Cryotherapy reduces pain post-hemorrhoidectomy (CYPHER): a randomized, controlled, superiority trial of intra-anal ice after surgery for grade III hemorrhoids

Isaac Seow-En; Lionel Raphael Hui Chen; Yun Zhao; Yvonne Ying-Ru Ng; Emile Kwong-Wei Tan

doi:10.3393/ac.2025.00549.0078

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Original Article Anorectal benign disease Cryotherapy reduces pain post-hemorrhoidectomy (CYPHER): a randomized, controlled, superiority trial of intra-anal ice after surgery for grade III hemorrhoids: Isaac Seow-En, Lionel Raphael Hui Chen, Yun Zhao, Yvonne Ying-Ru Ng, Emile Kwong-Wei Tan; Annals of Coloproctology 2025;41(6):537-544.
DOI: https://doi.org/10.3393/ac.2025.00549.0078
Published online: December 24, 2025

Department of Colorectal Surgery, Singapore General Hospital, Singapore

Correspondence to: Isaac Seow-En, MBBS, FRCS Department of Colorectal Surgery, Singapore General Hospital, Outram Rd, Singapore 169608 Email: Isaac.seow.en@gmail.com

• Received: May 5, 2025 • Revised: July 7, 2025 • Accepted: August 2, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
SUPPLEMENTARY MATERIALS
REFERENCES

Abstract

Purpose
We aimed to determine whether intra-anal cryotherapy reduces postoperative pain in patients undergoing hemorrhoidectomy.
Methods
This randomized controlled trial was conducted from January 2023 to August 2024. Patients with symptomatic grade III hemorrhoids were randomized 1:1 to receive either 1 minute of intra-anal cryotherapy or standard postoperative care. Because cryotherapy was applied before reversal of general anesthesia, patients were blinded to treatment allocation. The primary outcome was pain at rest on postoperative day (POD) 1. Secondary outcomes included pain after defecation, time to return to work or non-work activities, 30-day complications, and compliance with analgesia. Pain was measured using the visual analog scale.
Results
A total of 50 patients were randomized (25 per group). All 50 were included in the analysis. Baseline clinicodemographic characteristics were comparable between groups. The primary outcome, POD 1 pain at rest, did not demonstrate superiority of cryotherapy compared with standard care (median, 3.0 vs. 4.0, P=0.062). However, the POD 1 pain score after defecation was significantly lower with cryotherapy than without (3.0 vs. 4.0, P=0.046). On POD 2, median pain scores at rest and after defecation were both significantly lower in the cryotherapy cohort (at rest: 2.0 vs. 4.0, P=0.043; after defecation: 2.0 vs. 5.0, P=0.001).
Conclusion
Intra-anal cryotherapy significantly reduces pain after defecation in the early postoperative period following surgery for grade III hemorrhoids. Its therapeutic efficacy, ease of application, and safety support consideration for routine use.
Trial registration
ClinicalTrials.gov identifier: NCT06005727
Keywords: Cryotherapy; Hemorrhoidectomy; Postoperative pain; Pain management; Randomized controlled trial

INTRODUCTION

Hemorrhoidal disease is widely prevalent among adults, commonly causing pain, bleeding, and discomfort [1], and it poses a considerable economic burden on healthcare systems [2]. Surgical intervention, which is required for 1 in 10 patients, encompasses a range of hemorrhoidoplasty, hemorrhoidopexy, and hemorrhoidectomy techniques [3]. Despite the substantial volume of data, no single technique has proven to be the gold standard.

Because hemorrhoid surgery involves dissection of highly sensitive anoderm, with repeated trauma to raw operative surfaces during defecation, postoperative pain is an important and frequently studied outcome, alongside clinically relevant recurrence rates. Over recent decades, numerous techniques have been proposed to minimize post-hemorrhoidectomy wound discomfort. Lohsiriwat and Jitmungngan [4] described 4 general strategies to reduce postoperative pain: anesthetic methods, surgical techniques, intraoperative adjuncts, and postoperative interventions.

