to May 2017. Sixty patients, who had undergone hemorrhoid, were randomly assigned to receive 2% diltiazem ointment (n = 30) or a placebo ointment (n = 30) postoperatively. Ointments were applied to the perianal region three times daily for 7 days. Pain scores were recorded using visual analog scale at 6, 24, and 48 h and seventh day postoperatively and number of analgesic doses consumed by patients in the first 3 days.


Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week (p < 0.001) except for reading at 6 h. Also, there was significantly less number of analgesic doses consumed in the diltiazem group compared to the placebo group.


Perianal application of 2% diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial.


Posthemorrhoidectomy pain Diltiazem Topical Analgesic 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W (2013) Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 118:934–944CrossRefPubMedGoogle Scholar
  2. 2.
    Hiltunen KM, Matikainen M (1985) Anal manometric findings in symptomatic hemorrhoids. Dis Colon Rectum 28:807–809CrossRefPubMedGoogle Scholar
  3. 3.
    Ye F, Feng YX, Lin JJ (2007) A ropivacaine-lidocaine combination for caudal blockade in haemorrhoidectomy. J Int Med Res 35(3):307e313CrossRefGoogle Scholar
  4. 4.
    Hetzer FH, Demartines N, Handschin AE, Clavien P (2002) Stapled vs excision hemorrhoidectomy: long-term results of a prospective randomized trial. Arch Surg 137(3):337–340. CrossRefPubMedGoogle Scholar
  5. 5.
    Goldstein ET, Williamson PR, Larach SW (1993) Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management. Dis Colon Rectum 36:439–446CrossRefPubMedGoogle Scholar
  6. 6.
    Arabi Y, Alexander-Williams J, Keighley MR (1977) Anal pressures in hemorrhoids and anal fissure. Am J Surg 134:608e610CrossRefGoogle Scholar
  7. 7.
    Kanellos I, Zacharakis E, Christoforidis E, Angelopoulos S, Kanellos D, Pramateftakis MG, Betsis D (2005) Usefulness of lateral internal sphincterotomy in reducing postoperative pain after open hemorrhoidectomy. World J Surg 29:464–468CrossRefPubMedGoogle Scholar
  8. 8.
    Goligher JC, Graham NG, De Dombal FT et al (1969) The value of stretching of anal sphincters in the relief of pain after haemorrhoidectomy. Br J Surg 56:390CrossRefPubMedGoogle Scholar
  9. 9.
    Wasvary HJ, Hain J, Mosed-Vogel M, Bendick P, Barkel DC, Klein SN (2001) A randomized, prospective, double-blind, placebo-controlled trial of effect of nitroglycerin ointment on pain after hemorrhoidectomy. Dis Colon Rectum 44:1069–1073CrossRefPubMedGoogle Scholar
  10. 10.
    Karanlik H, Akturk R, Camlica H, Asoglu O (2009) The effect of glyceryl trinitrate ointment on posthemorrhoidectomy pain and wound healing: results of a randomized, double-blind, placebo-controlled study. Dis Colon Rectum 52:280–285CrossRefPubMedGoogle Scholar
  11. 11.
    Ratnasingham K, Uzzaman M, Andreani SM, Light D, Patel B (2010) Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing. Int J Surg 8:606–611CrossRefPubMedGoogle Scholar
  12. 12.
    Davies J, Duffy D, Boyt N, Aghahoseini A, Alexander D, Leveson S (2003) Botulinum toxin (botox) reduces pain after hemorrhoidectomy: results of a double-blind, randomized study. Dis Colon Rectum 46:1097–1102CrossRefPubMedGoogle Scholar
  13. 13.
    Nicholson TJ, Armstrong D (2004) Topical metronidazole (10 percent) decreases post hemorrhoidectomy pain and improves healing. Dis Colon Rectum 47:711–716CrossRefPubMedGoogle Scholar
  14. 14.
    Smith SL, Simon R (1979) Viscous lidocaine as a posthemorrhoidectomy analgesic. Dis Colon Rectum 22(1):40–41CrossRefPubMedGoogle Scholar
  15. 15.
    Shiau JM, Su HP, Chen HS, Hung KC, Lin SE, Tseng CC (2008) Use of a topical anesthetic cream (EMLA) to reduce pain after hemorrhoidectomy. Reg Anesth Pain Med 33:30–35CrossRefPubMedGoogle Scholar
  16. 16.
    Colak T, Akca T, Dirlik M, Kanik A, Dag A, Aydin S (2003) Micronized flavonoids in pain control after hemorrhoidectomy: a prospective randomized controlled study. Surg Today 33:828–832CrossRefPubMedGoogle Scholar
  17. 17.
    Elton C, Sen P, Montgomery AC (2001) Initial study to assess the effects of topical glyceryl trinitrate for pain after haemorrhoidectomy. Int J Surg Investig 2:353–357PubMedGoogle Scholar
  18. 18.
    Cook TA, Brading AF, Mortensen NJ (1999) Differences in contractile properties of anorectal smooth muscle and the effects of calcium channel blockade. Br J Surg 86:70–75CrossRefPubMedGoogle Scholar
  19. 19.
    Jonard P, Essamri B (1987) Diltiazem and internal anal sphincter. Lancet 1:754CrossRefPubMedGoogle Scholar
  20. 20.
    Carapeti EA, Kamm MA, Evans BK, Phillips RK (1999) Topical diltiazem and bethanechol decrease anal sphincter pressure without side effects. Gut 45:719e722CrossRefGoogle Scholar
  21. 21.
    Triggle DJ (1990) Calcium, calcium channels, and calcium channel antagonists. Can J Physiol Pharmacol 68:1474e1481Google Scholar
  22. 22.
    Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR (2018) The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum 61:284–292CrossRefPubMedGoogle Scholar
  23. 23.
    Rodríguez-Wong U, Ocharán-Hernández ME, Toscano-Garibay J (April–June 2016) Topical diltiazem for pain after closed hemorrhoidectomy. Rev Gastroenterol Mex (English Edition) 81(2):74–79CrossRefGoogle Scholar
  24. 24.
    Huang Y-J, Chen CY, Chen RJ, Kang YN, Wei PL (2017) Topical diltiazem ointment in post-hemorrhoidectomy pain relief: a meta-analysis of randomized controlled trials. Asian J Surg.

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of General SurgerySMS Medical CollegeJaipurIndia

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