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The Effect of Early Warm Plastic Bag Application on Postoperative Pain after
Hemorrhoidectomy: A Prospective Randomized Controlled Trial

Article  in  The American surgeon · February 2015

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The Effect of Early Warm Plastic Bag Application
on Postoperative Pain after Hemorrhoidectomy:
A Prospective Randomized Controlled Trial
AHMET ZIYA BALTA, M.D., YAVUZ OZDEMIR, M.D., ILKER SUCULLU, M.D., ALI ILKER FILIZ, M.D., ERGUN YUCEL, M.D.,
MEHMET LEVHI AKIN, M.D.

From the Department of Surgery, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey

Hemorrhoidectomy is used for the surgical treatment of high-grade hemorrhoids. The most
prominent complaint after hemorrhoidectomy is pain. Postoperative pain management is still
a big problem after surgery in patients with hemorrhoidectomy. The aim of the study was to assess
the effect of early application of warm bag on postoperative pain after hemorrhoidectomy. All patients
were randomly divided into warm plastic bag and control groups by using sealed envelopes, which
were prepared preoperatively. After standard spinal anesthesia, all patients underwent standard
Milligan-Morgan hemorrhoidectomy using Ligasureä. Although the study group received the warm
bag application, the control group did not receive such a treatment. Two separate visual analog scale
(VAS) measurements were performed for postoperative pain assessments on postoperative days, one
during the resting state and the other one during the straining phase after the onset of peristaltic
bowel movement. Postoperative VAS scores were significantly lower among the warm plastic bag
group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for
defecation. Additionally, a significant difference existed between the two groups in terms of the need
for additional anesthesia. Local thermal application appears to be a safe and effective method for pain
relief after hemorrhoidectomy.

for the surgical treat-
H EMORRHOIDECTOMY IS USED
ment of high-grade hemorrhoids or hemorrhoids
that do not respond to nonsurgical management. The
most prominent complaint after hemorrhoidal surgery
is pain, which is thought to arise from surgical trauma
and the associated inflammatory reaction resulting from
the spasm of the internal anal sphincter (IAS). Addi-
tionally, the intensive sensory neural network within the
perianal and anodermal regions may contribute to pain
perception.1–4
In addition to analgesics used for postoperative pain
control after hemorrhoidectomy, warm water baths are
commonly used for pain management as a safe method
with relatively lower morbidity.5 Similarly, the same
method is applied after certain gynecological and uro-
logical procedures both for pain control and to accel-
erate healing.6–9 It has been reported that warm water
baths are associated with a relaxation in the IAS
resulting in pain reduction and the continued relaxation
Presented as a poster at the European Society of Coloproctology’s
8th Scientific and Annual Meeting, September 25-27 2013, Belgrade,
Serbia.
Address correspondence and reprint requests to Ahmet Ziya
Balta, M.D., GATA Haydarpasa Teaching Hospital, Department
of Surgery, Selimiye Mah. Tibbiye Cad. 34668 Üsküdar, Istanbul,
Turkey. E-mail: ahmetzbalta@yahoo.com.
of the sphincter correlates with the temperature of the
water. The relaxation of IAS after the exposure of the
perianal skin to warm water has been referred to as
the ‘‘thermosphincteric reflex.’’10
On the other hand, there is no consensus as to the
preferred method and timing of warm water sitting baths.
Although it is commonly described as ‘‘sitting in a warm
water bath,’’ some other studies have recommended the
use of a warm water jet at the perianal region.3, 8, 11
In our study, the effect of early application of a warm
bag after hemorrhoidectomy on postoperative pain has
been examined.
Materials and Methods
In this single-center, prospective, randomized con-
trolled study conducted at the Department of General
Surgery between January 2010 and May 2012, patients
undergoing hemorrhoidectomy received or did not re-
ceive warm water bag application in addition to routine
hot water application.
Patients
After study protocol approval by local ethics commit-
tee, male and female patients between 18 and 80 years