A 2015 systematic review and network meta-analysis comparing 11 surgical approaches for 7,827 patients across 98 randomized clinical trials (RCTs) found greater pain and postoperative morbidity after open or closed hemorrhoidectomy, but fewer recurrences, than after stapled hemorrhoidectomy, which was associated with less postoperative pain and quicker recovery [5]. Closed hemorrhoidectomy, laser hemorrhoidoplasty, chemical sphincterotomy (using botulinum toxin, topical calcium channel blockers, or topical glyceryl trinitrate), oral metronidazole, laxatives, and several topical agents have all been reported in systematic reviews or meta-analyses to show varying levels of clinical efficacy in reducing post-hemorrhoidectomy pain [4, 6–11].

Ice application has long been used to reduce pain and swelling, with well-established physiological benefits. In this prospective randomized trial, we evaluated the intra-anal application of cryotherapy following hemorrhoidectomy as a novel method for reducing postoperative pain in the management of grade III hemorrhoids. Based on its currently established indications, we hypothesized that cryotherapy decreases postsurgical pain in the early postoperative period.

METHODS

Ethics statement

This study was approved by the SingHealth Centralized Institutional Review Board (No. 2022/2357). The trial was registered with ClinicalTrials.gov (identifier: NCT06005727). All participants were informed about the surgical procedures, study objectives, and potential risks and benefits, and provided written informed consent for study inclusion and subsequent publication of results before participation. Data confidentiality was maintained throughout. The study was conducted in accordance with the Declaration of Helsinki and was reported in line with the 2010 CONSORT (Consolidated Standards of Reporting Trials) guidelines [12].

Study design

This prospective, patient-blinded, superiority randomized controlled trial was conducted in the colorectal surgery department of a high-volume tertiary referral center from 2 January 2023 to 31 August 2024. Patients scheduled for hemorrhoidectomy were randomly assigned at a 1:1 ratio to receive intra-anal cryotherapy (intervention) or standard postoperative care (control). Patient recruitment was performed by the operating surgeon at the time of operative listing in the specialist outpatient clinic.

Participants

Eligible participants were adults aged 21–75 years with symptomatic grade III hemorrhoids who were planned for elective Milligan-Morgan hemorrhoidectomy or the procedure for prolapse and hemorrhoids (PPH) stapled hemorrhoidectomy and had an American Society of Anesthesiologists (ASA) physical status of I–II. Patients were excluded if they had thrombosed or ulcerated hemorrhoids; concurrent nonhemorrhoidal anal pathology (e.g., anal fissure, fistula, etc.); or prior anorectal surgery (e.g., anal fistulotomy, hemorrhoidectomy, low anterior resection, etc.). Pregnant women, patients with an ASA physical status ≥III, those on long-term antiplatelet or anticoagulation therapy, and patients undergoing urgent or emergent hemorrhoidectomy were not eligible. Patients planned for synchronous procedures (e.g., colonoscopy) were also excluded.

Randomization and blinding

Upon recruitment, patient identifiers and the scheduled date of surgery were recorded by a dedicated research coordinator. On the day of surgery, a computer-generated randomization sequence was used by the coordinator to allocate patients to the cryotherapy group or standard-care group. The allocation was written on a card, sealed in an opaque envelope, and attached to the patient’s case file, which accompanied the patient into the operating room. After completion of the hemorrhoidectomy, the envelope was opened and the allocation read by the surgeon, who administered cryotherapy if assigned.

Surgery, cryotherapy procedure, and postoperative care

The surgical approach (Milligan-Morgan or stapled hemorrhoidectomy) was determined by the operator and patient after discussion of the risks and benefits in the specialist outpatient clinic. All patients self-administered a sodium phosphate enema for preoperative bowel clearance on the morning of surgery. Procedures were conducted as ambulatory surgery under general anesthesia with the patient in the lithotomy position.

Open excisional Milligan-Morgan hemorrhoidectomy [13] or stapled hemorrhoidectomy using the PPH hemorrhoid stapler [14] was performed in standard fashion. Preoperative local anesthesia was standardized to 2 options (intersphincteric space block or pudendal nerve block) based on operator preference. All procedures were performed by 3 surgeons (ISE, LRHC, EKWT) experienced in both open and stapled techniques.

