UDK 616.351/.352-006.04-08 /STRU^NI RAD DOI:10.2298/ACI1003083G

Supportive therapies in ano-rectal diseases – Are they really...... useful?

P. J. Gupta, Fine Morning Hospital and Research Center, D/9, Laxminagar, Nagpur. India.

Epidemiological features of proctological disease Ointments containing opiates, xylocain, amethocain, are not well known because available studies have and cinchocain to relieve pain, belladonna to alleviate provided variable conclusions. Risk factors fre- sphincter spasm and silver nitrate to promote healing have quently mentioned include heredity, high socio- all had been in use. These mixtures are introduced either economic level, obesity, smoking, a diet rich in with the finger or through a short rectal bogie to ensure a fats, alcohol, spices and pepper as well low fluid thorough application over the affected part of the anus.

rezime intake have all been implicated. Recent reports of topical application of Solcoderm, While treating patients with various ano-rectal pa- Ketanserin gel, eutectic mixtures of 5% Prilocain and 5% thologies, apart from definitive treatment, various ad- Lidocain or combination of Policresulen and Cinchocain ditional or supportive therapies are being advised both have all shown good symptomatic relief in anal pain. 2 by the family physicians and surgeons. These include Topical sucralafte and metronidazole have been found local applications, sitz baths, modification in the diet to reduce pain after hemorrhoidectomy and promoting and life style. But are these supportive therapies really faster wound healing. beneficial or they are just empirical? Some hemorrhoids are associated with high resting anal This paper elaborates the various supportive therapies canal pressures. A topical glyceryl trinitrate 0.2% oint- advocated in the common anal disorders like hemor- ment was effective in relieving symptoms of early grade rhoids, anal fissure and fistula and summarizes the ad- hemorrhoids associated with high resting anal canal pres- vantages and pitfalls of these treatment additives. sures. Key words: suppository, haemorrhoid cream, sitz bath, A topical treatment for hemorrhoidal pain and for diet spasms of the sphincters and muscles containing amino acid L-arginine can be applied directly to the affected INTRODUCTION area. This topical preparation is effective in relieving the pain of hemorrhoids or in treating conditions resulting espite thousands of years and millions of patients from spasms of sphincters of the anal canal including anal Dwith pain, discomfort, and perceived embarrassment fissure and postoperative rectal pain. of ano-rectal disorders, where the exact nature and A rectal cream containing 0.25% oxethacaine chlor-hy- cause of the conditions is quite clear, the standard con- drate has been demonstrated to be clinically efficient in servative treatments are still a matter of debate. the treatment of Grades I and II hemorrhoids as well as in Therapies in vogue such as topical agents, hydrother- post surgical treatment both for the attenuation and elimi- apy, diet, and lifestyle factors are some of the non-inva- nation of pain and the clinical objectives of the pathology sive approaches to these conditions. in question. A heparin and enzyme (trypsin and chymotrypsin) paste Hemorrhoid creams has been reportedly found to improve the sympto-ms by The role of the hemorrhoid topical preparations is to resolution of acutely inflamed hemorrhoids. Topical nifedipine, diltiazem and 1% isosorbide dini- provide temporary relief from hemorrhoidal discomfort, 3 to prevent further irritation, to provide shrinkage of the trate, are few other options in the conservative treatment swollen hemorrhoidal tissue and prompt soothing relief of thrombosed external hemorrhoids. Synthetic Diosmine from painful burning, itching and discomfort.1 has also been used as a topical treatment for acute hemor- 84 P.J. Gupta ACI Vol. LVII rhoids. The treatment is very well tolerated and produces Some common astringents that are used include Hama- no unwanted side effects if properly used. melis water, which is a mild astringent prepared from A mixture of honey, olive oil, and beeswax has been twigs of Hamamelis virginiana. It helps in relief from the found to be clinically effective in the treatment of hemor- hemorrhoidal itch. Zinc oxide prevents the irritation at the rhoids and anal fissure. The honey mixture significantly perianal area by forming a physical barrier on the skin that reduced bleeding and relieved itching in patients with protects the contact of the irritated skin with aggravating hemorrhoids. Patients with anal fissure showed significant liquid or stool from the rectum. reduction in pain, bleeding, and itching after the treat- Vasoconstricting agents help in relieving symptoms of ment. No side effect was reported with use of the mixture. hemorrhoids. On application, these drugs reduce he-mor- These topical preparations should be used with caution rhoidal congestion. These products additionally contain in patients with heart disease, hypertension, thyroid dis- mild form of anesthetic, which helps in relieving pain and ease, diabetes, pregnant