Table 12: Glyceryl trinitrate (GTN) versus placebo ointment

Study

Surgery type

n treatment/ control

Comparison

Supplemental analgesia

Pain scores and type if specified

Use of supplemental analgesia

Functional outcomes

Other important outcomes

(Hwang 2003) LoE 1

Modified Milligan-Morgan

49/53

0.2% GTN ointment (GTN) or placebo (P) ointment applied 3 x per day to perianal wounds. Total amount of ointment applied over 3 weeks was 20 g. Daily amount was standardised using a measuring spoon with a capacity of approx 1 g

Painkillers were prescribed to all patients as needed. On the operation day, an IM injection of pethidine, ketorolac, or both was used. From the second postoperative day, amfenac sodium was prescribed as needed

VAS pain scores: GTN superior on day 1 (p=0.03), NS at 6 h or on days 2 or 3

NS pethidine, ketorolac or amfenac consumption

% of patients with completely healed wounds: GTN superior at 3 weeks (p=0.002)

Stricture:

NS

Length of hospital stay:

NS

Early or delayed bleeding:

NS

Urinary retention:

NS

Headaches:

NS

Itching:

NS

(Tan 2006) LoE 1

Open diathermy haemorrhoidectomy.

40/42

0.2% GTN ointment (GTN) or placebo (P) ointment applied 3 x per day to perianal wounds for a minimum of two weeks; patients measured out 330 mg for each application using a measuring spoon

Paracetamol 1 g four times per day and oral diclofenac 50 mg twice daily used as analgesics in both groups

NS VAS on days 1, 3, 7, 14 and 21

NS consumption of paracetamol and diclofenac

Number of patients with completely healed wounds: GTN superior at 3 weeks (p=0.021), NS at 6 weeks

Faecal impaction:

NS

Length of hospital stay:

NS

Secondary haemorrhage:

NS

Urinary retention:

NS

Headaches:

NS

Itching:

NS

Patient comfort at 24 h:

GTN superior (p=0.009)

Pain requiring readmission:

NS

(Wasvary 2001) LoE 1

Closed Ferguson technique

19/20

0.2% GTN ointment (GTN) or placebo (P) ointment applied 3 x per day to perianal wounds for 7 days; patients measured out 1 g for each application using a measuring spoon

Hydrocodone taken as needed for pain relief. Paracetamol and NSAIDs encouraged for additional analgesia

NS VAS pain scores from POD 1–7

Number of hydrocodone medications required: GTN superior on day 2 (p<0.05), NS on days 1, 3–7. NSAID/paracetamol requirement: P superior (p=0.0003)

Not reported

Morbidity related to ointment application (headaches): P superior (p< 0.001)

Frequency of surgical morbidity:

NS (morbidity was minor and included difficulty with urination or defecation and minor bleeding)

Study	Surgery type	n treatment/ control	Comparison	Supplemental analgesia	Pain scores and type if specified	Use of supplemental analgesia	Functional outcomes	Other important outcomes
(Hwang 2003) LoE 1	Modified Milligan-Morgan	49/53	0.2% GTN ointment (GTN) or placebo (P) ointment applied 3 x per day to perianal wounds. Total amount of ointment applied over 3 weeks was 20 g. Daily amount was standardised using a measuring spoon with a capacity of approx 1 g	Painkillers were prescribed to all patients as needed. On the operation day, an IM injection of pethidine, ketorolac, or both was used. From the second postoperative day, amfenac sodium was prescribed as needed	VAS pain scores: GTN superior on day 1 (p=0.03), NS at 6 h or on days 2 or 3	NS pethidine, ketorolac or amfenac consumption	% of patients with completely healed wounds: GTN superior at 3 weeks (p=0.002) Stricture: NS	Length of hospital stay: NS Early or delayed bleeding: NS Urinary retention: NS Headaches: NS Itching: NS
(Tan 2006) LoE 1	Open diathermy haemorrhoidectomy.	40/42	0.2% GTN ointment (GTN) or placebo (P) ointment applied 3 x per day to perianal wounds for a minimum of two weeks; patients measured out 330 mg for each application using a measuring spoon	Paracetamol 1 g four times per day and oral diclofenac 50 mg twice daily used as analgesics in both groups	NS VAS on days 1, 3, 7, 14 and 21	NS consumption of paracetamol and diclofenac	Number of patients with completely healed wounds: GTN superior at 3 weeks (p=0.021), NS at 6 weeks Faecal impaction: NS	Length of hospital stay: NS Secondary haemorrhage: NS Urinary retention: NS Headaches: NS Itching: NS Patient comfort at 24 h: GTN superior (p=0.009) Pain requiring readmission: NS
(Wasvary 2001) LoE 1	Closed Ferguson technique	19/20	0.2% GTN ointment (GTN) or placebo (P) ointment applied 3 x per day to perianal wounds for 7 days; patients measured out 1 g for each application using a measuring spoon	Hydrocodone taken as needed for pain relief. Paracetamol and NSAIDs encouraged for additional analgesia	NS VAS pain scores from POD 1–7	Number of hydrocodone medications required: GTN superior on day 2 (p<0.05), NS on days 1, 3–7. NSAID/paracetamol requirement: P superior (p=0.0003)	Not reported	Morbidity related to ointment application (headaches): P superior (p< 0.001) Frequency of surgical morbidity: NS (morbidity was minor and included difficulty with urination or defecation and minor bleeding)