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