Drug dosage forms of rectal use

DEPARTMENT

TECHNOLOGY OF DRUGS

THE PROJECT ON: ATL SUBJECT

DRUG DOSAGE FORMS OF RECTAL USE

PREPARED BY: Ammar Rashid

3^rd group 1^st group

CHECKED BY: assistant professor

For department of drug technology

Levachkova Yu.V

Definition:

Rectal medicines are medications prepared specifically for insertion into the rectum. They are compounded in many forms. Liquid rectal medicine solutions are given by enema. Creams, lotions and ointments are applied externally or inserted internally using an applicator. Suppositories are prepared by mixing medicine with a wax-like substance to form a semi-solid, bullet-shaped form that will melt after insertion into the rectum.

Purpose:

Rectal medications are administered for a localized effect on the rectum or for a systemic effect when a patient is vomiting, unable to swallow, or unconscious. Rectal medicine is most commonly used as a localized treatment for constipation or as a topical treatment for rectal inflammation or infection. Rectal suppositories may be used for the treatment of fever, nausea, and pain; they may also be prescribed to induce sedation or bronchodilation, or to reduce the nausea and vomiting that can accompany chemotherapy. Medicated enemas may be used to cleanse the bowel, to combat bacteria, or to kill parasites.

Precautions:

Rectal medications must be used with caution in the cardiac patient who has arrhythmias or has recently had a myocardial infarction (i.e., heart attack). Insertion of a rectal medicine can cause vagus nerve stimulation and may trigger an arrhythmiauch as bradycardia. Rectal medicines should not be given to the patient with undiagnosed abdominal pain because peristalsis of the bowel can cause an inflamed appendix to rupture. Rectal medicines should be used cautiously in patients who have undergone recent surgery on the rectum, bowel, or prostate gland. If the patient has rectal bleeding or a prolapse of rectal tissue from the rectal opening, the medicine should be withheld and the physician consulted before administration. Rectal medicines should not be taken orally, and only medications labeled as rectal preparations should be placed in the rectum.

Description:

Administration of rectal medication should be done after the patient is positioned correctly. Lifting the upper buttocks will enable visualization of his or her rectal opening. External lotions, ointments or creams can be applied directly, using a gloved finger or a 4 gauze pad. Prior to administering internal rectal medicine, the tip of the suppository, enema catheter, or applicator should be lubricated with a water-soluble lubricant. To insert a rectal suppository, the lubricated, tapered end of the suppository should be placed at the rectal opening and gently pushed into the rectum. The suppository should be pushed continually toward the umbilicus until the full length of the nurse's gloved index finger has been inserted into the rectal opening (i.e., about 3 inches, or7.5 cm, for an adult patient). When inserting suppositories into children, the suppository should be pushed about 1 inch (2.5 cm) beyond the rectal opening, or up to the first knuckle of the nurses's index finger. When inserting suppositories into infants, the little finger should be inserted one-half inch (1.25 cm) beyond the rectal opening. The buttocks should be released and the finger removed.

Administration of internal rectal medicated cream or ointment requires placement of the applicator's lubricated tip at the rectal opening, gently pushing the applicator into the rectal opening about 3 inches (7.5 cm) for an adult (or as indicated on the applicator's directions). The correct dosage of medicine should then be squeezed into the rectum. After withdrawal of the applicator tip, the buttocks should be released.

To administer rectal medicine using an enema solution, the lubricated tip of the enema catheter must also be placed at the rectal opening. The tip of the catheter should then be gently advanced into the rectum, about 3 inches (7.5 cm) for an adult (or as indicated on the enema tubing). After the patient is alerted, the enema tubing should be opened, allowing the enema solution to flow into the rectum. A prepared enema should also be administered in this manner. When all of the solution has been administered, the enema catheter should be removed. Then, the buttocks should be released.

Preparation:

Before administering rectal medicine, the door to the room should be closed to assure patient privacy. The patient should be encouraged to empty his or her bladder and bowels before the procedure. After removing lower garments and underwear, the patient should be positioned in bed on his or her left side, with the top knee bent and pulled slightly upward. A waterproof pad should be placed under the patient's hips to protect the bedding, and a sheet should be draped over the patient to cover all of his or her body except the buttocks.

After placing a bedpan within quick access, the nurse should explain the procedure to the patient. This explanation should include the importance of breathing slowly through the mouth to enhance relaxation of the rectal sphincter and to avoid oppositional pressure. The patient should be made aware that there may be an urge to push the medicine out, but that he or she should try to hold it for at least 105 minutes after instillation (30 minutes for suppositories), as most rectal medications need time to be absorbed. It is advisable for the professional to check the medication label each time the medicine is given, to avoid medication errors. It must be the right medicine and the right dose (strength), the right time, the right patient, and the right method. The expiration date on the label should be inspected. If the medicine is outdated, it should not be used.