180
No. 2 WARM PLASTIC BAG APPLICATION FOR HEMORRHOIDECTOMY
of age with third- or fourth-grade and American Society
of Anesthesiologists 1 to 2 hemorrhoidal disease who
were unresponsive to dietary modification and/or
medical treatment were included. Exclusion criteria
included a history of anorectal surgery, concomitant
anal fissure, anal fistulae or perianal dermatological
conditions, inflammatory bowel disease, pregnancy,
or unwillingness to participate. Forty patients fulfilling
these criteria were included in the study.
A simple randomization scheme involving the pre-
operative random selection of one of the sealed envelopes
by the patient that included information on the group
assignment (1, study group; 0, control group) was used.
Surgical Procedure
The rectal content was cleansed two hours before the
surgical procedure using lower colonic enema contain-
ing sodium phosphate (Fleet Enema; Kozmed, Ankara,
Turkey). In addition, all patients started to receive in-
travenous ornidazole infusion (Biteral; Roche, Basel,
Switzerland) just before incision for prophylaxis.
After standard spinal anesthesia, patients were posi-
tioned in the prone jackknife position and both gluteal
muscles were retracted from the perianal region using
adhesive bands. All procedures were performed by the
same surgeons experienced in colorectal surgery. All
patients underwent standard Milligan-Morgan hemor-
rhoidectomy using a Ligasureä (Valleylab, Boulder, CO)
energy device.
Protocol
Nonsterile surgical gloves were filled with warm
water (40°C) and used for the study procedures owing to
their ability to readily adjustable with the topographical
anatomy of the perianal region (Figs. 1 and 2). After
weaning from the effects of the spinal anesthesia, warm
plastic bags were applied to the perianal region four
times with 15-minute sessions two hours apart.
FIG. 1. Preparation of a warm plastic bag by using a nonsterile glove and its application.
? Balta et al. 181
Postoperative Period
Whereas patients in the study group received the
warm bag treatment as described, patients in the con-
trol group did not receive such a treatment. After
weaning from the effects of spinal anesthesia, a single
dose of diclofenac sodium (Diclomec; Abdi Ibrahim
Ilac, Istanbul, Turkey) was given intramuscularly for
pain management in both groups. Additional narcotic
analgesia was done when necessary. In addition, the
standard postoperative management protocol involving
the use of analgesics (Majezik; Sanovel, Istanbul, Tur-
key), laxatives (Magnesie Calcine; Deva, Istanbul,
Turkey), and twice-daily water jet application was rec-
ommended to all patients before discharge.
Assessments
Two separate visual analog scale (VAS) measure-
ments were performed for postoperative assessments
on Days 1, 3, 7, 14, and 28, one during the resting state
and the other one during the straining phase after the
onset of a peristaltic bowel movement. A pain control
form was delivered to all patients before discharge to
record VAS results that included the VAS itself, post-
operative days, and VAS scores. Patients were pro-
vided with information on the use of VAS scale (0
point: no pain, 10 points: possible severst pain) and
were asked to record the scores on study days. In ad-
dition, the total dose of additional narcotic analgesics
given during the postoperative period was recorded.
All patients were asked to return to the study center on
postoperative days 7 and 30, when the pain control
forms were collected.
Statistical Analyses
A minimum of 20 patients was required in each
group to determine a between-group difference at
a statistical power level of 80 per cent and a signifi-
cance level of 0.05. All analyses were performed using
182 THE AMERICAN SURGEON February 2015 Vol. 81