or breast-feeding women and pa- itching. The commonly used vasoconstrictors are Ephed- tients having dysurea due to enlarged prostate. The patient rine sulfate and Phenylephrine. should not exceed the recommended daily dosage unless Passing hard and dry stool is the most traumatic experi- directed. Patient is advised to report in case of bleeding or ence in patients having anal pathology as it results in tear- if condition worsens or does not improve within 7 days. ing of the skin around the anus, as also in tearing and These agents may provide short-term relief from anal cracking which ends in bleeding. Again, when this tender discomfort, but there is a lack of evidence to support their skin comes in contact with liquid or stool, it ca-uses the widespread use. They do not affect the underlying patho- skin to further itch and burn. logical changes in the anal cushions. Continuous applica- Protectants, when applied in the form of suppositories, tion can cause eczema and sensitization of the anoderm; form a physical barrier on the skin and results in reducing rectal absorption can lead to systemic side effects. 4 the pain quotient and the pruritus. These also protect the Suppositories - Rectal route is being used effectively in broken skin from coming in contact with offending parti- proctological disorders since time immortal. Drugs mixed cles in the stool. with various adjuvants and administered through the rec- While a variety of protectants are used in suppositories, tal route provide satisfactory pharmacokinetics, which a few commonly used are : have an acceptable local tolerance. Aluminium hydroxide gel, Glycerin, Lanolin, Aloe Suppositories are a medicated solid dosage form in- Vera, White petrolatum, Zinc Oxide and Calamine. tended for insertion into the body orifices. 5 The ano-rec- The anal and perianal skin are susceptible to variety of tal physiology provides a sufficiently adequate surface organisms, which can lodge there either from the adjoin- area for drug absorption. The surface area is also perme- ing area or from the contaminated stool. The chances of able to non-ionized drugs. Suppositories formulations are contamination further increase when the skin gets bruised rather efficient in variety of different bases to increase ab- during defecation. sorption and reduce complications. Antiseptics are used to keep the area clean and to pre- Suppositories come in various sizes and shapes, which vent infection. The commonly incorporated antiseptics in- facilitates their insertion and retention in the cavity. Adult clude- Benzalkonium chloride, Boric Acid and Fra-mycet- rectal suppositories weighed about 2 g while those for ine sulphate. children are about half that weight. Keratolytics are chemicals, which cause the outer layers Suppositories containing local anesthetics agents act by of skin and other tissues to disintegrate when applied. numbing the nerve endings and provide temporary relief They eventually help in better penetration in the tissues of from pain and itching. These act by causing a reversible other medications contained in the suppositories to bring block to conduction in the sensory nerves. These are well quicker relief. The two commonly used keratolytics are absorbed from the mucus membrane and used as surface Aluminium Chlorhydroxy Allantoinate and Resorcinol. anesthetics. These provide good relief from discomfort Policresulen coagulates necrotic or pathogenically al- encountered in cases of strangulated hemorrhoids, fissures tered tissue in anorectal disorder and promotes desqua- and perianal hematomas. mation of such tissues.6 The healthy tissues surrounding Several glucocorticosteroids are used in rectal supposi- the wound are not affected. As a local haemostatic, poly- tories. They include hydrocortisone and its derivatives, di- cresulen coagulates blood proteins thereby inducing mus- flucortolone valerate and predinisolon. The steroids act as cle fibers of small vessels to contract and thus any hemor- decongestant, anti-inflammatory and anti pruritic agents rhage in the anal canal or in the perianal area is controlled. and in doing so they eliminate inflammation and mucus It also induces hyperemia in the wound area and thereby discharge. It has been postulated that the analgesic effects stimulates regeneration and re-epithelization process. It of local anesthetics is apparently prolonged by an increase also has an antimicrobial property which guards against in the threshold for pain by the anti-inflammatory effect infection and prevents inflammation. Policresulen also has of steroids. astringent property and thus it suppresses oozing. Suppositories containing astringents causes the cells of It has been suggested that the suppositories should be the anal skin to clump thereby drying the skin, which inserted with the patient lying on the left lateral side with gives relief from burning and itching. the right knee bent. The suppositories should be dipped in water before use, which facilitates the easy insertion of the suppositories. It should be kept in cold water or refrig- Br. 3 Supportive therapies in ano-rectal diseases 85 Are really useful?