The nurse should wash his or her hands and put on gloves. The foil wrap should be removed from the rectal preparation or suppository. To prepare internal rectal creams, lotions or ointments, the applicator should be examined so that the nurse can estimate the proper amount to instill after insertion. In preparation for rectal enema instillations, the directions on the package of premixed disposable enemas should be read. Most premixed disposable enemas come with the tip already lubricated. The cap from the tip should be removed, and air should be expelled from the apparatus before use. If liquid medicine solutions are given using a standard enema bag and tubing, the procedure for enema instillation should be followed.

Arrhythmia n irregularity of the heartbeat.

Bradycardia n abnormal slowing of the heart rate to fewer than 60 beats per minute.

Myocardial infarction cardiac condition caused by decreased blood flow and oxygen to the heart muscle; may cause tissue death and heart damage. Commonly known as a heart attack.

Peristalsis he wave-like muscular contractions of the intestinal walls that move food and refuse through the gastrointestinal system.

Prostate gland gland found in males, located below the bladder and around the urethra, that secretes the fluid for semen and controls the release of urine from the bladder.

Rectum he last portion of the large intestine located just above the anal canal, where stool collects prior to evacuation from the body.

Vagus nerve ne of the paired cranial nerves that supplies motor and sensory enervation to the abdominal and thoracic organs.

Aftercare:

After administering rectal medicines, the nurse should remain near the patient in case there is a need for assistance with the bedpan, or to walk to the bathroom. If a suppository is expelled within the first few minutes of insertion, the tip should be relubricated and reinserted. Medicated enemas that are expelled immediately may need to be repeated, using fresh solution. Directions provided with a prepared enema should be followed, but the physician may need to be consulted. To assist the patient with retaining the medicine, the nurse can apply gentle pressure to the rectal opening, using a 4 gauze pad or by squeezing the buttocks together after rectal medicine instillation. A 4 gauze pad should also tucked between the buttocks to collect seepage; this may help the patient feel more secure. After the procedure is completed, the patient should be covered and instructed to remain still for 105 minutes (30 minutes if a suppository was inserted). This period will allow time for medication absorption. Items that can be reused, such as enema pouches, tubing, and applicator tips, should be cleaned with warm running water and allowed to air-dry. Ointments and creams need to be recapped and returned to the medicine boxes. Disposable items and gloves should be placed in an appropriate trash bag that can be sealed and discarded.

Complications:

Rectal medicines can cause tissue irritation or allergic reactions. If irritation, swelling, redness, bleeding or prolapse of the rectal tissue is apparent, or if the patient complains of pain or burning, the medication should be stopped and the physician notified.

Results:

When given correctly, rectal medications work within 300 minutes to relieve pain, nausea, constipation, or fever. Rectal ointments for swelling and irritation of hemorrhoids may reverse the condition within several days. Because of their liquid state, rectal enemas are absorbed quickly and work rapidly. Retention enemas are meant to be held for 30 minutes to achieve full therapeutic effect.

Health care team roles:

Rectal medicines are administered by a licensed nurse (R.N. or L.P.N.) in the health care setting. An alert and cooperative patient may be allowed to apply external and internal rectal ointments and suppositories under the direction of the nurse. The nurse, however, should assess the site and the effectiveness of the medicine. The patient or members of the patient's family can be taught to administer rectal medicines in the home setting.

Rectal (medicine):

The rectal route of administration (ROA) is a way of administering drugs into the rectum to beabsorbed by the rectum's blood vessels^{[Note 1]} and into the body's circulatory system which distributes the drug to the body's organs and various systems^{[Note 2]} where the drug elicits its effects.

A drug that is administered rectally will in general (depending on the drug) have a faster onset, higher bioavailability, shorter peak, and shorter duration than the oral route.

Another advantage of administering a drug rectally is that it tends to produce less nauseacompared to the oral route and also prevents any amount of the drug from being lost due toemesis (vomiting, "throwing up", or "puking") since the drug is in the rectum, not the stomach, and the contents of the rectum are not lost when there is emesis.

