Postoperative pain is a complex physiological and psychological response of the human body to tissue damage and repair processes, and it can be observed in almost all postoperative patients. For many years, persistent and severe pain after anal surgery has seriously affected patients' postoperative recovery and quality of life, limiting the promotion of surgical treatment for anal diseases. In order to effectively treat postoperative pain from anal diseases, many experts and scholars have conducted fruitful research on postoperative analgesia. While traditional analgesic methods are constantly being improved and enhanced, new concepts, methods, and drugs for analgesia are also being deeply researched and promoted in clinical practice in proctology, achieving good clinical results. Here's a summary:
1. Drug Analgesia
Oral analgesics for treating postoperative pain from anal diseases is the most primitive and simplest method in clinical practice and remains the most commonly used method, suitable for mild to moderate postoperative pain. Analgesics can be used alone or in combination with other analgesics and methods to improve efficacy and reduce side effects. Since oral administration requires time to reach an ideal analgesic blood concentration and is easily affected by gastrointestinal function, various routes of administration are adopted, including sublingual administration, nasal cavity, rectal cavity, transdermal patches, and subcutaneous, intramuscular, and intravenous injections. Additionally, medication can be administered via the epidural route.
Commonly used analgesics are divided into opioids and non-opioids. Opioids have been traditional postoperative analgesics since their discovery, with strong analgesic effects due to their action on sympathetic nerve fibers and sensory nerve endings. Common drugs include morphine, tramadol, pethidine, codeine, tramadol, fentanyl, etc. These drugs provide timely analgesia but vary significantly in effect among individuals. Pain may recur or worsen after defecation or dressing changes. Additionally, due to serious adverse reactions such as respiratory depression and addiction, their clinical application is restricted. Non-opioid analgesics mainly include non-steroidal anti-inflammatory drugs (NSAIDs) like diclofenac sodium controlled-release tablets, indomethacin, ibuprofen, heparin ointment, etc., and adjuvant analgesics. Their analgesic effects for postoperative pain are relatively weaker, and they are less recognized by surgeons and patients, often combined with opioids.
2. Long-acting Anesthetic Injection Analgesia
Local anesthetic drugs block harmful sensations from reaching the central nervous system, preventing central sensitization while having anti-inflammatory effects that reduce initial sensitization. Injecting methylene blue with local anesthetics postoperatively is one of the most common analgesic methods for anal diseases. Methylene blue has a strong affinity for nerve tissue, corroding the myelin sheath of nerve fibers and causing reversible damage, making local sensation dull, relaxing sphincter muscles, reducing or eliminating pain, thus achieving sustained analgesia lasting about two weeks. However, there is a burning sensation 2-4 hours after administration. Clinically, methylene blue is commonly used with bupivacaine. Common complications include temporary anal incontinence, local edema, and impaired bowel awareness. Reducing the concentration and dosage of methylene blue is an effective way to reduce and eliminate complications. Low-concentration small-dose use significantly reduces the degree and duration of postoperative pain with fewer adverse reactions and no significant impact on wound healing. Zhang Yougong et al. compared the analgesic effects of 10ml of 0.1% and 0.2% methylene blue injection solutions postoperatively, finding the former to be significantly better than the latter, recommending around 10ml of 0.1% solution per use. Liang Desen et al. achieved better analgesic effects using compound methylene blue injections postoperatively compared to using an epidural analgesic pump.
Biological alkaloid preparations have also been widely used in recent years for postoperative analgesia in anal diseases. The most commonly used drug clinically is hydrobromide of high aconitum, which is a non-anesthetic analgesic with strong analgesic effects, slower onset but longer-lasting than pethidine. Additionally, it has antipyretic and anti-swelling effects without addictive properties, suitable for moderate to severe pain. However, some patients may experience discomfort symptoms such as urticaria, palpitations, chest tightness, and dizziness.
The use of compound menthol brain injection locally to relieve postoperative pain from anal diseases has been reported more frequently in recent years. Its chemical components are menthol alcohol compounds, belonging to long-acting local anesthetic preparations. This drug blocks peripheral nerve transmission, causing numbness and reduced sensation in the anal skin and relaxing the sphincter muscle, thereby achieving rapid and long-lasting analgesic effects, with analgesia lasting up to 48-240 hours. However, clinical findings show that compound menthol brain injection increases incisional swelling.
