Hemorrhoids/Pinworms
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Hemorrhoid Characteristics
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cluster of dilated, abnormally large conglomerates of blood vessels, supporting tissues, and overlying mucus membranes or sink in the lower rectum or anus
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Internal Hemorrhoid
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Above the dentate line in the anus
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External Hemorrhoid
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Below the dentate line; outside anus
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Hemorrhoid Symptoms
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Itching Inflammation Discomfort Irritation Swelling/pain Seepage Thrombosis (bluish clot) Changes in bowel habits Bleeding (after wiping) Prolapse (hemorrhoid moves)
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Hemorrhoid Characteristics
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External: anal/perianal - swelling, covered by highly innervated skins Internal: first degree - enlarged, not in anal canal; second degree - distends and retracts on its own; third degree - distends and can be pushed back; fourth degree - push but doesn't want to move back
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Hemorrhoid Aggravating Factors
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Diet: inadequate intake of fiber, dehydration, alcohol, caffeinated beverages, citrus, spicy foods Improper bowel habits: soft toilet paper Medications: NSAIDs and aspirin (bleeding risk) At risk patients: pregnancy, post-partum, obesity, spinal injury, 45-65 yo, certain occupations (sedentary often), family history
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Exclusions for Hemorrhoid Self-Care
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Patients <12 yo Severe bleeding Family history of colon cancer Diagnosed UC or Crohn's disease Change in bowel habits not related to medications (seepage) Thrombosis Lack of response to OTC meds
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Nonpharmacologic Options for Hemorrhoids
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Goal: reduce straining/pressure, prevent constipation Avoid heavy lifting, aggravating foods, certain OTC meds Increase fiber/water intake Don't sit on toilet for longer than 10 minutes Exercise Good perianal hygiene (Sitz baths, washing area, proper toilet paper)
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Analgesics
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Where used: External hemorrhoids Ingredients: Camphor, MENTHOL, Juniper tar Adverse effects: cool, warm, tingling If symptoms develop or increase, discontinue and consult doctor
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Local Anesthetics
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Where used: External hemorrhoids Ingredients: dibucaine 1%, pramoxine 1%, benzocaine 20%, tetracaine, lidocaine Adverse effects: hypersensitivity reactions Caution: cardiovascular, thyroid, prostate, antidepression
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Astringents
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Where used: Internal/external hemorrhoids (except witch hazel Ingredients: calamine, ZINC OXIDE, WITCH HAZEL Adverse effects: not typical except witch hazel or long term use - systemic toxicity
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Corticosteroids
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Where used: External hemorrhoids Ingredients: hydrocortisone Onset of action: 12 hours Dose: 1% Adverse effects: skin atrophy (rare skin reactions)
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Protectants
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Where used: Internal/external hemorrhoids (except glycerin) Ingredients: aluminum hydroxide gel, kaolin, cocoa butter, lanolin, hard fat, MINERAL OIL, WHITE PETROLUM, TOPICAL STARCH, shark liver oil, ZINC OXIDE, calamine Dosage: up to 6 times daily, after each stool Remove greasy ointments, use first
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Vasoconstrictors
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Where used: External only (epinephrine); internal and external (phenylephrine and ephedrine) Adverse effects: nervousness, tremor, nausea, sleeplessness, increased BP, contact dermatitis; Long term use: anxiety, paranoia, rebound vasodilation Contraindications: cardiovascular disease, angina, HTN, hyperthyroidism, diabetes, BPH, TCAs, MAO-I's
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Keratolytics
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Where used: External Ingredients: Alcloxa, Resorcinol Adverse effects: tinnitus, increased pulse, sweating, SOB, methemoglobinemia, circulatory collapse, unconsciousness, convulsions, death (infants) Not FDA approved (avoid this class)
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Hemorrhoid Counseling Points
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Proper application of creams/ointments Insertion of suppositories Wash area/hands If irritation develops - stop use and contact PCP Duration of use: 1 weeks
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Pinworms
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Enterobius vermicularis Most common worm infection in US (in children) Highest risk patients: congested districts, institutionalized groups, family members
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Pinworm Life Cycle
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Eggs ingested by human (viable for 20 days) Eggs on perianal folds - larvae mature in 4-6 hours Larvae hatch in small intestine Adults in lumen of cecum - migrate to perianal region to lay eggs at night
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Transmission of Pinworms
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Person to person Touching surfaces Clothing Sexual transfer
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Signs/Symptoms of Pinworms
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Itching/prickling sensation in perianal region Diarrhea, abdominal pain Nervousness Inability to concentrate Insomnia Lack of appetite Worms
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Complications of Pinworms
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Infections Females: vulvovaginitis
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Exclusions for Self-Care of Pinworms
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Vague symptoms and negative visual inspection: Vaginitis/Vaginal Bleeding; UTI/urethritis/dysuria Liver disease Anemia Pregnancy or breast-feeding <2 years of age or <25 lbs Helminthic infections other than pinworms Hypersensitivity to pyrantel pamoate Repeat dosing - 1 dose (max dose)
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Diagnosis of Pinworms
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Nighttime perianal or perineal itching in a child Visual inspection Stool - see larvae sometimes Cellophane tape test (3 consecutive nights)
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Nonpharmacological Options Pinworms
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Expose room to sunlight Wash clothes/bedding/towels Teach about proper cleaning (fingernails/hands, disinfectants) Vacuuming Wear close-fitting shorts at bedtime Notify school
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Pharmacologic Therapy Pinworms
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Pyrantel pamoate MOA: neurotransmitter blocker Who to treat: everyone in the house Dosage forms: liquid, chewable tablet, caplet Dosing: 11 mg/kg; max dose: 1 gram Efficacy: 2 weeks (do not repeat dose until 2 weeks have passed)
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Counseling Points Pinworms
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Liquid: suspension so shake well Caplet: swallow whole Chewable tablet: completely chew before swallowing Side effects: nausea, vomiting, abdominal cramps Duration of use: 1 week before PCP consultation if no improvement
