Treatment and Prevention of Hemorrhoids

Self-Study Project: Hemorrhoids (Anorectal Disorders)

Three Questions:

1. What is the generally accepted application process of hemorrhoidal medications for self-treatment?
2. What are non-pharmacologic options I may be able to implement for prevention/relief form hemorrhoids?
3. What patient specific factors must be considered before choosing a product (medical history, current prescriptions, physical ability, etc.)?

The one area of self-care products I currently feel uncomfortable with is recommending a treatment option to a patient with hemorrhoids (anorectal disorders). During my career as a pharmacist, this is a condition I don’t see being eradicated with roughly 10 million cases being reported by Americans each year.¹ Hemorrhoids have been affecting humans for a very long time, including Napoleon Bonaparte during his infamous battle of Waterloo.² In order to help my future patients, I need to be knowledgeable about appropriate use of nonprescription options to fast-track them to relief.

The application of medication in the anorectal region can pose one of the biggest challenges. Incorrect application can lead to fecal incontinence, a terrible disorder affecting roughly 24 % of the population.³ There are three defined methods depending on location or applicator used according to the Mayo Clinic: external, internal, and aerosol.⁴ First, any region with an external hemorrhoid must be cleaned with mild soap/water or a cleansing wipe. After, pat gently with a soft towel or toilet paper until dry. Apply the medicine to the sore area using tissue, gauze, or finger cot.⁴ Direct finger to skin contact is not recommend as this could introduce a potential for infection or other issues. Second, internal hemorrhoids usually require the assistance of an applicator. The patient will need to remove the cap from the tube of ointment/cream and attach the applicator to the open end.⁴ Next, squeeze the tube until ointment/cream flows gently out the applicator.⁴ Evenly spread the excess ointment/cream over the outside of the applicator to assist in entry.⁴ Insert slowly in the rectum as this is an innervated area with nerves and can be sensitive. Slowly squeeze the tube until a desire amount of medication is released inside the rectum to provide relief.⁴ Lastly, some hemorrhoid products come as an aerosol foam. Identical to the internal medications, these also come with an applicator; however, the aerosol container will not be inserted.⁴ The applicator is usually a plunger which is attached to the aerosol container.⁴ While holding the aerosol container upright, release foam into the applicator. After, remove the applicator, place a small amount of foam over the outside for lubrication, and insert slowly into the rectum.⁴ Operate the plunger as far as possible and remove after medicine has been placed internally. The three methods listed above should cover most hemorrhoid products but by no means is complete.

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Many patients may not be aware anorectal disorders, such as hemorrhoids, can be treated or prevented by non-medication alternatives. A diet high in fiber is crucial for proper bowel movements. It is estimated that 95 % of Americans do not eat enough dietary fiber and only have a mean intake of 16.2 grams.⁵ This is a natural way to soften stools and reduce strain. This will suppress the chance of hemorrhoid development or becoming further irritated. The suggested amount of fiber is 25-40 grams/day and examples include fruits (oranges, apples, bananas, etc.), vegetables (dark color), breads/grains (whole grain, rye, cracked wheat), and nuts (almonds, pistachios, pumpkin seeds).^6,7 It is important to understand to eat nondigestible carbohydrates and macromolecules commonly found in plants.⁵  The increased in intake needs to occur slowly and if fiber intake cannot be increased, other alternatives such as psyllium or methylcellulose can be implemented.^4,6 In addition, the necessary amount of fluid intake could work in synergy along side fiber. Patients need to avoid caffeinated beverages and need a minimum of 1.5 to 2 liters/day.⁶ This fate is easier said than done with 85 % of Americans consuming at least one caffeinated beverage a day.⁸ This helps avoid constipation and creates a regular bowel movement from proper hydration. Further, anytime an urge for a bowel movement arises, go and do not hold.While the bowel movement is occurring, do not spend ample time on the toilet.⁶ Both exercises lead to increased strain of the vessels in the anorectal region causing new hemorrhoids. Other options include a sitz bath or keeping proper hygiene of the anorectal by proper cleaning after each bowel movement with lubricated wipes/pads.⁶ If the hemorrhoid is beyond self-care, there are surgery options including rubber band ligation and hemorrhoidectomy.¹

Every patient walking into a pharmacy could all have the common denominator of a hemorrhoid, but previous life circumstances may prevent them from the use of certain products. Before the selection, several factors need to be considered. First, determine if the hemorrhoid is internal or external.⁶ This answer can immediately remove certain products as some are external use only. Next, a medication profile review will eliminate the possibility of drug-drug interactions and any allergies the patient has reported. An example includes the drug-drug interaction of vasoconstrictors with antihypertensives, monoamine oxidase inhibitors (MOAIs), and tricyclic antidepressants (TCAs).⁶ Also, ask the patient further if the list is up-to-date along with if they are taking any current supplements. Then, as a pharmacist, I can further dive into the patients’ description of their hemorrhoids collecting information such as type, location, and severity to focus on the correct product.⁶ Lastly, analyze the patients’ ability to be able to apply the medication. If they are physically unable to, then an alternative would need to be considered. However, I believe the most important factor is to get the patient comfortable with talking about their hemorrhoids.

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The area of anorectal disorders is always difficult to discuss because not only will the pharmacist shy away form the discussion, but the patient also struggles. Therefore, I choose this topic to be able to expand my knowledge. I felt I really struggled to grasp all the details to be able to make an evidence-based decision on a product. The assignment allowed me to explore other resources and garner information enhancing my comfort over hemorrhoidal products. This will in return allow the patient to trust they are in good hands and on a path for relief/removal of hemorrhoidal discomfort.

References

1. Sun Z, Migaly J. Review of Hemorrhoid Disease: Presentation and Management. Clin Colon Rectal Surg. 2016;29(1):22–29. doi:10.1055/s-0035-1568144. Accessed October 6, 2019.
2. Villalba H, Abbas MA. Hemorrhoids: modern remedies for an ancient disease. Perm J. 2007;11(2):74–76. doi:10.7812/tpp/06-156. Accessed October 6, 2019.
3. Foxx-Orenstein AE, Umar SB, Crowell MD. Common anorectal disorders. Gastroenterol Hepatol (N Y). 2014;10(5):294–301. Accessed October 6, 2019.
4. Anesthetic, Local (Rectal Route) Proper Use. Mayo Clinic. https://www.mayoclinic.org/drugs-supplements/anesthetic-local-rectal-route/proper-use/drg-20069963. Published October 1, 2019. Accessed October 6, 2019.
5. Quagliani D, Felt-Gunderson P. Closing America’s Fiber Intake Gap: Communication Strategies From a Food and Fiber Summit. Am J Lifestyle Med. 2016;11(1):80–85. Published 2016 Jul 7. doi:10.1177/1559827615588079. Accessed October 6, 2019.
6. Chan J. Chapter 17: Anorectal Disorders. In: Handbook of Nonprescription Drugs: An Interactive Approach. 19th ed. Washington, D.C.: American Pharmacists Association; 2018.
7. High-Fiber Foods. Metamucil®. https://www.metamucil.com/en-us/articles/Fiber-and-diet/high-fiber-foods. Accessed October 6, 2019.
8. Mitchell D.C., Knight C.A., Hockenberry J., Teplansky R., Hartman T.J. Beverage caffeine intakes in the U.S. Food Chem. Toxicol. 2014;63:136–142. doi: 10.1016/j.fct.2013.10.042. Accessed October 6, 2019.