In recent years, there have been reports of using Zhusima oil, glycerin, Mintor, papaverine, tramadol, strong pain relievers, etc., combined with local anesthetics and long-acting procaine for postoperative analgesia. However, clinical usage is not very widespread, with fewer related reports and comparative observations. Further research is needed on their efficacy, advantages, disadvantages, and side effects.
3. Patient-Controlled Analgesia (PCA)
PCA refers to the method of allowing patients to self-administer predetermined small doses of medication for analgesia when experiencing pain after surgery using programmed micro-pump technology. This technique maintains the minimum effective analgesic concentration according to individual requirements, enabling patients to promptly and quickly manage pain at different moments and intensities. Patients can maintain analgesic drug concentrations based on pain levels, administering intermittent small doses themselves, avoiding periodic changes in drug concentration and analgesic effects, achieving better analgesic results with smaller amounts of analgesics. The routes of administration are mostly epidural and intravenous, with some reports of subcutaneous administration. To make analgesia take effect quickly, last longer, and reduce toxic side effects, several drugs are usually combined. Generally, opioid drugs are combined with local anesthetics, along with small amounts of sedatives and drugs to suppress the side effects of anesthetics. PCA, as a relatively mature analgesic method, has been widely applied domestically in postoperative analgesia for anal diseases, though there are differences in administration routes, drug ratios, and usage methods. Li Hongmei applied PCA pumps to 250 postoperative anal disease cases with significant comparative observation effects. Zhang Hongguang et al. compared PCA with intramuscular pethidine in 64 postoperative hemorrhoid fistula patients, finding PCA to have significantly better analgesic effects than intramuscular pethidine.
Clinical PCA also has some adverse reactions, mainly vascular and epidural cavity infections and hematomas caused by catheter placement, as well as the toxic side effects of the drugs used. Due to its stable and reliable analgesic effects and convenience of use, PCA is favored by surgeons and patients. However, its relatively high cost, requirements for cultural literacy of treated patients, and occasional adverse reactions limit its widespread promotion.
4. Preemptive Analgesia
Preemptive analgesia refers to blocking harmful sensations before surgery to achieve postoperative pain relief or reduction. The mechanism of preemptive analgesia is that using analgesics before surgery produces more effective postoperative analgesic effects than using them after surgery, and using analgesics during surgery can reduce secondary stage pain. Li Dongbing et al. gave patients undergoing hemorrhoid ligation 50mg of tramadol orally 30 minutes before surgery, while setting up a control group that did not receive preoperative medication. The treatment group had good analgesic effects, with significantly superior analgesic intensity and postoperative duration compared to the control group. Since the introduction of preemptive analgesia in clinical applications, there have been few reports of adverse reactions, but its clinical efficacy remains controversial. Further research is needed on its mechanism, administration methods, timing, and dosages.
5. Balanced Analgesia
Balanced analgesia, also known as multimodal complementary analgesia, uses the synergistic effects of different analgesic drugs and methods to achieve sufficient analgesia while reducing doses and minimizing side effects. Due to the synergistic effect between opioids and local anesthetics, when both are used together, drug dosages can be reduced and adverse reactions minimized, so opioids and local anesthetics are often combined in clinical practice. Balanced analgesia, with its good analgesic effects and low side effects, has become increasingly popular in domestic proctology clinics in recent years, providing a safer and more effective pathway for postoperative analgesia in anal diseases. Hu Jie et al. achieved significant effects using balanced analgesia methods to prevent and treat postoperative pain in 80 patients with anal diseases.
Chen Zhicheng et al. studied preemptive balanced analgesia for postoperative pain in anal diseases, utilizing preemptive analgesic effects and balanced analgesic effects to fully leverage positive synergistic drug interactions, achieving ideal analgesic effects while reducing drug dosages and side effects, achieving good results without increasing adverse reactions.