the SPSS statistical software package (SPSS, Chicago, Postoperative VAS scores were significantly lower
IL) Version 16.0. Student’s t test was used for the among the study participants as compared with control
comparison of continuous variables, whereas the x2 test subjects on Days 1 and 3 for resting state and on Day 3
was used for the comparison of categorical variables. for defecation (Fig. 3). Postoperative follow-up results
are summarized in Table 2.
Intramuscular pethidine was administered for addi-
Results tional anesthesia on patients’ demand. Only one pa-
Forty patients (20 study patients, 20 control sub- tient required additional analgesia in the study group,
jects) were included. The mean age was 52.2 ± 11.7 whereas the corresponding figure was eight among the
years versus 47.6 ± 11.1 years in the study and control control subjects. A significant difference existed be-
groups, respectively. Male-to-female ratio was similar tween the two groups in terms of the need for addi-
in both groups. The patient characteristics are sum- tional anesthesia (P 4 0.03).
marized in Table 1. No complications arising from local thermal appli-
The two groups were similar with respect to the cation were noted and the two groups were similar
number of hemorrhoid packages removed, i.e., one to with respect to wound healing.
three packages in both groups. No patients had post-
operative complications, whereas nine patients (six in the Discussion
study group and three in the control group) had urinary
retention. Hemorrhoidal disease is a common condition with
a peak age between 45 and 65 years resulting in peri-
anal complaints including pain, rectal bleeding,
mucosal protrusion, and anal discharge.12 Although
perianal pain is common during the course of the
disease, it is more prominent during the early post-
operative period representing the most common post-
operative complaint after surgery.13–15 A variety of local
or systemic medications as well as surgical techniques
have been used to relieve the sphincteric spasm, which is
thought to be involved in the pathophysiology of post-
hemorrhoidectomy pain.16–18 Findings of the studies in-
dicate a correlation between reduced sphincteric pressure
FIG. 2. Visual analog scale (VAS) scores at rest. and pain relief. In a study by Shafik and Dodi, warm
water sitting baths have been manometrically found to
reduce the IAS spasm, resulting in decreased pain per-
ception.10, 19 Jiang has shown that local thermal appli-
TABLE 1. Patient Characteristics cation in the gluteal region results in relaxation in IAS
Warm Plastic Control through the somatoanal reflex that is even more marked
Bag Group Subjects P in patients with painful conditions such as anal fissure or
Age (years), 52.2 (11.7) 47.6 (11.1) NS hemorrhoids.20 On the other hand, in randomized con-
mean (SD) trolled studies by Gupta using VAS assessment after
Female 6 (30%) 6 (30%) NS hemorrhoidectomy or postanal sphincterectomy, warm
Male 14 (70%) 14 (70%) NS sitting baths had no effect on postoperative pain.11, 21, 22
SD, standard deviation; NS, nonsignificant. In a study by Maestra comparing the effect of cold or
warm sitting baths on pain in patients with hemorrhoidal
disease or anal fissure, no statistically significant differ-
ences have been found.23 Similarly, in a study with 40
patients, Pinho et al.24 observed no relaxation effect on the
sphincter muscle with cold or hot sitting baths. In their
review for evidence-based management strategies in
hemorrhoid treatment, Tejirian and Lang have pointed to
the relative lack of evidence for warm sitting baths, al-
though acknowledging its possible advantages such as low
morbidity, patient satisfaction, and hygienic effects.6, 25
Despite the common prescription of warm sitting
FIG. 3. Visual analog scale (VAS) scores during straining. baths, the method is often not defined adequately. This
No. 2 WARM PLASTIC BAG APPLICATION FOR HEMORRHOIDECTOMY ? Balta et al. 183

TABLE 2. Assessments during Postoperative Follow-up

Variable Warm Plastic Bag Group Water Jet Group P
Pain intensity (VAS), mean (SD)
Postoperative 24 hours Rest 3.7 (2.8) 5.9 (2.5) 0.013
Postoperative 72 hours Rest 3.6 (2.3) 5 (1.7) 0.039
Defecation 4.3 (2.6) 6.5 (1.3) 0.003
Postoperative 7 days Rest 2.3 (1.7) 2.7 (1.5) NS
Defecation 3.2 (2) 4.3 (1.4) NS
Postoperative 14 days Rest 1.4 (1.6) 2.3 (1.9) NS
Defecation 2.4 (1.9) 3.2 (1.7) NS
Postoperative 28 days Rest 0.8 (1.1) 1.4 (1.2) NS
Defecation 1.5 (1.3) 2.2 (1.2) NS
Additional analgesic use, no. (%) 1 (5) 8 (40) 0.03
Complication 0 0 NS
Urinary retention, no. (%) 6 (30) 3 (15) NS
VAS, visual analog scale; SD, standard deviation; NS, nonsignificant.

method has undergone very little change since its
first description in 1800s, and only few papers such
as Hagatawa’s present a clear description of the
method.6, 26 Generally sitting in a warm water con-
tainer that provides warm water exposure to the perianal
and gluteal region is recommended, but the water jet
method has also been described by some authors such
as Hsu et al.3 In Gatson’s paper, depictions involving
the use of a portable device have been presented.27
Importantly, almost all published studies refer to a rec-
ommendation for warm sitting baths after the first
postoperative day. Therefore, local thermal application
has been started during the early postoperative pe-
riod in our study as well.
Our results have shown lower VAS scores on post-
operative days 1 and 3 and reduced the need for
additional analgesia with early postoperative adminis-
tration of local heat at the perianal region. Considering
the literature data and pathophysiological mechanisms
proposed, we believe that this beneficial effect results
from the prevention or reduction of early postoperative
sphincteric spasm.
In conclusion, early application of plastic warm
bags after hemorrhoidectomy provided the advantage
of reduced need for additional analgesia and de-
creased pain perception (on Days 1 and 3) during the
early postoperative period. Local thermal application
appears to be a safe and effective method for pain
relief after hemorrhoidectomy.
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