Non-Cochrane · intervention · PM41586878
Metronidazole is an effective method of analgesia following haemorrhoidectomy: a systematic review and meta-analysis.
O'Mahony Aaron, Cullinane Carolyn, MacCurtain Benjamin M, et al. · International journal of colorectal disease · 2026 · PubMed · doi:10.1007/s00384-025-05066-7
Findings
Population Adults after excisional haemorrhoidectomy
13 findings
| Metronidazole, oral or topical, after haemorrhoidectomy | Placebo or no metronidazole control | Post-operative pain, VAS 0-10 (POD 7) post-operative day 7 · Post-operative, excisional haemorrhoidectomy | MD -1.72 [-2.27, -1.18] GRADE not reported 10 studies · 611 participants |
| Metronidazole, oral or topical, after haemorrhoidectomy | Placebo or no metronidazole control | Post-operative pain, VAS 0-10 (POD 1) post-operative day 1 · Post-operative, excisional haemorrhoidectomy | MD -1.18 [-1.63, -0.73] GRADE not reported 10 studies · 549 participants |
| Metronidazole, oral or topical, after haemorrhoidectomy | Placebo or no metronidazole control | Post-operative pain, VAS 0-10 (POD 3) post-operative day 3 · Post-operative, excisional haemorrhoidectomy | MD -0.86 [-1.18, -0.54] GRADE not reported 4 studies · 160 participants |
| Metronidazole, oral or topical, after haemorrhoidectomy | Placebo or no metronidazole control | Post-operative pain, VAS 0-10 (POD 2) post-operative day 2 · Post-operative, excisional haemorrhoidectomy | MD -1.15 [-1.9, -0.4] GRADE not reported 7 studies · 425 participants |
| Oral metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 2) post-operative day 2 · Post-operative, excisional haemorrhoidectomy | MD -0.96 [-1.24, -0.67] GRADE not reported 5 studies · 358 participants |
| Oral metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 1) post-operative day 1 · Post-operative, excisional haemorrhoidectomy | MD -1.29 [-1.95, -0.63] GRADE not reported 7 studies · 442 participants |
| Oral metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 7) post-operative day 7 · Post-operative, excisional haemorrhoidectomy | MD -1.82 [-2.56, -1.08] GRADE not reported 7 studies · 504 participants |
| Oral metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 3) post-operative day 3 · Post-operative, excisional haemorrhoidectomy | MD -0.68 [-1.13, -0.24] GRADE not reported 3 studies · 120 participants |
| Topical metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 1) post-operative day 1 · Post-operative, excisional haemorrhoidectomy | MD -0.97 [-1.69, -0.25] GRADE not reported 3 studies · 107 participants |
| Topical metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 2/3) post-operative day 2/3 · Post-operative, excisional haemorrhoidectomy | MD -1.54 [-2.73, -0.34] GRADE not reported 3 studies · 107 participants |
| Topical metronidazole | Placebo | Post-operative pain, VAS 0-10 (POD 7) post-operative day 7 · Post-operative, excisional haemorrhoidectomy | MD -1.37 [-2.12, -0.62] GRADE not reported 3 studies · 107 participants |
| Oral metronidazole | Topical metronidazole | Post-operative pain, VAS 0-10 (POD 1) post-operative day 1 · Post-operative, excisional haemorrhoidectomy | MD 0.07 [-0.18, 0.32] GRADE not reported 4 studies · 310 participants |
| Oral metronidazole | Topical metronidazole | Post-operative pain, VAS 0-10 (POD 3) post-operative day 3 · Post-operative, excisional haemorrhoidectomy | MD 1.38 [0.44, 2.32] GRADE not reported 5 studies · 430 participants |
Included primary studies 17
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Abbas 2020 Comparison of mean pain score using topical and oral metronidazole in post milligan morgan hemorrhoidectomy patient; A randomized… PMID:32704254 | 2020 | this review only | not stated | not extracted yet |
| Abdullah 2024 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Al-Mulhim 2006 Post hemorrhoidectomy pain. A randomized controlled trial. PMID:17013479 | 2006 | this review only | not stated | not extracted yet |
| Ala 2008 Topical metronidazole can reduce pain after surgery and pain on defecation in postoperative hemorrhoidectomy. PMID:18176825 | 2008 | this review only | not stated | not extracted yet |
| Balfour 2002 A randomized, double-blind trial of the effect of metronidazole on pain after closed hemorrhoidectomy. PMID:12352234 | 2002 | this review only | not stated | not extracted yet |
| Carapeti 1998 Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. PMID:9449871 | 1998 | this review only | not stated | not extracted yet |
| Firdous 2025 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Ghumro 2023 Comparative Study of Placebo Versus Metronidazole as a Role of Pain Relief Post Hemorrhoidectomy DOI:10.48036/apims.v19i2.782 | 2023 | this review only | not stated | not extracted yet |
| Munawar 2023 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Neogi 2018 Is metronidazole a panacea for post-hemorrhoidectomy pain? DOI:10.18203/2349-2902.isj20184629 | 2018 | this review only | not stated | not extracted yet |
| Ng 2006 Pre‐emptive analgesia and metronidazole on post‐haemorrhoidectomy pain control DOI:10.1111/j.1744-1633.2006.00308.x | 2006 | this review only | not stated | not extracted yet |
| Nicholson 2004 Topical metronidazole (10 percent) decreases posthemorrhoidectomy pain and improves healing. PMID:15054681 | 2004 | this review only | not stated | not extracted yet |
| Rabelo 2021 Benefits of flavonoid and metronidazole use after excisional hemorrhoidectomy: a randomized double-blind clinical trial. PMID:34057643 | 2021 | this review only | not stated | not extracted yet |
| Razzaq 2020 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Solorio-Lopez 2015 Efficacy of metronidazole versus placebo in pain control after hemorrhoidectomy. Results of a controlled clinical trial. PMID:26541658 | 2015 | this review only | not stated | not extracted yet |
| Wilkie 2021 Efficacy of postoperative oral metronidazole for haemorrhoidectomy pain: a randomized double-blind, placebo-controlled trial. PMID:32750730 | 2021 | this review only | not stated | not extracted yet |
| Xia 2022 Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial. PMID:34897211 | 2022 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Adults (18 years or older) undergoing open or closed haemorrhoidectomy | Adults after excisional haemorrhoidectomy (open and closed techniques) (n=1297) |
| Intervention | Oral and/or topical metronidazole after haemorrhoidectomy | Oral metronidazole (9 studies plus Neogi), topical metronidazole (2 studies plus Neogi) |
| Comparison | Placebo or control; oral versus topical metronidazole | Placebo (11 studies); oral versus topical (6 studies) |
| Outcomes | Post-operative pain scores (VAS) on POD 1 (primary), POD 2, POD 3 and POD 7 | VAS pain POD 1, 2, 3, 7 (Likert 0-10 treated as equivalent) |
| Study designs | RCTs | 17 RCTs (Balfour excluded from meta-analysis for missing SD) |
| Timing | Not specified | POD 1 to POD 7 |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | No | No | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes | NRSI: N/A · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: No | NRSI: N/A · RCT: No | no |
| 12Impact of risk of bias on the pooled results | No | No | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | No | No | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Critically Low | Critically Low | yes |