Symptoms in the Pharmacy :Gastrointestinal Tract Problems(19)
Haemorrhoids treatment timescale
If symptoms have not improved after 1 week, patients should see their
doctor.
Management
Symptomatic treatment of haemorrhoids can provide relief from discomfort
but, if present, the underlying cause of constipation must also
be addressed. The pharmacist is in a good position to offer dietary
advice, in addition to treatment, to prevent the recurrence of symptoms
in the future.
Local anaesthetics can help to reduce the pain and itching associated
with haemorrhoids. There is a possibility that local anaesthetics may
cause sensitisation and their use is best limited to a maximum of 2
weeks.
Skin protectors
Many antihaemorrhoidal products are bland, soothing preparations
containing skin protectors (e.g. zinc oxide and kaolin). These products
have emollient and protective properties. Protection of the perianal
skin is important, because the presence of faecal matter can cause
symptoms such as irritation and itching. Protecting agents form a
barrier on the skin surface, helping to prevent irritation and loss of
moisture from the skin.
Topical steroids
Ointment and suppositories containing hydrocortisone with skin protectors,
previously POM, are now available OTC. The steroid reduces
inflammation and swelling to give relief from itching and pain. The
treatment should be used each morning and at night and after a bowel
movement. The use of such products is restricted to those over 18.
Treatment should not be used continuously for longer than 7 days.
Astringents
Astringents such as zinc oxide, hamamelis (witch hazel) and bismuth
salts are included in products on the theoretical basis that they will
cause precipitation of proteins when applied to mucous membranes
or skin which is broken or damaged. A protective layer is then thought
to be formed, helping to relieve irritation and inflammation. Some
astringents also have a protective and mild antiseptic action (e.g.
bismuth).
Antiseptics
These are among the ingredients of many antihaemorrhoidal products,
including the medicated toilet tissues. They do not have a specific
action in the treatment of haemorrhoids. Resorcinol has antiseptic,
antipruritic and exfoliative properties. The exfoliative action is
thought to be useful by removing the top layer of skin cells and aiding
penetration of medicaments into the skin. Resorcinol can be
absorbed systemically via broken skin if there is prolonged use and
its antithyroid action can lead to the development of myxoedema
(hypothyroidism).
Counter-irritants
Counter-irritants such as menthol are sometimes included in antihaemorrhoidal
products on the basis that their stimulation of nerve
endings gives a sensation of cooling and tingling, which distracts
from the sensation of pain. Menthol and phenol also have antipruritic
actions.
Shark liver oil/live yeast
These agents are said to promote healing and tissue repair, but there is
no scientific evidence to support such claims.
Laxatives
The short-term use of a laxative to relieve constipation might
be considered. A stimulant laxative (e.g. senna) could be supplied
for 1 or 2 days to help deal with the immediate problem while
dietary fibre and fluids are being increased. For patients who cannot
or choose not to adapt their diet, bulk laxatives may be used longterm.
Practical points
Self-diagnosis
Patients may say that they have piles, or think they have piles, but
careful questioning by the pharmacist is needed to check whether this
self-diagnosis is correct. If there is any doubt, referral is the best course
of action.
Hygiene
The itching of haemorrhoids can often be improved by good anal
hygiene, since the presence of small amounts of faecal matter
can cause itching. The perianal area should be washed with
warm water as frequently as is practicable, ideally after each bowel
movement. Soap will tend to dry the skin and could make itching
worse, but a mild soap could be tried if the patient wishes to do so.
Moist toilet tissues are available and these can be very useful where
washing is not practical, e.g. at work during the daytime, and some
patients prefer them. These tissues are better used with a patting
rather than a rubbing motion, which might aggravate symptoms.
Many people with haemorrhoids find that a warm bath soothes their
discomfort.
An increased intake of dietary fibre will increase bowel output, so
patients should be advised to take care in wiping the perianal area and
to use soft toilet paper to avoid soreness after wiping.
How to use OTC products
Ointments and creams can be used for internal and external haemorrhoids
and should be applied in the morning, at night and after each
bowel movement. An applicator is included in packs of ointments and
creams and patients should be advised to take care in its use, to avoid
any further damage to the perianal skin.
Suppositories can be recommended for internal haemorrhoids. After
removing the foil or plastic packaging (patients have been known to
try and insert them with the packaging left on), a suppository should
be inserted morning, night and after bowel movements. Insertion is
easier if the patient is crouching or lying down.