In addition the rectal route bypasses first-pass metabolism, meaning the drug will reach the circulatory system with significantly less alteration and in greater concentration

Classification:

Routes of administration are usually classified by application location (or exposition). The route or course the active substance takes from application location to the location where it has its target effect is usually rather a matter of pharmacokinetics (concerning the processes of uptake, distribution, and elimination of drugs). Nevertheless,some,routes,,especially,the transdermal or transmucosal routes, are commonly referred to routes of administration. The location of the target effect of active substances are usually rather a matter of pharmacodynamics(concerning e.g. the physiological effects of drugs^[2]). Furthermore, there is also a classification of routes of administration that basically distinguishes whether the effect is local (in "topical" administration) or systemic (in "enteral" or "parenteral" administration).

Application location:

Gastrointestinal/enteral:

Administration through the gastrointestinal tract is sometimes termed enteral or enteric administration (strictly meaning 'through theintestines'). Enteral/enteric,administration usually.includes oral ^[3] (through the mouth) and rectal (into the rectum)^[3] administration, in the sense that these are taken up by the intestines. However, uptake of drugs administered orally may also occur already in the stomach, why gastrointestinal (along the gastrointestinal tract) may be a more fitting word for this route of administration. Furthermore, some application locations often classified as enteral, such as sublingual^[3] (under the tongue) and sublabial or buccal (between the cheek and gums/gingiva), are taken up in the proximal part of the gastrointestinal tract without reaching the intestines. Strictly enteral administration (directly into the intestines) can be used for systemic administration, as well as local (sometimes termed topical), such as in enema where e.g. contrast media is infused into the intestines for imaging. However, in the classification system basically distinguishing substances by location of their effects, the term enteral is reserved for substances with systemic effects.

Many drugs as tablets, capsules, or drops are taken orally. Administration methods directly into the stomach include those by gastric feeding tube or gastrostomy. Substances may also be placed into the small intestines, as with a duodenal feeding tube and enteral nutrition.Some enteric coated tablets will not dissolve in stomach but it is directed to the intestine because the drug present in the enteric coated tablet causes irritation in the stomach.

Central nervous system:

§ epidural (synonym: peridural) (injection or infusion into the epidural space), e.g. epidural anesthesia

§ intracerebral (into the cerebrum) direct injection into the brain. Used in experimental research of chemicals^[4] and as a treatment for malignancies of the brain.^[5] The intracerebral route can also interrupt the blood brain barrier from holding up against subsequent routes.^[6]

§ intracerebroventricular (into the cerebral ventricles) administration into the ventricular system of the brain. One use is as a last line of opioid treatment for terminal cancer patients with intractable cancer pain.^[7]

§

§

§ Other locations

§ epicutaneous or topical (application onto the skin). It can be used both for local effect as in allergy testing and typical local anesthesia, as well as systemic effects when the active substance diffuses through skin in a transdermal route.

§ intradermal, (into the skin itself) is used for skin testing some allergens, and also for mantoux test for Tuberculosis

§ subcutaneous (under the skin), e.g. insulin. Skin popping is a slang term that includes this method of administration, and is usually used in association with recreational drugs.

§ nasal administration (through the nose) can be used for topically acting substances, as well as for insufflation of e.g. decongestant nasal sprays to be taken up along the respiratory tract. Such substances are also called inhalational, e.g. inhalational anesthetics.

§ intravenous (into a vein), e.g. many drugs, total parenteral nutrition

§ intraarterial (into an artery), e.g. vasodilator drugs in the treatment of vasospasm and thrombolytic drugs for treatment of embolism

§ intramuscular (into a muscle), e.g. many vaccines, antibiotics, and long-term psychoactive agents. Recreationally the colloquial term 'muscling' is used.^[8]

§ intracardiac (into the heart), e.g. adrenaline during cardiopulmonary resuscitation (no longer commonly performed)

§ intraosseous infusion (into the bone marrow) is, in effect, an indirect intravenous access because the bone marrow drains directly into the venous system. This route is occasionally used for drugs and fluids in emergency medicine and pediatrics when intravenous access is difficult.

§ intrathecal (into the spinal canal) is most commonly used for spinal anesthesia and chemotherapy

§ intraperitoneal, (infusion or injection into the peritoneum) e.g. peritoneal dialysis

§ Intravesical infusion is into the urinary bladder.

§ intravitreal, through the eye

§ Intracavernous injection, an injection into the base of the penis

§ Intravaginal administration, in the vagina

§ Intrauterine

§ Extra-amniotic,administration,between the endometrium and fetal membranes

Route from application to target:

The route or course the active substance takes from application location to the location where it has its target effect is usually rather a matter of pharmacokinetics (concerning the processes of uptake, distribution, and elimination of drugs). Nevertheless, the following routes are commonly referred to as routes of administration:

§ transdermal (diffusion through the intact skin for systemic rather than topical distribution), e.g. transdermal patches such as fentanyl in pain therapy, nicotine patches for treatment of addiction and nitroglycerine for treatment of angina pectoris.