Intra-anal cryotherapy was delivered using water frozen within a disposable proctoscope (Fig. 1A). Devices were prepared preoperatively and retrieved from the operating room freezer when required. In the intervention group, the surgeon inserted the ice pack transanally to the proximal anal canal for 1 minute while the patient remained under general anesthesia (Fig. 1B). The ice pack was then removed and discarded, anesthesia was reversed, and the patient was monitored in the ambulatory surgery ward before discharge with routine advice.

Postoperative analgesia was standardized to oral paracetamol 1 g 4 times daily for 14 days and oral etoricoxib 60, 90, or 120 mg once in the morning (according to body weight) for 1 week. In the event of drug allergies, oral tramadol 50 mg 3 times daily or as needed was used to substitute paracetamol or etoricoxib. All patients also received oral metronidazole 400 mg 3 times daily and oral lactulose 10 mL twice daily for 1 week. Follow-up was standardized at 1 month after surgery, with an optional earlier review at 2 to 3 weeks according to patient and surgeon preferences. Local analgesic ointments and sitz baths were not routinely prescribed.

Outcomes and data collection

The primary outcome was postoperative day (POD) 1 pain at rest, defined as hemorrhoidectomy wound pain upon waking in the morning before defecation, measured on a visual analog scale (VAS) from 0 (no pain) to 10 (worst pain imaginable). Secondary outcomes were pain at rest on POD 2, 3, 4, 7, 21, and 28; pain after defecation on POD 1, 2, 3, 4, 7, 21, and 28; time to return to work or usual non-work activities; 30-day postoperative return to the emergency department or consultations with a general practitioner for surgical wound–related issues; 30-day complication rate; and 30-day readmission rate. To facilitate reporting, compliance with postoperative analgesia was recorded categorically as 0%, 25%, 50%, 75%, or 100%.

Patient-reported outcome measures were collected by the research coordinator via telephone on POD 1–4, 7, 21, and 28. The coordinator was otherwise not involved in perioperative care. Patients were not informed of their treatment allocation, and this information, together with all recorded patient-reported outcome measures, was not entered into or displayed within the electronic medical record.

Baseline demographic and clinical data were collected, including age, sex, ASA physical status, body mass index, smoking status, presence of diabetes mellitus, type of local anesthesia used, and method of hemorrhoidectomy (Milligan-Morgan or stapled).

Sample size

A prior RCT comparing stapled versus excisional hemorrhoidectomy reported mean POD 1 VAS pain scores of 2.7 and 6.3, respectively [15]. Assuming a mean POD 1 post-hemorrhoidectomy pain score of 5±1 and a hypothesized 25% reduction in the intervention group, with α=0.05 and β=0.1 (power=0.9), we estimated that 21 patients per group would be required to detect a clinically relevant effect. Allowing for a 20% dropout rate, the target sample size was 50 patients (25 per group).

Statistical analysis

All analyses were performed using R ver. 4.4.1 (R Foundation for Statistical Computing). Continuous variables were summarized as medians with interquartile ranges and compared between groups using the Wilcoxon-Mann-Whitney test. Categorical variables were summarized as frequencies and percentages and compared using the chi-square test or Fisher exact test, as appropriate. Pain scores were plotted as mean values with 95% confidence intervals over the 28-day postoperative period. A subgroup analysis compared postoperative pain scores between patients undergoing conventional (excisional) hemorrhoidectomy and those undergoing stapled hemorrhoidectomy. Statistical significance was defined as a 2-sided P-value of <0.05.

RESULTS

The study CONSORT flowchart is shown in Fig. 2. Clinicodemographic and surgical characteristics are compared in Table 1, with no significant differences between the standard care (no ice) and cryotherapy (ice) groups. Intraoperative and postoperative outcomes are summarized in Table 2. The median operating time was 25 minutes in both groups. No patients required intraoperative or postoperative blood transfusions. Median compliance with postoperative analgesia was 75% in both groups.

