Pudendal Nerve Block Techniques for Pain Control After Hemorrhoidectomy

Hemorrhoidectomy is frequently associated with severe postoperative pain despite multimodal analgesia. Ultrasound-guided pudendal nerve block has become an effective regional analgesic technique, but it remains unknown whether blockade performed proximally at the ischial spine provides superior analgesia compared with the more distal transperineal approach. The PINPOINT Trial is a prospective randomized assessor-blinded superiority trial comparing ultrasound-guided transgluteal (proximal) and transperineal (distal) pudendal nerve block in adults undergoing elective hemorrhoidectomy. The primary objective is to determine whether the proximal approach reduces cumulative opioid consumption during the first 48 postoperative hours. Secondary outcomes include pain intensity, opioid-related outcomes, recovery, complications, and patient-reported outcomes.

Inclusion Criteria * Adults aged 18 years or older. * Scheduled for elective hemorrhoidectomy. * Hemorrhoidectomy performed using either the Milligan-Morgan or Ferguson technique. * ASA Physical Status I-III. * Able to understand the study procedures and provide written informed consent. * Able to complete postoperative pain and quality-of-recovery assessments. Exclusion Criteria * Chronic opioid use exceeding 30 mg morphine milligram equivalents per day. * Known allergy or contraindication to local anesthetics. * Coagulopathy or other contraindication to peripheral nerve block. * Infection at the planned injection site. * Pregnancy. * Cognitive impairment preventing reliable completion of study questionnaires or pain assessments.