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2017 HCHB_digital

Haemorrhoids

Haemorrhoids Haemorrhoids (also called “piles”) are common, affecting around one in two adults at some point in their lives. They occur when the anal cushions (pillows of vein-containing tissues that seal the anal canal and maintain continence) become engorged and swollen. They can be classified into two types: • internal haemorrhoids, which occur inside the lower rectum and are not usually visible. They can cause a feeling of pressure in the rectum and often bleed but are usually painless. Occasionally, they may prolapse (pop out) through the rectum with a bowel motion, which can be quite painful. Some easily “pop back in”, either by themselves or when pushed with a finger, but others may remain prolapsed which can lead to complications • external haemorrhoids, which develop under the skin around the anus. These are typically visible surrounding the anal sphincter. They look like small bunches of grapes and when inflamed become red and very tender, itchy and/ or painful and usually bleed with every bowel motion. Occasionally a blood clot forms inside an external haemorrhoid, and can be felt as a firm, tender mass in the anal area, about the size of a pea. It can cause severe pain. If the clot does not go away by itself with haemorrhoid creams, it can be removed by a doctor in a minor office procedure. When the clot dissolves, excess skin may be left behind which may itch or become easily irritated. Causes of haemorrhoids Haemorrhoids are thought to be caused by certain factors that increase pressure in the anal cushions or degenerate the elastic tissue around the anus. Chronic (long-lasting) constipation, straining during bowel movements, and prolonged sitting on the toilet all interfere with blood flow to and from the rectal area and carry the most risk. Pressure or tissue degeneration in the anal region can also be due to aging, obesity, heavy lifting, chronic diarrhoea or a low-fibre diet, poor posture, pregnancy or childbirth, sitting or standing for long periods of time, spinal cord injury, anal intercourse and, rarely, rectal or bowel tumours. Some families may be genetically more susceptible to developing haemorrhoids. Symptoms of haemorrhoids The most reported symptom is bleeding from the rectal area, especially after a bowel motion. This may be visible either as bright red blood on toilet tissue, in the toilet bowl, or on the outside of the stools. Constant wiping of protruding haemorrhoids can cause an irritation called pruritus ani which results in itching. Some people may also report a burning or dull pain in the rectal area, especially when trying to pass a bowel motion, or when sitting for long periods. Constipation is often associated with haemorrhoids. Initial assessment Many people with haemorrhoids are reluctant to discuss their condition and may prefer to self-select a product. However, a tactful enquiry such as "Are you managing your condition okay or would you like further information from a pharmacist", may be appreciated. Always refer patients reporting rectal bleeding who have not yet seen a doctor to a pharmacist. TREATMENT OPTIONS Category Examples Comments Products for haemorrhoids Natural / herbal products / supplements [GENERAL SALE] eg, Anusol ointment and suppositories (contains zinc oxide, Peruvian balsam, benzyl benzoate) eg, Rectogesic finger protectors [PHARMACY ONLY] eg, Proctosedyl ointment and suppositories* (contains cinchocaine and hydrocortisone) [PHARMACIST ONLY] eg, Rectogesic ointment (contains glyceryl trinitrate) [PRESCRIPTION] eg, Ultraproct ointment and suppositories (contains fluocortolone and cinchocaine) Artemis Vein Support, Calendula, grape seed extract, horse chestnut, witch hazel, Lucas Papaw ointment, Weleda Haemorrhoid ointment Products are usually made up of a combination of different ingredients. Anaesthetics (eg, cinchocaine) numb the area to relieve pain, burning and itching. Astringents (eg, zinc oxide) reduce secretion of mucus and fluids from damaged skin cells and provide a protective barrier. Anti-inflammatories (eg, hydrocortisone) reduce inflammation and swelling of the haemorrhoid, but are recommended only for short-term use as they can cause skin atrophy. Skin protectants (eg, Peruvian balsam) provide a protective coating over the damaged skin, preventing further irritation and relieving itchiness. Benzyl benzoate has weak antiseptic properties and is also used as a vehicle for dissolving other active ingredients. Suppositories may be better for internal haemorrhoids. Remind customers to always remove the foil or plastic wrap before inserting the suppository. Products are best used after a bowel motion. For some treatment products the dosage may change over days or weeks; always follow instructions. Most products are well tolerated but discontinue use if skin irritation or sensitivity develops. Finger protectors protect fingers when applying ointments to the anal area. Glyceryl trinitrate relaxes the internal and sphincter muscle, allowing anal fissures to heal. Antioxidants (eg, grape seed extract) and astringents (eg, witch hazel) can help relieve haemorrhoids. Weleda ointment contains horse chestnut, witch hazel and calendula which can help temporarily relieve the itching, burning and discomfort associated with haemorrhoids. Papaw ointment can temporarily relieve the discomfort of haemorrhoids. Products with an asterisk have a detailed listing in the Haemorrhoids section of OTC Products, starting on page 239. READY, SET, LEARN! Page 80 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION Treatment of haemorrhoids Treatment generally relieves symptoms such as itching, pain and swelling, but will not cure haemorrhoids. The choice of treatment depends on the severity of symptoms and if the haemorrhoids are internal or external. Suppositories or topical ointments that are packaged with a nozzle for internal rectal use are used to treat internal haemorrhoids. Initially it may be more comfortable to apply ointment with a finger rather than use the nozzle, particularly if the haemorrhoids are very inflamed and painful. Topical ointments can be applied directly to external haemorrhoids using a fingertip. Products are best applied after defecation once the anal area has been thoroughly cleaned (unfragranced wet wipes are usually more effective and kinder at cleaning the region than toilet paper). It can take up to one week for external haemorrhoids to disappear or improve. Many patients will require further specialised therapy, such as sclerotherapy (injection of a substance into the haemorrhoid), rubber-band ligation therapy (small rubber bands are placed around the haemorrhoid causing it to shrink), laser or infrared coagulation (causes the haemorrhoid to harden and shrivel), stapled haemorrhoidopexy (staples are used to anchor the haemorrhoid in place) or surgery for persistent haemorrhoids. Advice for customers • Keeping the stools soft helps prevent haemorrhoids from occurring. »» Eat a diet high in fibre (fruit, vegetables, wholegrains). »» Maintain a reasonable fluid intake (six glasses of water a day). »» Treat any constipation if present (see Constipation) and avoid straining when passing a bowel motion if possible. • Avoid foods and drinks that may make haemorrhoids worse, including spicy foods, nuts and seeds, and alcohol. • Get plenty of exercise and avoid sitting for long periods. • Do not ignore the urge to go to the toilet (“holding-on” can lead to increased pressure inside the anus). • Use unfragranced wet wipes instead of toilet paper to clean the anal area. »» Avoid soap as this may further aggravate the problem. »» Ensure used wipes are discarded appropriately and not flushed as they can easily block sanitary systems. • Apply products only as directed and for the recommended time. If treatment fails to improve haemorrhoids, seek further medical advice. • A cold compress applied to the area may help with symptoms. »» Alternatively sitting in a warm bath for 15–20 minutes at a time (a sitz bath) after each bowel movement may provide relief. »» Gently pat the area to dry afterward, or alternatively use a hair dryer. • Wear cotton underwear to minimise discomfort. • Avoid scratching the anal area. • Sit on a cushion rather than a hard surface to reduce the swelling of existing haemorrhoids and prevent the formation of new ones. Refer to PHARMACIST Generally, all patients with rectal bleeding who have not received a formal diagnosis should be referred to a doctor. Pharmacists should also refer any customers with “yes” answers to the following questions to a doctor. • Does the person have any other health conditions (eg, immunosuppression, diabetes, is pregnant or breastfeeding)? • Does the person take any other medication, either prescribed by a doctor or bought from a shop or supermarket (including herbal/ complementary medications) that may be causing constipation? • Is the person unsure of the diagnosis? • Is there any rectal bleeding not related to bowel motions? • Is blood mixed into the stool (not just sitting on top of it)? • Have the symptoms lasted more than three weeks? • Have the symptoms not improved after a week of treatment? • Does the haemorrhoid prolapse and have to be pushed back in, or can’t be pushed back in with a finger? • Is there any pus or other signs of infection around the anal area? • Is there any severe sharp pain with bowel motions or a feeling of not being able to completely empty the bowel? • Are any other symptoms present (eg, abdominal pain, fever, vomiting, nausea, loss of appetite)? • Has the person with the haemorrhoids noticed an unexplained weight loss or feels tired all the time? • Have there been any recent changes in bowel habits (eg, onset of constipation or diarrhoea for the first time)? • Is the person buying for a child with supposed haemorrhoids? • Does the person have any allergies to topical medicines? Locate this icon throughout the Healthcare Handbook. Then find the corresponding Pharmacy Today and ELearning articles. Read all three to unleash learning prizes and giveaways! Page 81

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