The primary outcome, POD 1 pain at rest, did not demonstrate superiority of cryotherapy compared with standard care (median, 3.0 vs. 4.0, P=0.062). In contrast, the POD 1 pain score after defecation was significantly lower with cryotherapy than without (3.0 vs. 4.0, P=0.046). On POD 2, median pain scores were significantly reduced in the cryotherapy cohort both at rest (2.0 vs. 4.0, P=0.043) and after defecation (2.0 vs. 5.0, P=0.001).

From POD 3 onward, there were no statistically significant differences in pain scores; however, there was a consistent trend toward lower pain in the cryotherapy group for pain at rest (Fig. 3A) and pain after defecation (Fig. 3B) compared to the standard-care group.

There were no between-group differences in time to return to work, time to return to non-work activities, 30-day emergency department visits or general practitioner consultations, or 30-day morbidity or readmission rates. No patients required additional rescue analgesia. Three patients in the cryotherapy arm sought additional consultation with their general practitioner for concerns about minor wound discharge or bleeding. Three patients in the standard arm and one in the cryotherapy arm reported greater-than-expected postoperative bleeding; all cases resolved spontaneously without readmission or transfusion. One patient in the standard-care group developed postoperative urinary retention and was converted from day surgery to a short-stay ward; the urinary symptoms resolved, and the patient was discharged the following morning.

A subgroup analysis compared postoperative pain following Milligan-Morgan hemorrhoidectomy versus stapled hemorrhoidectomy (Supplementary Table 1). Although no statistically significant differences were detected, there was a trend toward lower median pain scores in the stapled group during the first 4 postoperative days.

DISCUSSION

Cryotherapy has a long history in medicine and surgery. In the mid-1800s, Arnott [16] first reported using cold therapy to relieve cancer pain. For acute soft-tissue trauma or sports injury, cooling has been used to decrease the inflammatory response, reduce edema, minimize hematoma formation through vasoconstriction and decreased tissue permeability, diminish muscle spasm, and modulate pain perception; these effects are well described in modern practice [17–20].

Ice therapy has also demonstrated therapeutic efficacy in the postoperative setting for both arthroscopic and open orthopedic procedures [21, 22], as well as intraoral surgical procedures [23]. A 2024 meta-analysis of 1,462 studies reported that patients receiving cryotherapy after total knee replacement experienced threefold less pain than those who did not receive cooling therapy [22].

Cryotherapy has previously been applied for hemorrhoids, although as a surgical modality rather than an analgesic adjunct. Cryosurgery uses a probe cooled by liquid nitrogen, reaching temperatures as low as −196 °C, to freeze the hemorrhoidal tissue and pedicle, resulting in shrinkage. Cryosurgical hemorrhoidectomy, first described in 1969 [24], became popular in the 1970s and 1980s, with reports of good patient tolerability, excellent outcomes, and minimal complications even in grade IV or prolapsed hemorrhoids [25–29]. In 1980, Macleod compared sclerotherapy, ligation, and cryotherapy across 528 procedures, demonstrating the efficacy and safety of cryotherapy for internal hemorrhoids, using repeated applications of 1 minute each time [28].

To our knowledge, cryotherapy per se has not been used to reduce post-hemorrhoidectomy pain. We hypothesized that ice would provide benefits similar to those observed in soft-tissue injury and other postoperative conditions. Using a lubricated proctoscope filled with frozen water enabled straightforward application up to the anorectal junction, uniform circumferential contact with the anal mucosa, and a mild tamponade effect within the sphincteric high-pressure zone. The 1-minute duration of cryotherapy applied in our study was obtained from a prior technical report by MacLeod [28].

Limitations and strengths

This study is limited by a relatively small sample size, which increases the risk of type II error, particularly regarding the lack of statistical significance for POD 1 pain at rest. Moreover, the sample size calculation was based on a hypothesized treatment effect because no prior studies had evaluated this novel technique. Although the primary outcome of POD 1 pain at rest did not reach statistical significance and superiority was not demonstrated, cryotherapy produced clinically meaningful reductions in POD 1 pain after defecation and lower POD 2 pain scores. The observed differences in this pilot study should therefore be used to power a larger RCT.

