One of the most significant consequences of undergoing excisional hemor­rhoidectomy is postoperative pain. Although one can argue as to whether pain is a complication versus an expected consequence of excisional hemorrhoidectomy, it is nonetheless, probably the most significant factor that patients have to contend with postoperatively. Unfortunately, despite newer alternatives and multimodal approaches, pain control postoperatively remains one of the major challenges for patient and surgeon. Despite the widespread adoption of performing excisional hemorrhoidectomy as an ambulatory procedure, it still remains the most common reason for delaying discharge after ambulatory surgery [2]. Additionally, increased pain can also contribute to the development of urinary retention in patients that is another cause of unplanned admission to the hospital after day case surgery. In a study looking at predictive factors for postoperative pain in the ambulatory setting Gramke [3] found that the presence of pain preoperatively, the age of the patient, the patient’s fear of their surgery, and the expectations of patient and physician regarding postoperative pain were the strongest predictors in the outpatient setting.

The process of dealing with postsurgical pain management for excisional hemorrhoidectomy begins preoperatively. When the patient is seen in the office a candid discussion regarding pain expectations and strategies to control it are essential to the outcome and satisfaction of the procedure. Unfortunately, obtaining a balance of adequate pain control while preventing opioid-related side effects can sometimes be easier said than done. Nevertheless, when the patient is educated preoperatively as to the multimodal approach to analgesia they realize that the physician can target their pain from a number of different angles. This stepwise multidrug approach to pain management will lead to fewer intolerable adverse events, increased efficacy, and improved patient satisfaction.