Local Preparations for Haemorrhoids and Perianal Conditions

Haemorrhoids may be classified according to symptoms and position, as below.

• Bleeding often occurs at the same time as opening the bowels. It is usually bright red.
• It can vary from a smear on the toilet paper to dripping into the pan. It may be seen on the surface of the stool, but not mixed into it.
• A feeling of fullness in the rectum may occur if rectal prolapse occurs during a bowel movement.
• Soiling may occur with 3rd or 4th degree haemorrhoids, as a result of impaired continence, or mucus discharge.

• Malignancy in colon/rectum
• Inflammatory bowel disease
• Diverticular disease
• Adenomatous polyps
• Ulcer
• Anal fissure
• Also consider other causes of itching e.g. threadworms, dermatitis
• Fistula, abscess, warts

Refer for Specialist opinion

Pregnant women often develop haemorrhoids. They should use conservative measures where appropriate, as above, and be reassured that the haemorrhoids normally resolve after delivery.³General measures to recommend:

• Avoidance of constipation by increasing fibre content of diet ^2,4
• Avoidance of straining at the stool
• Losing weight and taking more exercise contribute to a healthier bowel habit
• Good peri-anal hygiene will provide some relief from irritation and help prevent dermatitis

There are a variety of preparations available, but there is insufficient controlled evidence on their efficacy. Many people report relief from local anaesthetics with corticosteroids.

• Soothing, bland preparations: Germoloids™ (zinc oxide lidocaine), Preparation H ™(shark liver oil) and witch hazel. These may relieve local irritation.
• Anaesthetic preparations e.g.lignocaine may help alleviate burning, itching and pain. They should only be used for a few days, as they cause sensitisation of the anal skin.
• Topical corticosteroids may reduce inflammation and pain. Local infection must be excluded before use. Should only be used for 7 days maximum. Longer use may lead to skin atrophy and dermatitis.
• The cream or ointment base may have additional soothing effect.
• Phlebotonics: There has been some research into dietary supplementation with flavonoids. They act to increase venous tone and improve capillary resistance. The results are inconsistent and there is no license for their use in the UK.

This is defined as an uncontrollable desire to scratch the anus. It is present in approximately 5% of the population and is four times more common in men than women. It can occur at any time of life but is more common between 40-70 years of age. It is most commonly experienced after a bowel motion or at night. The itch may be worsened by wool, heat, moisture, leaking and stress.⁶

• Take a thorough history to include potential irritant factors such as powders, creams and soaps. There may be problems keeping the area dry.
• Dietary factors e.g. tomatoes, citrus fruit, spicy foods may be implicated.
• Appearance varies according to severity and chronicity. The anal ring may eventually appear shiny.
• A digital rectal examination should be performed to exclude local malignancy.
• Exclude secondary causes⁷; infections, fistula, fissure, dermatological conditions, systemic disease e.g. Diabetes, lymphoma, renal failure, anaemia or hyperthyroidism. Topical treatments and systemic medications e.g. Colchicine or peppermint oil.

Persistent scratching may lead to dermatitis, excoriation and infection. Depression may follow severe, persistent symptoms. Unless a cause is found it may become a chronic complaint. Most people respond well to simple measures, but may have periodic relapse.

• Avoidance of irritants and good personal hygiene are the mainstays of treatment.
• Symptomatic treatment may help alleviate symptoms whilst these measures are put in place.
• Dietary modification may be useful if implicated in causation.
• Excessive moisture around the anus can contribute to the problem, particularly if obese and/or hairy. A hair dryer may be useful for thoroughly drying the area after washing. A cotton tissue placed in the underwear may help absorb extra moisture throughout the day. Cotton underwear should be used in preference to synthetics.

• Bland, protective, soothing ointments are first-line treatment.
• A short course of a mildly potent corticosteroid may be used. Long-term use is to be avoided as it may cause dermatitis and exacerbate the itch.
• There is no evidence that anti-histamines will help the underlying condition, but a short course may alleviate symptoms that are disturbing sleep.
• Avoid using local anaesthetics, systemic steroids, capsaicin⁸ or hypnosis.⁹

Referral should be considered in any patient who has had no relief after 3-4 weeks of conservative measures.