In addition, inclusion of both Milligan-Morgan and stapled hemorrhoidectomy introduces cohort heterogeneity. Stapled hemorrhoidectomy is known to be associated with less postoperative pain than Milligan-Morgan hemorrhoidectomy, with potential differences in response to cryotherapy as well. Nonetheless, the use of both techniques reflects real-world practice in our unit, and there were no statistical differences in the proportions of each procedure between the control and intervention groups.

Pain is a subjective symptom with multiple contributory factors, which may influence the generalizability of outcomes across patient cohorts and geographical settings. Long-term outcomes and recurrence rates were not evaluated, although the surgical techniques were comparable across arms, and cryotherapy used purely as an analgesic would not be expected to affect hemorrhoidal recurrence. This randomized trial is, to our knowledge, the first to demonstrate the beneficial effects of ice application in the early postoperative period following hemorrhoidectomy. In this setting, cryotherapy is safe, quick, and easy to perform, and requires minimal additional cost.

Conclusions

Intra-anal cryotherapy significantly reduces pain after defecation within the first 2 postoperative days following excisional or stapled hemorrhoidectomy for grade III hemorrhoids. Given its therapeutic efficacy, ease of application, and safety, intra-anal cryotherapy merits consideration for routine use.

ARTICLE INFORMATION

Conflict of interest

Emile Kwong-Wei Tan is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.

Funding

None.

Acknowledgments

The authors thank the study research coordinators Sin Yee Koh and Rachel Kar Yan Chiang, as well as Ziyun Loh, the department executive, at Singapore General Health for their assistance.

Author contributions

Conceptualisation: ISE; Data curation: ISE, LRHC, YZ; Formal analysis: ISE, LRHC, YZ; Investigation: ISE, LRHC, YZ; Methodology: ISE, LRHC, YZ; Project administration: ISE, LRHC, YZ; Resources: ISE, LRHC, YZ, YYRN, EKWT; Supervision: ISE; Validation: ISE; Visualization: ISE; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

SUPPLEMENTARY MATERIALS

Supplementary Table 1.

Comparison of pain scores for patients who underwent conventional hemorrhoidectomy versus stapled hemorrhoidectomy (n=50)

ac-2025-00549-0078-Supplementary-Table-1.pdf

Supplementary materials are available from https://doi.org/10.3393/ac.2025.00549.0078.

Fig. 1.

Intra-anal cryotherapy. (A) Cryotherapy was applied using water frozen within a disposable proctoscope. (B) The proctoscope was lubricated and inserted to the anorectal junction for a duration of 1 minute.

Fig. 2.

CONSORT (Consolidated Standards of Reporting Trials) flowchart of the study.

Fig. 3.

Postoperative pain scores. (A) Pain score at rest. (B) Pain score after defecation.

Table 1.

Comparison of demographics and surgical characteristics of patients who underwent hemorrhoidectomy with or without cryotherapy (n=50)

Characteristic	Standard-care group (n=25)	Cryotherapy group (n=25)	P-value^a
Age (yr)	50.0 (43.0–64.0)	51.0 (45.0–57.0)	0.734
Sex			0.777
Female	12 (48.0)	14 (56.0)
Male	13 (52.0)	11 (44.0)
ASA physical status			0.700
I	3 (12.0)	5 (20.0)
II	22 (88.0)	20 (80.0)
III	0 (0)	0 (0)
Body mass index (kg/m²)	22.9 (20.5–26.1)	25.2 (22.3–27.2)	0.179
Smoking	6 (24.0)	3 (12.0)	0.462
Diabetes mellitus	0 (0)	2 (8.0)	0.470
Type of local anesthesia			>0.999
Intersphincteric block	8 (32.0)	8 (32.0)
Pudendal block	17 (68.0)	17 (68.0)
Method of surgery			0.550
Conventional hemorrhoidectomy	10 (40.0)	7 (28.0)
Stapled hemorrhoidectomy	15 (60.0)	18 (72.0)
No. of hemorrhoids excised in conventional hemorrhoidectomy			0.304
1–2	5 (20.0)	1 (4.0)
3–4	5 (20.0)	6 (24.0)

Values are presented as median (interquartile range) or number (%).

ASA, American Society of Anesthesiologists.

