Anorectal diseases are common in the world, with most of these conditions being temporary and not requiring surgical treatment. For those patients who do need surgery, such procedures can usually be performed as day surgery with a minimal number of complications. The treatment of proctological disease does not finish at the time of surgery. In most cases, the patient is discharged from hospital with an open wound, and post-surgical healing takes several, or even a dozen, weeks. The rate of minor complications is relatively high, with some studies indicating that it may reach up to 50%, but serious postoperative complications are not common (1). Hence, postoperative care, instructing the patient on post-surgical procedures, conducting follow-up visits, and identifying potential complications fast, are of great importance. There are not many publications on the postoperative care regimen for proctological patients, and it is a challenge to design a good prospective study because individual procedures differ and are difficult to compare. Most papers focus on haemorrhoidal disease. The ESCP guidelines and other coloproctological societies do not provide recommendations for postoperative care, and the 2018 ERAS guidelines do not address proctological patients (2). Postoperative care has its onset before the surgery. The obligatory consent form for the procedure is not always understandable to the patient. The patient should be informed about the inconvenience of postoperative treatment, such as possible pain after the procedure and the need for regular dressing changes (3).

For the purposes of systematizing this article, postoperative care in patients with specific diseases will be presented.

Wound healing after haemorrhoidectomy is usually not problematic. The wound is in the anal canal and does not need special care. Severe anal pain, which intensifies after defecation, is the primary issue. The pain has been the subject of many scientific studies.

Pain after haemorrhoidectomy is described as moderate to severe and constitutes a challenge in postoperative care (4). Various pharmacological treatments, anaesthesia strategies, and surgical techniques have been investigated to provide postoperative analgesia. The PROSPECT (procedure-specific pain management) working group, a collaboration of anaesthesiologists and surgeons, has prepared recommendations for pain management specific to common surgical procedures. Previous PROSPECT guidelines concerning pain management were published in 2010 and 2017. Their update was made in 2023 (5), and it is summarized in the table 1.

In a systematic review published in 2022, the authors featured additional methods for managing postoperative pain (6). Approximately 157 studies along with data from 15 meta-analyses were included in the review. In general, strategies to reduce pain after haemorrhoidectomy were divided into four groups: anaesthetic methods, surgical techniques, intraoperative aids, and postoperative interventions, as presented in table 2.

Lateral internal sphincterotomy may be performed as a supplement to surgery to reduce pain after haemorrhoidectomy, however it increases the risk of gas incontinence. Chemical sphincterotomy (botulinum toxin, topical calcium channel blockers, and topical glyceryl trinitrate) has also been effective in reducing postoperative pain. Similarly, other topical agents such as anaesthetic cream, 10% metronidazole ointment, and 10% sucralfate ointment have been effective. Postoperative administration of oral metronidazole, flavonoids, and laxatives has been associated with significant pain reduction after haemorrhoidectomy.

Various data on the use of metronidazole is reported in the above-mentioned guidelines. The mechanism by which metronidazole alleviates pain after haemorrhoidectomy is vague. A popular theory states that metronidazole has a strong antibacterial effect on anaerobic bacteria that may make wound healing more difficult. Another suggested mechanism is that metronidazole has antioxidant properties that support wound healing. Research has shown that haemorrhoid wounds heal without the use of antibiotics. There is ongoing debate about the usefulness of metronidazole after haemorrhoidectomy, especially in the era of increasing bacterial resistance to antibiotics, which the World Health Organization considers one of the greatest threats to global health. In another study on the effects of metronidazole (7), the authors made an analysis of four RCTs involving 336 participants, with 169 patients randomly assigned to the metronidazole group and 167 to the control group. A significant reduction in VAS was observed at all time points, with the maximum reduction noticed on the 5th day after haemorrhoidectomy (mean difference -2.28; 95% confidence interval [CI] -2.49 to -2.08; P < 0.001). Generally, there was a reduction in the number of patients requiring additional pain treatment in favour of metronidazole. There was a trend towards fewer painkiller tablets taken in favour of metronidazole, but this did not reach statistical significance.

Diet plays an extremely important role in the postoperative period (4). After haemorrhoid surgery, it is not necessary to starve the patient or put them on a liquid diet; a high-fibre diet and drinking at least 1.5-2 litres of water per day are recommended. It is critical to maintain the consistency of stools. If it is necessary, the use of paraffin or lactulose is recommended, but strong laxatives should be avoided. Both hard stools and diarrhoea may worsen healing in the postoperative period. Hard stools cause mechanical injury to the wound in the anal canal, whereas frequent passage of liquid stools may irritate the healing wound (8).

There has also been a first prospective study on the effect of stool consistency on postoperative pain (9), where the Bristol scale was used to assess stool consistency after haemorrhoidectomy. That has been the first study to prove that the harder the stool, the greater the pain. Unlike previously described risk factors for postoperative pain, such as gender and age, patients can control stool consistency through conventional postoperative recommendations given by surgeons, such as the use of oral laxatives and the consumption of adequate amounts of water. Such routine management should successfully reduce stool hardness and thus pain during defecation.