Hemorrhoids/Pinworms

question

Hemorrhoid Characteristics
answer

cluster of dilated, abnormally large conglomerates of blood vessels, supporting tissues, and overlying mucus membranes or sink in the lower rectum or anus
question

Internal Hemorrhoid
answer

Above the dentate line in the anus
question

External Hemorrhoid
answer

Below the dentate line; outside anus
question

Hemorrhoid Symptoms
answer

Itching Inflammation Discomfort Irritation Swelling/pain Seepage Thrombosis (bluish clot) Changes in bowel habits Bleeding (after wiping) Prolapse (hemorrhoid moves)
question

Hemorrhoid Characteristics
answer

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
question

Hemorrhoid Aggravating Factors
answer

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
question

Exclusions for Hemorrhoid Self-Care
answer

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
question

Nonpharmacologic Options for Hemorrhoids
answer

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)
question

Analgesics
answer

Where used: External hemorrhoids Ingredients: Camphor, MENTHOL, Juniper tar Adverse effects: cool, warm, tingling If symptoms develop or increase, discontinue and consult doctor
question

Local Anesthetics
answer

Where used: External hemorrhoids Ingredients: dibucaine 1%, pramoxine 1%, benzocaine 20%, tetracaine, lidocaine Adverse effects: hypersensitivity reactions Caution: cardiovascular, thyroid, prostate, antidepression
question

Astringents
answer

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
question

Corticosteroids
answer

Where used: External hemorrhoids Ingredients: hydrocortisone Onset of action: 12 hours Dose: 1% Adverse effects: skin atrophy (rare skin reactions)
question

Protectants
answer

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
question

Vasoconstrictors
answer

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
question

Keratolytics
answer

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)
question

Hemorrhoid Counseling Points
answer

Proper application of creams/ointments Insertion of suppositories Wash area/hands If irritation develops – stop use and contact PCP Duration of use: 1 weeks
question

Pinworms
answer

Enterobius vermicularis Most common worm infection in US (in children) Highest risk patients: congested districts, institutionalized groups, family members
question

Pinworm Life Cycle
answer

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
question

Transmission of Pinworms
answer

Person to person Touching surfaces Clothing Sexual transfer
question

Signs/Symptoms of Pinworms
answer

Itching/prickling sensation in perianal region Diarrhea, abdominal pain Nervousness Inability to concentrate Insomnia Lack of appetite Worms
question

Complications of Pinworms
answer

Infections Females: vulvovaginitis
question

Exclusions for Self-Care of Pinworms
answer

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)
question

Diagnosis of Pinworms
answer

Nighttime perianal or perineal itching in a child Visual inspection Stool – see larvae sometimes Cellophane tape test (3 consecutive nights)
question

Nonpharmacological Options Pinworms
answer

Expose room to sunlight Wash clothes/bedding/towels Teach about proper cleaning (fingernails/hands, disinfectants) Vacuuming Wear close-fitting shorts at bedtime Notify school
question

Pharmacologic Therapy Pinworms
answer

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)
question

Counseling Points Pinworms
answer

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

Get instant access to
all materials

Become a Member