^aCategorical variables were calculated by the chi-square or Fisher exact test and continuous variables were calculated by the Wilcoxon-Mann-Whitney test.

Table 2.

Comparison of outcomes for patients who underwent hemorrhoidectomy with or without cryotherapy

Outcome	Standard-care group (n=25)	Cryotherapy group (n=25)	P-value^a
Duration of surgery (min)	25.0 (20.0–30.0)	25.0 (20.0–25.0)	0.310
Blood transfusion	0 (0)	0 (0)	-
Overall compliance with postoperative analgesia (%)	75 (50–100)	75 (75–75)	0.980
POD 1 pain score
At rest	4.0 (2.0–5.5)	3.0 (2.0–4.0)	0.062
After defecation	4.0 (3.3–7.0)	3.0 (0–4.0)	0.046^*
POD 2 pain score
At rest	4.0 (3.0–5.5)	2.0 (0.8–4.0)	0.043^*
After defecation	5.0 (4.3–5.8)	2.0 (0–3.0)	0.001^*
POD 3 pain score
At rest	3.0 (2.0–4.0)	2.5 (1.0–3.0)	0.228
After defecation	4.0 (2.0–5.0)	4.0 (1.5–4.0)	0.390
POD 4 pain score
At rest	3.0 (2.0–3.0)	2.0 (0–3.0)	0.558
After defecation	4.0 (3.0–5.0)	3.0 (2.0–4.0)	0.510
POD 7 pain score
At rest	2.0 (0.5–2.5)	1.5 (0–3.0)	0.936
After defecation	3.0 (1.8–3.3)	1.0 (0–3.8)	0.109
POD 14 pain score
At rest	0 (0–1.0)	0 (0–1.3)	0.558
After defecation	1.0 (0–2.0)	1.0 (0–3.3)	0.989
POD 21 pain score
At rest	0 (0–0)	0 (0–0)	0.689
After defecation	0 (0–1.0)	0 (0–0)	0.578
POD 28 pain score
At rest	0 (0–0)	0 (0–0)	0.890
After defecation	0 (0–0.5)	0 (0–0)	0.791
Time to return to work (day)	16.0 (14.0–20.5)	16.0 (14.0–20.5)	0.913
Time to return to normal non-work activity (day)	14.5 (14.0–24.3)	16.0 (14.0–17.0)	0.638
30-Day ED or GP visit	0 (0)	3 (12.0)	0.234
30-Day complication rate	4 (16.0)	1 (4.0)	0.346
30-Day readmission rate	0 (0)	0 (0)	-

Values are presented as median (interquartile range) or number (%).

POD, postoperative day; ED, emergency department; GP, general practitioner.

^aCategorical variables were calculated by the Fisher exact test and continuous variables were calculated by the Wilcoxon-Mann-Whitney test.

^*P<0.05.

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Cryotherapy reduces pain post-hemorrhoidectomy (CYPHER): a randomized, controlled, superiority trial of intra-anal ice after surgery for grade III hemorrhoids

Ann Coloproctol. 2025;41(6):537-544. Published online December 24, 2025

DOI: https://doi.org/10.3393/ac.2025.00549.0078

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Figure

Cryotherapy reduces pain post-hemorrhoidectomy (CYPHER): a randomized, controlled, superiority trial of intra-anal ice after surgery for grade III hemorrhoids

Fig. 1. Intra-anal cryotherapy. (A) Cryotherapy was applied using water frozen within a disposable proctoscope. (B) The proctoscope was lubricated and inserted to the anorectal junction for a duration of 1 minute.

Fig. 2. CONSORT (Consolidated Standards of Reporting Trials) flowchart of the study.

Fig. 3. Postoperative pain scores. (A) Pain score at rest. (B) Pain score after defecation.

Fig. 1.

Fig. 2.

Fig. 3.