erator for half an hour before use if the suppositories are It is found that hot water sitz bath produced relaxation of too soft to be inserted, especially during warm weather. internal urethral sphincter, causing vesical contraction and Emptying of bowel should be avoided for at least an hour eased urination in patients operated for hemorrhoidec- after insertion of the suppositories to allow it to be fully tomy. absorbed. At time a good response is achieved with a "contrast Although, it is a practice to introduce the tapering end of bath" of both hot and cold. For this a patient should have a the suppositories first and the base at last, one rando- tub of hot water (about 1100 F/430 C) and one tub of ice mized study has found that the retention rate was higher water. The patient should sit in the hot water for three to and spontaneous expulsion rate was lower when the sup- four minutes and in the cold for 30-60 seconds. This is re- positories was introduced with "base first’"technique. It peated three to five times, always ending with the cold was postulated that reversed vermicular contractions or water. pressure gradient of the anal canal might have been re- If two tubs are not handy, the patient may sit in a hot sponsible for this finding. It was also suggested that "tor- bath (up to the navel). Then the patient stands up in the pedo-shaped" suppositories should be designed which water and pulls a cold towel between the legs and over the would have a better acceptability and efficacy. pelvis in front and back. The cold towel is held in place Suppositories containing non-steroidal antiinflammatory for up to 60 seconds. Then the patient should sit back into drugs are commonly used for relief of pain in the pediat- the hot bath, and repeat the process 3-5 times, ending with ric, obstetrical and general surgical practice. However, re- the cold towel. ports are available where these suppositories have caused A variety of medicaments and additives have been used complications like rectal and anal ulcerations, rectal stric- and recommended with the sitz bath for different proc- ture, anal stenosis, proctitis and perirectal cellulites. Sys- tological disorders. These include antiseptic solutions, ta- temic absorption of topically applied steroids can occur in ble salt, Povidone Iodine, Potassium Permanganate, Vine- children. 7 gar and Hydrogen peroxide. Aromatherapy application us- Absorption of drugs through suppositories can be er- ing essential oils with Lavender, Myrrh, Neroli, Rose, ratic and unpredictable. Some suppositories either leak or Grapefruit, Mandarin, Orange, and Roman Chamomile are expelled after insertion resulting in a futile exercise. are also being recommended. How far these additives are useful remains a mystery. Sitz bath It should be understood that the basis of sitz bath is ap- plication of variable temperature to the ano-perianal re- A sitz bath, also called a hipbath is a type of bath in gion and the other factors are secondary. It should also be which only the hips and buttocks are soaked in water or remembered that the addition of medicaments to the water saline solution. A sitz bath is used for patients who have has caused harm than help at many occasions. Local aller- had surgery in the area of the rectum, or to ease the pain gic reactions, dermatitis, dissemination of genital herpes, of hemorrhoids,8 uterine cramps, prostate infections, pain- dissolution of sutures of surgical wound, and development ful ovaries, and/or testicles. Inflammatory bowel diseases of pustules and bullae have been reported. are also treated with sitz baths. Sitz bath is frequently prescribed but proper instructions Sitz bath is frequently recommended by physicians for a as to how to perform it are seldom given to pati-ents. In variety of disorders including anorectal diseases and general, the water is expected to cover only the perineum gynecologic conditions. Warm sitz baths are one of the and lower pelvis. Immersing other parts of the body in easiest and most effective ways to ease the pain of hemor- warm water could lead to systemic vasodi-latation and de- rhoids. A brief, cool sitz bath helps ease inflammation, crease circulation to the perineal area.10 constipation, and vaginal discharge. It can be used to tone Because of the explicit nature of this treatment, patients the muscles in cases of bladder or bowel incontinence. should be given specific instructions on how to correctly Even though no scientific evidence is available to indi- perform sitz bath, including the temperature of the water, cate that sitz bath can promote faster healing or offer re- time and frequency for which the bath should be taken. It duction in postoperative complications, it is probably fre- should ideally be taken twice daily for about ten minutes quently recommended because of the low morbidity it each time. The temperature of water should not be too hot carries. 