A randomized, double-blind trial of the effect of metronidazole on pain after closed hemorrhoidectomy.

PURPOSE: Patients consider hemorrhoidectomy to be a painful operation. Attempts to reduce the length of inpatient stay have concentrated mainly on a reduction in postoperative pain. Metronidazole has been shown to reduce pain after open hemorrhoidectomy. The aim of this study was to evaluate the effect of metronidazole after closed hemorrhoidectomy. METHODS: Thirty-eight patients undergoing closed hemorrhoidectomy were randomly allocated to receive metronidazole 400 mg (n = 18) or placebo (n = 20) three times daily for seven postoperative days. All patients received a stool softener and analgesics perioperatively. Linear analog scales were used to assess expected pain, actual pain and patient satisfaction. Time to first bowel movement, return to normal activity, complications, and use of additional analgesics were recorded. RESULTS: Both groups of patients experienced less pain than expected. Patients in the metronidazole group required fewer additional analgesics postoperatively (6.3 vs. 26.3 percent), and satisfaction scores in the placebo group were higher at one week (0.5 vs. 2.5), although these differences were not statistically significant. There were no differences in pain actually experienced, time to first bowel movement, return to normal activity, or complications between the two groups. Satisfaction scores at six weeks for all patients were relatively high, with no significant difference between the groups. CONCLUSION: Closed hemorrhoidectomy results in high patient satisfaction and low pain scores. The use of postoperative metronidazole did not reduce postoperative pain.

Role of resting pressure gradient in the investigation of idiopathic fecal incontinence.

PURPOSE: One-third of patients who suffer from idiopathic fecal incontinence are found to have maximum mean resting pressures within the normal range. The objective of this study was to determine whether measuring the gradient of pressure at rest throughout the anal canal is a more sensitive predictor of incontinence in these patients. METHODS: Anorectal physiology measurements were retrospectively reviewed in patients referred over an 18-month period. Two patient groups were selected for the study: Group 1, continent patients (n = 80); and Group 2, patients with idiopathic fecal incontinence (n = 47). Maximum resting pressures, vector volumes, and resting pressure gradients were all contrasted, sensitivities and specificities were calculated, and receiver operating characteristic curve analyses were performed. Reproducibility studies were also performed for the calculation of the pressure gradient. RESULTS: Patient demographics were similar in the two groups. The resting pressure gradient, maximum mean resting pressure, and vector volumes were significantly lower in incontinent patients compared with the normal patients (P < 0.0001, all comparisons). The sensitivity (and specificity) of resting pressure gradient, maximum mean resting pressure, and vector volumes were 89 percent (96 percent), 55 percent (98 percent), and 53 percent (88 percent), respectively. CONCLUSION: The resting pressure gradient is the most accurate in detecting fecal incontinence. The authors conclude that this test is simple, reproducible, and identifies an abnormality in the majority of patients with idiopathic fecal incontinence.