Cryotherapy reduces pain post-hemorrhoidectomy (CYPHER): a randomized, controlled, superiority trial of intra-anal ice after surgery for grade III hemorrhoids

Characteristic	Standard-care group (n=25)	Cryotherapy group (n=25)	P-value^a
Age (yr)	50.0 (43.0–64.0)	51.0 (45.0–57.0)	0.734
Sex			0.777
Female	12 (48.0)	14 (56.0)
Male	13 (52.0)	11 (44.0)
ASA physical status			0.700
I	3 (12.0)	5 (20.0)
II	22 (88.0)	20 (80.0)
III	0 (0)	0 (0)
Body mass index (kg/m²)	22.9 (20.5–26.1)	25.2 (22.3–27.2)	0.179
Smoking	6 (24.0)	3 (12.0)	0.462
Diabetes mellitus	0 (0)	2 (8.0)	0.470
Type of local anesthesia			>0.999
Intersphincteric block	8 (32.0)	8 (32.0)
Pudendal block	17 (68.0)	17 (68.0)
Method of surgery			0.550
Conventional hemorrhoidectomy	10 (40.0)	7 (28.0)
Stapled hemorrhoidectomy	15 (60.0)	18 (72.0)
No. of hemorrhoids excised in conventional hemorrhoidectomy			0.304
1–2	5 (20.0)	1 (4.0)
3–4	5 (20.0)	6 (24.0)

Outcome	Standard-care group (n=25)	Cryotherapy group (n=25)	P-value^a
Duration of surgery (min)	25.0 (20.0–30.0)	25.0 (20.0–25.0)	0.310
Blood transfusion	0 (0)	0 (0)	-
Overall compliance with postoperative analgesia (%)	75 (50–100)	75 (75–75)	0.980
POD 1 pain score
At rest	4.0 (2.0–5.5)	3.0 (2.0–4.0)	0.062
After defecation	4.0 (3.3–7.0)	3.0 (0–4.0)	0.046^*
POD 2 pain score
At rest	4.0 (3.0–5.5)	2.0 (0.8–4.0)	0.043^*
After defecation	5.0 (4.3–5.8)	2.0 (0–3.0)	0.001^*
POD 3 pain score
At rest	3.0 (2.0–4.0)	2.5 (1.0–3.0)	0.228
After defecation	4.0 (2.0–5.0)	4.0 (1.5–4.0)	0.390
POD 4 pain score
At rest	3.0 (2.0–3.0)	2.0 (0–3.0)	0.558
After defecation	4.0 (3.0–5.0)	3.0 (2.0–4.0)	0.510
POD 7 pain score
At rest	2.0 (0.5–2.5)	1.5 (0–3.0)	0.936
After defecation	3.0 (1.8–3.3)	1.0 (0–3.8)	0.109
POD 14 pain score
At rest	0 (0–1.0)	0 (0–1.3)	0.558
After defecation	1.0 (0–2.0)	1.0 (0–3.3)	0.989
POD 21 pain score
At rest	0 (0–0)	0 (0–0)	0.689
After defecation	0 (0–1.0)	0 (0–0)	0.578
POD 28 pain score
At rest	0 (0–0)	0 (0–0)	0.890
After defecation	0 (0–0.5)	0 (0–0)	0.791
Time to return to work (day)	16.0 (14.0–20.5)	16.0 (14.0–20.5)	0.913
Time to return to normal non-work activity (day)	14.5 (14.0–24.3)	16.0 (14.0–17.0)	0.638
30-Day ED or GP visit	0 (0)	3 (12.0)	0.234
30-Day complication rate	4 (16.0)	1 (4.0)	0.346
30-Day readmission rate	0 (0)	0 (0)	-

Table 1. Comparison of demographics and surgical characteristics of patients who underwent hemorrhoidectomy with or without cryotherapy (n=50)

Values are presented as median (interquartile range) or number (%).

ASA, American Society of Anesthesiologists.

Categorical variables were calculated by the chi-square or Fisher exact test and continuous variables were calculated by the Wilcoxon-Mann-Whitney test.

Table 2. Comparison of outcomes for patients who underwent hemorrhoidectomy with or without cryotherapy

Values are presented as median (interquartile range) or number (%).

POD, postoperative day; ED, emergency department; GP, general practitioner.

Categorical variables were calculated by the Fisher exact test and continuous variables were calculated by the Wilcoxon-Mann-Whitney test.

P<0.05.