9 Furthermore the other perceived benefits include as there are reports of gluteal and perineal burns following improved anal hygiene and symptomatic relief for some sitz bath especially in children. patients. Food and its ingredients have a pivotal role in causing The exact physiology of sitz bath is not known. It has and preventing ano-rectal diseases. People who consis- been hypothesized that pain relief after sitz bath could be tently eat a high-fiber diet are less likely to get hemor- the result of internal anal sphincter relaxation with a re- rhoids, but those who prefer a diet high in processed foods sulting diminution of the rectal neck pressure. A decrease can expect them. A low-fiber diet or inadequate fluid in- in internal sphincter pressure during the sitz bath has been take can cause constipation, which can contribute to hem- observed. It is found that warmer water led to a longer du- orrhoids in two ways: It promotes straining during defeca- ration of low internal sphincter pressure. It is postulated tion and it also aggravates the hemorrhoids by producing that the relaxation of the internal sphincter muscle is me- hard stools that further irritate the swollen hemorrhoidal diated through sensory perianal skin receptors getting cushions. 11 stimulated by warm water. The decrease in spasm and pain relief is attributed to this ‘thermosphincteric reflex’. 86 P.J. Gupta ACI Vol. LVII

Chilies and other spices have been known to aggravate and myths about diet as discussed above before recom- symptoms of anal pathologies. Chilies are generally be- mending it.16 lieved to be harmful to patients with anal pathologies like anal fissures and hemorrhoidal disease. Consequently, CONCLUSIONS these patients are advised to take a relatively bland diet Supportive therapies have a definite role in the manage- containing little or no spices and chili. This view is per- ment of ano-rectal diseases. Dietary modifications, local haps based on experimental findings that red chili powder creams and ointments, hydrotherapy, change in lifestyle damages the colonic mucosa. Intragastric instillation of and toilet training have their own place in the treatment of red chili powder in human volunteers caused a consider- these diseases both before and after surgical intervention. able increase in the deoxyribonucleic acid content of gas- While it is expected that the a physician should take a tric aspirate, suggesting exfoliation of the surface epi- good advantage of these measures, he should be prudent thelial cells. 12 not to get carried away with the claims made by the Sun dried chilies, which contains capsaicin and dihydro- manufacturers of the various topical preparations. A judi- capsaicin contains nitrophenols, which by producing ni- cious application of these measures on case to case basis trosation of foodstuff, often believed to be gastric stimu- should certainly be beneficial in reducing the aggressive- lant, are known to cause toxicity in the gastro-intestinal ness of the disease as well as preparing the patient for sur- tract. Capsaicin is known to affect visceral sensory per- gery in the best environment, followed by better postop- ception. erative convalescence and reduced complications. The exact mechanism by which chilies influence the colonic and rectal physiology is not well understood. Cap- SUMMARY saicin, the pungent principle of hot pepper, has the ability to excite and later defunctionalize a subset of primary af- SUPORTIVNA TERAPIJA KOD ANOREKTALNIH ferent neurons. Chilies are known to cause rectal hyperal- OBOLJENJA - DA LI JE ZAISTA KORISNA? gesia in patients with irritable bowel syndrome. A signifi- cant increase in the number of mucosal inflammatory Epidemiološka obele‘ja proktoloških oboljenja nisu ši- cells and an increase in BrdU-immunoreactive nuclei roko poznata, pošto su do sada sprovedene studije dale were detected following mucosal exposure to capsaicin in razli~ite zaklju~ke. U spomenute faktore rizika spadaju the colon. Chilies are known to cause accelerated gut tran- nasledje, visok socioekonomski nivo, gojaznost, pušenje, sit increasing frequency of stool which itself could be a ishrana bogata mastima, alkohol, za~ini i biber, kao i ni- factor aggravating symptoms of anal pathologies. zak unos te~nosti. Whilst fruits and vegetables are an essential part of our U toku le~enja pacijenata sa raznom anorektalnom pa- dietary intake, the role of fiber in the prevention of col- tologijom, osim definitivnog tretmana, razne dodatne i su- orectal diseases remains controversial.13 The main feature portivne terapije su zagovarane od strane lekara i hirurga. of a high-fiber diet is its poor digestibility. Soluble fiber U njih spadaju lokalne aplikacije, kupke, modifikacije like pectins, guar and ispaghula produce viscous solutions ishrane i na~ina ‘ivota. Ali, da li pacijent zaista ima bene- in the gastrointestinal tract delaying small bowel absorp- fita od ovih suportivnih terapija ili imaju samo empirijsko tion and transit. Insoluble fiber mainly coming from leafy zna~enje? vegetables and fruits, on the other hand, pass largely unal- Ovaj rad elaborira razli~ite suportivne terapije tered through the gut. The more fiber is ingested, the more zagovarane kod ~estih analnih patologija, kao što su stools will have to be passed. Fermentation in the intes- hemoroidi, analne fisure i fistule, i rezimira prednosti i tines results in build up of large amounts of gases in the zamke ovakvog pristupa. colon. Addition of dietary fiber may improve symptoms Klju~ne re~i: suppository, hemorrhoid cream, sitz of internal bleeding hemorrhoids although with no imme- bath, diet diate effect. Any increase in dietary fiber intake should necessarily be accompanied by an increase in water in- REFERENCES take. 1. Roxas MF, Talip BN, Crisostomo AC. 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