Home' Australian Pharmacist : Australian Pharmacist October 2012 Contents 798 Australian Pharmacist October 2012 I © Pharmaceutical Society of Australia Ltd.
COUNSELLING IN PRACTICE
• persistent change in bowel habit
• loss of appetite
• unexplained weight loss
• haemorrhoids which have to be
• sharp, stabbing pain on defecation
• symptoms that have persisted for longer
than three weeks
• symptoms that do not resolve with
lifestyle modifications and self-treatment.
Jessica’s symptoms, and the fact that she is
pregnant, make it very likely that she has
haemorrhoids. She should be questioned
further to confirm that there are no other
symptoms indicating the need for referral.
She should also be asked whether she has
been experiencing constipation. If there is
any doubt about the diagnosis, she should
be referred to her GP. She should be advised
to increase her dietary fibre and fluid
intake, and be provided with information
about perianal hygiene and measures to
minimise pressure on her perianal area.
The benefits of doing pelvic floor exercises
during pregnancy could also be discussed.
If constipation is a problem, she can take
a suitable laxative. If she is finding the
haemorrhoid symptoms troublesome,
she can use a topical haemorrhoid
treatment for a few days. If the symptoms
become severe, persist for longer than
three weeks, or do not respond to topical
treatment, she should be advised to see
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symptomatic and/or complicated haemorrhoids in
pregnancy and the puerperium. Cochrane Database of
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reference. At: http://emedicine.medscape.com/article/775407-
4. National Institute for Health and Clinical Excellence. NHS
Clinical Knowledge Summaries. Haemorrhoids 2011. At:
5. Rutter P, Newby N. Community pharmacy: symptoms,
diagnosis and treatment. Chatswood: Elsevier Australia; 2008.
6. Rossi S, ed. Australian medicines handbook. Adelaide:
Australian Medicines Handbook; 2012.
7. Mayo Clinic. Hemorrhoids [revised Dec 2010]. Mayo
Foundation for Medical Education and Research. At: www.
8. Approved product information. eMIMs. St Leonards:
CMPMedica Australia; 2012.
9. Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the
pharmacy: a guide to the management of common illness. 6th
edn. Oxford: Wiley-Blackwell; 2009.
10. eTG complete [online]. Melbourne: Therapeutic Guidelines;
11. American Pregnancy Association. Kegel exercises. 2011. At:
12. The Royal Women’s Hospital. Pelvic floor exercises [revised Jul
2010]. The Royal Women’s Hospital. At: www.thewomens.org.
1. Which of the following are
considered to be risk factors for
a) Excessive fibre intake, prolonged
sitting, chronic diarrhoea.
b) Increasing age, pregnancy, obesity.
c) Inadequate fibre intake, young age,
inflammatory bowel disease.
d) Chronic constipation, excessive fluid
intake, family history of haemorrhoids.
2. Which of the following people is
MOST LIKELY to be suffering from
a) A person who finds bright red blood in
the toilet bowl and experiences severe
pain during bowel movements.
b) A person who experiences a sensation
of incomplete evacuation and finds
bright red blood on the toilet paper
after bowel movements.
c) A person who has diarrhoea and
abdominal tenderness and finds
blood on the toilet paper after bowel
d) A person whose stools contain dark-
3. Which of the following would be
the LEAST appropriate laxative
to recommend for a pregnant
woman who is constipated and has
4. Which of the following lifestyle
modifications may help to prevent
or alleviate the symptoms of
a) Increase daily intake of dietary fibre
b) Minimise physical activity, as this
can increase pressure on the anal
c) Sit on the toilet for as long as
necessary to achieve a bowel
d) Wash the perianal area with hot water
and soap at least once each day.
5. A customer comes into the
pharmacy and asks for something
to treat his haemorrhoids. You
question him about his symptoms.
Which of the following symptoms
warrants referral to his GP?
a) Bright red blood in the toilet bowl
after bowel movements.
b) Perianal itching.
c) A sensation of incomplete evacuation
with bowel movements.
d) Black, tarry stools.
Key learning points
Haemorrhoids are abnormally
swollen vascular cushions in the anal
canal. Risk factors for developing
haemorrhoids include inadequate
fibre intake, chronic constipation,
increasing age, and factors which
cause increased intra-abdominal
pressure such as pregnancy and
prolonged sitting. The most common
symptoms are bleeding during
bowel movements, and anal itching
and discomfort. Because anorectal
symptoms may be due to another
more serious cause, if there is any
doubt about the diagnosis the
person should be advised to see a
doctor. Most cases of haemorrhoids
resolve with lifestyle modifications
such as increasing dietary fibre and
fluid intake, improving perianal
hygiene, and trying to minimise
pressure on the anal venous
cushions. An over-the-counter topical
preparation can be recommended
for short-term use to alleviate itching
and discomfort. If symptoms worsen
or do not resolve despite lifestyle
modifications and self-treatment,
the person should be advised to see
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