§ transmucosal (diffusion through a mucous membrane), e.g. insufflation (snorting) of cocaine, sublingual, i.e. under the tongue, sublabial, i.e. between the lips and gingiva, nitroglycerine, vaginal suppositories

Local or systemic effect:

Routes of administration can also basically be classified whether the effect is local (in topical administration) or systemic (in enteral or parenteral administration):

§ topical: local effect, substance is applied directly where its action is desired.^[9] Sometimes, however, the term topical is defined as applied to a localized area of the body or to the surface of a body part,^[10] without necessarily involving target effect of the substance, making the classification rather a variant of the classification based on application location.

§ enteral: desired effect is systemic (non-local), substance is given via the digestive tract.

§ parenteral: desired effect is systemic, substance is given by routes other than the digestive tract.

Topical:

§ epicutaneous (application onto the skin), e.g. allergy testing, typical local anesthesia

§ inhalational, e.g. asthma medications

§ enema, e.g. contrast media for imaging of the bowel

§ eye drops (onto the conjunctiva), e.g. antibiotics for conjunctivitis

§ ear drops - such as antibiotics and corticosteroids for otitis externa

§ through mucous membranes in the body

Enteral:

In this classification system, enteral administration is administration that involves any part of the gastrointestinal tract and has systemiceffects:

§ by mouth (orally), many drugs as tablets, capsules, or drops

§ by gastric feeding tube, duodenal feeding tube, or gastrostomy, many drugs and enteral nutrition

§ rectally, various drugs in suppository

Parentera l:

§ intravenous (into a vein), e.g. many drugs, total parenteral nutrition

§ intra-arterial (into an artery), e.g. vasodilator drugs in the treatment of vasospasm and thrombolytic drugs for treatment of embolism

§ intraosseous infusion (into the bone marrow) is, in effect, an indirect intravenous access because the bone marrow drains directly into the venous system. This route is occasionally used for drugs and fluids in emergency medicine and pediatrics when intravenous access is difficult.

§ intra-muscular

§ intracerebral (into the brain parenchyma)

§ intracerebroventricular (into cerebral ventricular system)

§ subcutaneous (under the skin)

Disadvantages

§ Typically a more addictive route of administration because it is the fastest, leading to instant gratification. In addition, drugs taken by inhalation do not stay in the bloodstream for as long, causing the user to redose more quickly and intensifying the association between consuming the drug and its effects.

§ Difficulties in regulating the exact amount of dosage^{[ citation needed ]}

§ Patient having difficulties administering a drug via inhaler

Advantages:

§ Fast: 15–30 seconds for IV, 3–5 minutes for IM and subcutaneous (subcut)

§ 100% bioavailability

§ suitable for drugs not absorbed by the digestive system or those that are too irritant (anti-cancer)

§ One injection can be formulated to last days or even months, e.g., Depo-Provera, a birth control shot that works for three months

§ IV can deliver continuous medication, e.g., morphine for patients in continuous pain, or saline drip for people needing fluids

Disadvantages:

§ Onset of action is quick, hence more risk of addiction when it comes to injecting drugs of abuse

§ Patients are not typically able to self-administer

§ Belonephobia, the fear of needles and injection.

§ If needles are shared, there is risk of HIV and other infectious diseases

§ It is the most dangerous route of administration because it bypasses most of the body's natural defenses, exposing the user to health problems such as hepatitis, abscesses, infections, and undissolved particles or additives/contaminants

§ If not done properly, potentially fatal air boluses (bubbles) can occur.

§ Need for strict asepsis

Uses:

§ Some routes can be used for topical as well as systemic purposes, depending on the circumstances. For example, inhalation of asthma drugs is targeted at the airways (topical effect), whereas inhalation of volatile anesthetics is targeted at the brain (systemic effect).

§ On the other hand, identical drugs can produce different results depending on the route of administration. For example, some drugs are not significantly absorbed into the bloodstream from the gastrointestinal tract and their action after enteral administration is therefore different from that after parenteral administration. This can be illustrated by the action of naloxone (Narcan), an antagonist of opiates such as morphine. Naloxone counteracts opiate action in the central nervous system when given intravenously and is therefore used in the treatment of opiate overdose. The same drug, when swallowed, acts exclusively on the bowels; it is here used to treat constipation under opiate pain therapy and does not affect the pain-reducing effect of the opiate.

