Houston, we have a problem with the release hatch

4. August 2011
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Napoleon was, during the Battle of Waterloo, barely able to lead his troops because he was tormented by haemorrhoids. Even if advertising promises after using their haemorrhoids-lotion to be easily able to go camel-riding, the truth is something else.

Haemorrhoids is classified into four stages:

  • Stage 1: The knots, ie. varicosities, are only proctoscopically visible; symptoms: bleeding, itching and oozing
  • Stage 2: The varicosity knots prolapse during defecation and reduce spontaneously. Symptoms: bleeding, irritable itching, oozing discharge, a foreign-body sensation and feeling of incomplete emptying.
  • Stage 3: The knots prolapse during defecation, but are still reducible; symptoms similar to stage 2, additionally some mild incontinence.
  • Stage 4: Very painful: The prolapse is acutely incarcerated and has thrombosis.
  • Stage 4b: The knots are chronically fibrosed and irreducible. The symptoms vary: bleeding is possible but rare, more frequently eczema and hygiene problems appear.

Haemorrhoids are not, as has long been claimed, anal varicose veins, according to the German Society of Dermatology in its guidelines. Recent findings show that the inner variant is a varicose dilatation and hyperplasia of the corpus cavernosum recti. Morphologically-speaking, it is an inflammation of vascular bundles, which are covered with squamous epithelium.

Deal with Rosette itching in a targeted way

In the choice of the therapeutic agent, it is not only the degree of the anal affliction which plays a role, but also the form of discomfort expressed by patients. Among pharmaceuticals used there are anti-inflammatory drugs, local anaesthetics, antifungals, astringents and corticosteroids. The reason explaining the often accompanying itching of haemorrhoids is that it causes stasis dermatitis. For severe itching without mycosis, alongside hydrocortisone and prednisolone as a treatment there is, in addition, the more potent fluocinolone acetonide which has proven itself. These substances have antiphlogistic, antiallergic, immunomodulating and strong antiproliferative effects. If the cause of the itch is a candida infection, nystatin is available as a local or systemic treatment or azol-containing medications are available as external agents. Corticosteroids are contraindicated in this case. Lidocain is suitable as an analgesic and antipruritic agent. Due to its rapid onset, long duration of action and a relatively low allergenic potential, it is in this area of proctology the medication of first choice.

With weeping dermatoses and haemorrhoidal anal eczema, astringents are a sensible choice. They reduce scabbing and work against bacterial and fungal superinfection, their effect is anti-inflammatory and antipruritic. Such astringents, as tannins derived from nature, include for example oak bark and witch hazel. Chemical forms which work include urea, formaldehyde and phenolic compounds. The oxidizing agent polyvidone-iodine has antifungal, bactericidal and virucidal effects. It does not delay wound healing and is tolerated well by the body.

Mariscae want to become hide

External haemorrhoids are not really such. In reality they are benign flaps of skin around the anus which are correctly called Mariscae. These benign flaps of skin can begin to swell in some women, for example during the menstrual period, and then rub onto underwear and can become inflamed. If stool particles get stuck in the skin folds, the skin gets irritated in this area. Bacteria and fungi set in. The softened skin loses its elasticity and can tear while passing a stool, or eczema can develop.

The important thing in this case is proper hygiene after defecation. Dry toilet paper is unsuitable. The manufactured moist version often contains alcohol as a preservative, which dries the sensitive mucous membranes. Useful substances for cleaning are instead water, black tea (because of its tannins) or oil-containing baby wipes.

The correct type of medicament determines therapeutic success

In most cases of haemorrhoids (and Mariscae), symptom-oriented treatment is necessary. The patient should however be informed that this therapy helps to relieve his or her symptoms, but does not shrink the haemorrhoids. This (which) is what some advertising falsely claims. The effect depends crucially on the choice of the correct form of treatment: suppositories, lotions or (anal)tampons. “Suppositories for internal haemorrhoids, external ointments for external haemorrhoids”: it is, unfortunately, not as simple as that. With conventionally shaped suppositories, the active ingredient does not reach the “place of residence” of the haemorrhoids, ie. the proximal anal canal. Either the user applies the suppository too far in or the hard wax melts and runs out with the active ingredient beyond the anus. In instances where therapy has failed, the use of tampons is a sensible choice. Here, the suppository is almost twice as long as usual preparations and surrounded by a protective “lint-tube”. Because of this, a long retention period of the active ingredient is guaranteed.

For external haemorrhoids, ointments and, where necessary, pastes are a good choice. These preparations come usually with an insertion pipe/introducer, or even an anal extender. Regular use of the latter should make the rectal opening smooth, expand, and thus facilitate the passage of a stool. With the application of ointments in the internal anal area, the same problem arises as with a suppository.
The treasure-trove of natural medicine also offers homeopathic remedies and phytotherapy.
Despite recent pathophysiological gains in knowledge there are such agents used in the treatment of haemorrhoids, which are also sensible in the treatment of vein discomforts and varicose veins.

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It’s all over for the “haemo-star”

An agent known as bufexamac used since the 1970s against various dermatological diseases and in proctology can cause severe contact dermatitis. It was THE most common substance in established preparations for haemorrhoids. The evidence base for the benefit was very low. This contrasted with numerous studies and case reports on the severe, sometimes fatal, side effects. The anogenital eczema, which the medicament can cause, is similar to the indication. The European Medicines Agency EMA has revoked approval for the use of the medication.

Nitroglycerin is often beyond the fissure budget

Stabbing pain and painful spasms of the sphincter during defecation and prolonged after-pains: this is how anal fissures make their presence felt. For patients with chronic discomfort, an effective pharmacotherapy running over six weeks should be considered.

Nitroglycerin is an established medication in the treatment of angina pectoris, cardiac pulmonary edema and colic. With cases involving painful and difficult healing of anal fissures as well it’s already long ago that this was a “secret tip”. Explosives for the fissure? The local application of 0.2 – 0.4% nitroglycerin cream reduces the sphincter pressure by up to 30 percent and increases the blood flow in the fissure. This can usually allow the fissure to heal faster. Nitro fields release nitric oxide (NO) and imparts an anorectal inhibition reflex – the internal anal sphincter relaxes. (Patients with anal fissures tend to have significantly higher resting anal pressure.)

Side effects may include among others the occurance of headache. Some ready-to-use preparations for cardiac indications contain 2 percent (!) Nitroglycerin. Unfortunately, the products have a relatively high price. Alternatively, the more easily tolerated Nifedipine can be used in 0.2 percent concentration or as a combination of both drugs. The application takes place 2-3 times daily.
Then one really can climb back onto a camel.

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