Haemorrhoids in practice
Case 1
Tom Harris, a customer whom you know quite well, asks if you can
recommend something for his usual problem. You ask him to tell you
more about it: Mr Harris suffers from piles occasionally; you have
dispensed prescriptions for Anusol HC and similar products in the
past; and have previously advised him about dietary fibre and fluid
intake. He has been away on holiday for 2 weeks and says he hasn’t
been eating the same foods he does when at home. His symptoms are
itching and irritation of the perianal area but no pain and he has a
small swelling, which hangs down from the anus after he has passed
a motion, but which he is able to push back again. He is a little
constipated, but he is not taking any medicines.
The pharmacist’s view
Mr Harris has a previous history of haemorrhoids, which have been
diagnosed and treated by his doctor. It is likely that his holiday and
temporary change in diet have caused a recurrence of the problem, so
that he now has a second-degree pile, and it would be reasonable to
suggest symptomatic treatment for a few days. You could recommend
the use of an ointment preparation containing hydrocortisone and
skin protectors for up to 1 week, and remind Mr Harris that the
area should be kept clean and dry. You might consider recommending
a laxative to ease the constipation until Mr Harris’s diet gets back to
normal (you advise that he returns to his usual high-fibre diet); a small
supply of a stimulant laxative (perhaps a stimulant/stool softener such
as docusate sodium) would be reasonable. He should see his doctor
after 1 week if the problem has not cleared up.
The doctor’s view
The treatment suggested by the pharmacist should settle Mr Harris’s
symptoms within 1 week. The treatment is of course symptomatic and
not curative. If he continues to suffer from frequent relapse, referral
should be considered. His doctor could advise whether or not to refer
him for injection or removal of the piles.
Case 2
Mr Briggs is a local shopkeeper in his late fifties who wants you to
recommend something for his piles. He tells you that he has had them
for quite a while – a couple of months. He has tried several different
ointments and suppositories, all to no avail. The main problem now is
bleeding, which has become worse. In fact he tells you, somewhat
embarrassed, that he has been buying sanitary towels because this is
the only way he can prevent his clothes from becoming stained. He is
not constipated and has no pain.
The pharmacist’s view
Mr Briggs should be referred to his doctor at once. His symptoms have
a history of 2 months and there must be quite profuse rectal bleeding,
which may well be due to a more serious disease. He has already tried
some OTC treatments, with no success. His age and the description of
his symptoms mean that further investigation is needed.
The doctor’s view
Mr Briggs should be advised to see his doctor. This is not a typical
presentation of piles. He will need a more detailed assessment by his
doctor who will need to look for a cancer of the colon or rectum. Piles
can bleed at times other than when defecating but this is uncommon.
The doctor would gather more information by questioning and from
an examination. The examination would usually include a digital
rectal assessment to determine whether or not a rectal tumour is
present. It is quite likely that this man would require outpatient
hospital referral for further investigations, which would involve sigmoidoscopy
and barium enema.
Case 3
Caroline Andrews is a young woman in her mid-twenties, who works
as a graphic designer in a local art studio. She asks your advice about
an embarrassing problem: she is finding it very painful to pass
motions. On questioning, she tells you she has had the problem for a
few days and has been constipated for about 2 weeks. She eats a diet
that sounds relatively low in fibre and has been eating less than usual
because she has been very busy at work. Caroline says she seldom
takes any exercise. She takes the contraceptive pill but is not taking
any medicines and has no other symptoms such as rectal bleeding.
The pharmacist’s view
Caroline would probably be best advised to see her doctor, since the
symptoms and pain which she has described might be due to an anal
fissure, though they may be caused by a haemorrhoid.
The doctor’s view
A fissure would be the most likely cause of Caroline’s problem. An
examination by her doctor should quickly confirm this. Correction of
the constipation and future preventative dietary advice could well
solve the problem. The discomfort could be helped by a local
anaesthetic-containing cream or gel. If this is applied prior to a
bowel action, the discomfort would be less. In severe cases that are
not settling, referral to a specialist surgeon is necessary in order to
release one of the muscles in spasm for rapid relief of pain. Topical
nitrate (e.g. glyceryl trinitrate 0.2–0.3% ointment) is also now used by
hospital specialists to treat anal fissure (unlicensed indication).
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