Understanding Options for Helping Patients with Anorectal Conditions

This article is sponsored by Ferndale Healthcare, Inc.

Patients may be hesitant to discuss uncomfortable anorectal conditions such as pruritus ani, anal fissures, and hemorrhoids with their health care providers. An understanding of these conditions and how they are managed can help pharmacists to proactively bridge the communication gap and assist patients who may be experiencing anorectal discomfort.

SUPPORTIVE CARE FOR ANORECTAL DISORDERS

Anal pruritus, or pruritus ani, which is characterized by itching and discomfort, affects an estimated 1% to 5% of the general population and occurs most often in patients older than 40 years.¹ Although pruritus ani may occur in association with ulcerative colitis or irritable bowel syndrome (IBS), its cause is often unknown. Potential causative factors include infection, systemic disease, poor hygiene, and exposure to local irritants.^1-3

Anal fissures are another painful condition affecting the anorectal area. These small tears in the lining of the anus, typically less than 5 mm in length, may form as a result of straining during defecation.² Anal fissures are present in up to 10% of patients presenting to proctology clinics and up to 20% of patients with hemorrhoids; patients with Crohn’s disease may also be affected.^3,4

Patients with pruritus ani and anal fissures may benefit from the use of a topical anesthetic for relief of anorectal pain and discomfort.^2,5,6 RectiCare^® is not used to treat anal fissures, IBS, or ulcerative colitis, but topical anesthetics may provide symptomatic relief of pain, itch, and irritation, and are available in various formulations, including RectiCare Anorectal Cream (5% lidocaine) and RectiCare Medicated Anorectal Wipes (5% lidocaine and 20% glycerin). These products contain the highest strength of lidocaine available over the counter and are appropriate for managing the painful symptoms of anorectal conditions.^7-9 In addition to lidocaine, RectiCare Medicated Anorectal Wipes contain the skin protectant glycerin.⁸ This easy-to-carry product is especially convenient for use when away from home.

SUPPORTIVE CARE FOR HEMORRHOIDS

Hemorrhoids are inflamed normal anatomic structures that may have a role in maintaining bowel continence.⁵ Painful, inflamed hemorrhoids, which are also known colloquially as piles, affect an

estimated 10 million to 23 million individuals in the United States and result in more than 3 million ambulatory care visits to physicians and 2 million prescriptions annually.¹⁰

Symptoms may include rectal bleeding resulting from irritation of internal hemorrhoids, with bleeding usually occurring immediately after defecation. Other symptoms may include itching, perianal discomfort, and soiling.^11,12 Constipation, pregnancy, heavy lifting, or strenuous exercise may exacerbate these symptoms.¹² Prolonged sitting, obesity, and low-fiber diets are other possible contributing factors.²

Supportive care strategies may include lifestyle changes, such as adopting a high-fiber diet, increasing fluid intake, avoiding straining during defecation, and using topical products for symptom relief.^2,5 As hemorrhoidal tissues are inflamed, topical vasoconstrictors are commonly used to shrink blood vessels in the anorectal area and temporarily relieve swelling. Topical anesthetics may also be used to relieve pain, itch, and irritation.^2,5,10,13

One product option that combines a vasoconstrictor and topical anesthetic is the RectiCare Complete Hemorrhoid Care System. This complete system contains RectiCare Advanced Hemorrhoidal Cream, which combines the local anesthetic lidocaine (5%), the vasoconstrictor phenylephrine (0.25%), and the skin protectants mineral oil (17%) and white petrolatum (39%) to soothe and protect the affected area. The system also includes RectiCare Advanced Hemorrhoidal Wipes, which contain the local anesthetic lidocaine (5%), the vasoconstrictor phenylephrine (0.25%), and the skin protectant glycerin (20%), and are a convenient and discreet option for use away from home.⁹ The TABLE^7-9 shows the available RectiCare products, along with their active ingredients and uses.^7-9

ROLE OF THE PHARMACIST

Anorectal conditions such as pruritus ani, anal fissures, and hemorrhoids are associated with pain and discomfort, and many patients may be uncomfortable discussing these conditions with their health care providers. Pharmacists are trusted health care providers in the community setting, however, and are in a position to offer education and guidance to patients in a sensitive manner. Given the myriad of products available over the counter, pharmacists can assist patients in selecting an appropriate product to help relieve their symptoms. In addition to recommending OTC products, pharmacists can provide information about additional supportive care strategies for these conditions, including increased fiber and fluid intake.

For patients with hemorrhoids, a product that includes a vasoconstrictor, such as the RectiCare Complete Hemorrhoid Care System, can help shrink swollen tissue. For patients with other anorectal disorders, a product with a topical anesthetic, such as RectiCare Anorectal Cream or RectiCare Medicated Anorectal Wipes, can help relieve pain, itch, and irritation. By taking into account patient needs and preferences, pharmacists can help patients with anorectal conditions select appropriate products to achieve symptom relief.

REFERENCES

• Markell KW, Billingham RP. Pruritus ani: etiology and management. Surg Clin North Am. 2010;90(1):125-135. doi: 10.1016/j.suc.2009.09.007.
• McQuaid KR. Gastrointestinal disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment 2015. New York, NY: McGraw-Hill; 2014.
• Schubert MC, Sridhar S, Schade RR, Wexner SD. What every gastroenterologist needs to know about common anorectal disorders. World J Gastroenterol. 2009;15(26):3201-3209.
• Lacy BE, Weiser K. Common anorectal disorders: diagnosis and treatment. Curr Gastroenterol Rep. 2009;11(5):413-419.
• Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal disease: a comprehensive review. J Am Coll Surg. 2007;204(1):102-117.
• Pfenninger JL, Zainea GG. Common anorectal conditions: part I: symptoms and complaints. Am Fam Physician. 2001;63(12):2391-2398.
• RectiCare lidocaine 5% anorectal cream [drug facts]. Ferndale, MI: Ferndale Laboratories, Inc; 2014.
• RectiCare medicated anorectal wipes [drug facts]. Ferndale, MI: Ferndale Laboratories, Inc; 2015.
• RectiCare complete hemorrhoid care system [drug facts]. Ferndale, MI: Ferndale Laboratories, Inc; 2015.
• Ganz RA. The evaluation and treatment of hemorrhoids: a guide for the gastroenterologist. Clin Gastroenterol Hepatol. 2013;11(6):593-603. doi: 10.1016/j.cgh.2012.12.020.
• Jacobs D. Clinical practice: hemorrhoids. N Engl J Med. 2014;371(10):944-951.doi: 10.1056/NEJMcp1204188.
• Chan EL, McCafferty MH, Galandiuk S. Diagnosis and contemporary management of hemorrhoids. Pract Gastroenterol. 2003;27(8):13-46.
• Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009-2017. doi: 10.3748/wjg.v18.i17.2009.