6. Traditional Chinese Medicine (TCM) Analgesia
TCM has accumulated valuable clinical experience in analgesia. According to traditional Chinese medicine, pain occurs when the body's local qi and blood stagnate, leading to obstruction and pain, with main causes being qi stagnation, blood stasis, and damp heat. Therefore, the treatment method involves regulating qi, activating blood circulation, and resolving stasis, commonly using herbs such as Corydalis yanhusuo, frankincense, myrrh, peach kernel, safflower, red peony root, rhubarb, etc., with adjustments based on symptoms. Different formulations are made according to different routes of administration, including decoctions, washes, ointments, powders, aerosols, suppositories, and transdermal patches, with ointments being the most commonly used locally. Moist Burn Cream (MEBO) and Musk Hemorrhoid Ointment are widely used externally for postoperative anal pain. Some scholars have achieved good results using self-made ointments for postoperative anal pain. Foam aerosols are a new formulation for external TCM analgesia developed in recent years, convenient to use clinically, achieving ideal analgesic effects through good penetration, showing good research prospects.
7. Acupuncture Analgesia
Acupuncture analgesia refers to preventing and treating pain through acupuncture at specific acupoints. Acupuncture can unblock meridians and promote the flow of qi and blood, supplemented by reinforcing and reducing techniques, playing a unique analgesic role clinically. Commonly used distant and local acupoint combinations include Changqiang point as the primary acupoint for anal diseases, paired with distant points such as Shenmen, Sanyinjiao, Taichong, Lingquan, specific points Shuangcubone, and intradermal needles for treating postoperative anal pain in proctology. Through controlled experiments, the analgesic effects of acupuncture postoperatively are similar to those of drug-based analgesia. Li Ning et al. used acupuncture to treat postoperative pain in 40 anal fistula patients, achieving better analgesic effects than oral tramadol.
8. Other Non-traditional Analgesia
9.1 Acupoint Pressure Analgesia: "Rongchang Zhitai" Shenque acupoint patch is used postoperatively for anal diseases, showing good analgesic effects clinically. Chen Xueling used auricular acupoint pressure to prevent postoperative pain in 908 proctology cases with significant effects.
9.2 Acupoint Injection Analgesia: Injecting a certain amount of anesthetic and analgesic drugs at the Changqiang and Huiyin acupoints provides long-lasting analgesia postoperatively for anal diseases, widely recognized clinically. Some scholars use distant acupoint block therapy for postoperative anal pain. Liu Shuxia et al. achieved a 98% effective rate using vitamin K3 injection at the Zusanli acupoint for postoperative anal pain.
9.4 Local Physical Therapy Analgesia: Local physical therapy for anal diseases postoperatively has been widely promoted in domestic proctology clinics in recent years, achieving relatively ideal analgesic effects. Common methods include microwave, infrared, and far-infrared therapies, promoting blood circulation and unblocking meridians through thermal and magnetic effects to achieve local analgesia.
9.5 Transdermal Drug Analgesia: Using fentanyl transdermal patches for postoperative anal pain in anal diseases shows ideal effects, advocating early administration due to continuous slow skin absorption. Li Jihua et al. compared the analgesic effects of fentanyl transdermal patches with oral dispersible tablets for postoperative hemorrhoid pain, finding the analgesic effect of fentanyl transdermal patches significantly better than that of dispersible tablets.
9.6 Self-psychological Analgesia: Since pain itself is a psychological sensation, self-psychological analgesia methods have gradually gained recognition in academic circles and have been used in combination in postoperative analgesia in some hospitals' proctology departments, though domestic reports on efficacy are scarce. Specific methods include breathing analgesia, self-suggestion, relaxation analgesia, distraction analgesia, and stimulating symmetrical skin methods.
With the shift in medical paradigms, holistic concepts have gradually permeated into postoperative pain management. Some patients actively accept previously unfamiliar non-traditional analgesic measures. These analgesic methods are non-invasive to the body, have fewer side effects, and emphasize the unity of the body, mind, and spirit, adapting to the overall needs of patients but requiring good and full cooperation from nursing staff. As the medical paradigm further develops, these analgesic methods have broad development prospects in the treatment and care of postoperative pain in anal diseases.
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