Hemorrhoids (cont.)
How are hemorrhoids treated?
General measures
It is believed generally that
constipation and straining to have bowel movements promote hemorrhoids and that
hard stools can traumatize existing hemorrhoids. It is recommended, therefore,
that individuals with hemorrhoids soften their stools by increasing the fiber in
their diets. Fiber is found in numerous foodstuffs including fresh and dried
fruits, vegetables, grains, and cereals. Generally 20-30 grams per day of fiber
are recommended whereas the average American diet contains less than 15 grams of
fiber. Supplemental fiber (psyllium, methylcellulose, or calcium polycarbophil) also may be used to increase the
intake of fiber. Stool softeners and increased drinking of liquids also may be
recommended. Nevertheless, there is no strong, scientific support for the
benefits of fiber, liquids, or stool softeners.
Diarrhea is believed to aggravate the symptoms of hemorrhoids and it is
recommended that diarrhea be controlled with fiber and anti-motility drugs.
Over-the-counter medications for hemorrhoids
Many over-the-counter products are sold for the treatment of hemorrhoids. These
often contain the same drugs that are used for treating anal symptoms such as
itching or discomfort. There are few studies showing that they do anything for
hemorrhoids. They probably only reduce the symptoms of hemorrhoids. It is
possible, however, that their effectiveness relates to their treatment of anal
conditions other than hemorrhoids, for example, idiopathic anal itching, that
often accompany hemorrhoids.
Products used for the treatment of hemorrhoids are
available as ointments, creams, gels, suppositories, foams, and pads. Ointments,
creams, and gels - when used around the anus - should be applied as a thin covering. When applied to the anal canal, these products should be inserted with
a finger or a "pile pipe." Pile pipes are most efficient when they have holes on
the sides as well as at the end. Pile pipes should be lubricated with ointment
prior to insertion.
Suppositories or foams do not have advantages over ointments, creams, and gels.
Most products contain more than one type of active ingredient. Almost all
contain a protectant in addition to another ingredient. Only examples of
brand-name products containing one ingredient in addition to the protectant are
discussed below.
Local anesthetics: Local
anesthetics temporarily relieve pain, burning, and itching by numbing the nerve
endings. The use of these products should be
limited to the perianal area and lower anal canal. Local anesthetics can cause
allergic reactions with burning and itching; therefore, if burning and itching
increase with the application of anesthetics, they should be discontinued.
Local
anesthetics include:
- Benzocaine 5% to 20% (Americaine Hemorrhoidal,
Lanacane Maximum Strength, Medicone)
- Benzyl alcohol 5% to 20%
- Dibucaine 0.25% to 1.0% (Nupercainal)
- Dyclonine 0.5% to 1.0%
- Lidocaine 2% to 5%
- Pramoxine 1.0% (Fleet Pain-Relief, Procto Foam
Non-steroid, Tronothane Hydrochloride)
- Tetracaine 0.5% to 5.0%
Vasoconstrictors: Vasoconstrictors are chemicals that resemble epinephrine, a
naturally occurring chemical. Applied to the anus, vasoconstrictors make the
blood vessels become smaller, which may reduce swelling. They also may reduce
pain and itching due to their mild anesthetic effect. Vasoconstrictors applied
to the perianal area - unlike vasoconstrictors that are taken orally or by
injection - have a low likelihood of causing serious side effects, such as high blood
pressure, nervousness, tremor, sleeplessness, and aggravation of diabetes
or hyperthyroidism.
Vasoconstrictors include:
- Ephedrine sulfate 0.1% to 1.25%
- Epinephrine 0.005% to 0.01%
- Phenylephrine 0.25% (Medicone Suppository, Preparation H, Rectacaine)
Protectants: Protectants prevent irritation of the perianal area by forming a
physical barrier on the skin that prevents contact of the irritated skin with
aggravating liquid or stool from the rectum. This barrier reduces irritation,
itching, pain, and burning. There are many products that are themselves
protectants or that contain a protectant in addition to other medications.
Protectants include:
- Aluminum hydroxide gel
- Cocoa butter
- Glycerin
- Kaolin
- Lanolin
- Mineral oil (Balneol)
- White petrolatum
- Starch
- Zinc oxide or calamine
(which contains zinc oxide) in concentrations of up to 25%
- Cod liver oil or shark liver oil if the amount of vitamin A is 10,000 USP
units/day.
Astringents: Astringents cause coagulation (clumping) of proteins in the cells
of the perianal skin or the lining of the anal canal. This action promotes
dryness of the skin, which in turn helps relieve burning, itching, and pain.
Astringents include:
- Calamine 5% to 25%
- Zinc oxide 5% to 25% (Calmol 4, Nupercainal,
Tronolane)
- Witch hazel 10% to 50% (Fleet Medicated, Tucks, Witch Hazel Hemorrhoidal Pads)
Antiseptics: Antiseptics
inhibit the growth of bacteria and other organisms. However, it is unclear
whether antiseptics are any more effective than soap and water.
Examples of antiseptics include:
- Boric acid
- Hydrastis
- Phenol
- Benzalkonium chloride
- Cetylpyridinium chloride
- Benzethonium chloride
- Resorcinol
Keratolytics: Keratolytics are chemicals that cause the outer layers of skin or
other tissues to disintegrate. The rationale for their use is that the
disintegration allows medications that are applied to the anus and perianal area
to penetrate into the deeper tissues.
The two approved keratolytics used are:
- Aluminum chlorhydroxy allantoinate (alcloxa) 0.2% to
2.0%
- Resorcinol 1% to 3%
Analgesics: Analgesic
products, like anesthetic products, relieve pain, itching,
and burning by depressing receptors on pain nerves.
Examples of analgesics include:
- Menthol 0.1% to 1.0% (greater than 1.0% is not
recommended)
- Camphor 0.1% to 3% (greater than 3% is not
recommended)
- Juniper tar 1% to 5%
Corticosteroids: Corticosteroids reduce inflammation and can relieve itching,
but their chronic use can cause permanent damage to the skin. They should not be
used for more than short periods of a few days to two weeks. Only products with
weak corticosteroid effects are available
over-the-counter. Stronger corticosteroid products that are available by
prescription should not be used
for treating hemorrhoids.
Next: Nonoperative procedures for internal hemorrhoids »
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