§ Enteral routes are generally the most convenient for the patient, as no punctures or sterile procedures are necessary. Enteral medications are therefore often preferred in the treatment of chronic disease. However, some drugs can not be used enterally because their absorption in the digestive tract is low or unpredictable. Transdermal administration is a comfortable alternative; there are, however, only a few drug preparations that are suitable for transdermal administration.

§ In acute situations, in emergency medicine and intensive care medicine, drugs are most often given intravenously. This is the most reliable route, as in acutely ill patients the absorption of substances from the tissues and from the digestive tract can often be unpredictable due to altered blood flow or bowel motility.

§

Suppository:

A suppository is a drug delivery system that is inserted into the rectum (rectal,suppository), vagina (vaginal suppository) or urethra (urethral suppository), where it dissolves or melts.

They are used to deliver both systemically-acting and locally-acting medications.

The alternative term for delivery of medicine via such routes is pharmaceutical pessary.

The general principle is that the suppository is inserted as a solid, and will dissolve or melt inside the body to deliver the medicine pseudo received by the many blood vessels that follow the larger intestine.

Rectal suppositories:

Rectal suppositories are commonly used for:

§ laxative purposes, with chemicals such as glycerin or bisacodyl

§ treatment of hemorrhoids by delivering a moisturizer or vasoconstrictor

§ delivery of many other systemically-acting medications, such as promethazine or aspirin

§ general medical administration purposes: the substance crosses the rectal mucosa into the bloodstream; examples include paracetamol (acetaminophen), diclofenac, opiates, andeucalyptol suppositories.

Mode of insertion:

In 1991, Abd-El-Maeboud and his colleagues published a study in The Lancet,^[1] based upon their investigation into whether there was some hidden and forgotten knowledge behind the traditional shape of a rectal suppository.

Their research very clearly demonstrated that there was, indeed, a very good reason for the traditional torpedo shape; namely, that the shape had a strong influence on the extent to which the rectal suppository traveled internally — and, thus, upon its increased efficiency.

They (counter-intuitively) found that the ideal mode of insertion was to insert suppositories blunt end first, rather than the generally used mode of inserting the tapered end first. This conclusion was based on the greater distance of internal travel of the suppository once inserted, which was entirely a mechanical consequence of the natural actions of the bowel's muscular structure and the rectal configuration.

As a consequence, and in order to guarantee the maximum optimal efficiency, they recommended that all rectal suppositories be inserted blunt end first. The findings of this single study have been challenged as insufficient evidence on which to base clinical practice.^[2]

Non-laxative rectal suppositories:

Non-laxative rectal suppositories are to be used after defecation, so as not to be expelled before they are fully dissolved and the substance is absorbed. The use of an examination glove or a finger cot can ease insertion by protecting the rectal wall from fingernail(s).

Vaginal suppositories:

Vaginal suppositories are commonly used to treat gynecological ailments, including vaginal infections such as candidiasis.

Urethral suppositories:

Alprostadil pellets are urethral suppositories used for the treatment of severe erectile dysfunction. They are marketed under the name Muse in the United States.^[3] Its use has diminished since the development of oral impotence medications.

Constituents:

Some suppositories are made from a greasy base, such as cocoa butter, in which the active ingredient and other excipients are dissolved; this grease will melt at body temperature (this may be a source of discomfort for the patient, as the melted grease may pass through theanus during flatulences). Other suppositories are made from a water soluble base, such as polyethylene glycol. Suppositories made frompolyethylene glycol are commonly used in vaginal and urethral suppositories. Glycerin suppositories are made of glycerol and gelatin.

Indications:

Suppositories may be used for patients in the event it may be easier to administer than tablets or syrups.

Suppositories may also be used when a patient has a vomiting tendency, as oral medication can be vomited out.

Drugs which often cause stomach upset, for example diclofenac sodium (Voltaren) are better tolerated in suppository form.

Artesunate suppositories:

Artesunate suppositories are used for the treatment of malaria. Artesunate is an antimalarial water-soluble derivative of dihydroartemisinin.Artemisinins are sesquiterpene lactones isolated from Artemisia annua, a Chinese traditional medicine.

The risk of death from severe malaria is largely dependent on the time lag between the onset of symptoms and treatment. Rapid access to effective treatment is therefore essential. For many patients, readily available oral drugs cannot be taken because of their symptoms (e.g., vomiting, convulsions, coma), and hospitals providing alternative, non-oral treatment are often inaccessible. The drug artesunate, given insuppository form, provides a potential solution to this problem: it can be made available in remote areas and thus can be given at the onset of symptoms.

Artesunate is one of a number of artemisinin derivatives discovered and developed by Chinese scientists and registered in China in the 1980s. Since the 1990s, UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) supported studies to assess the properties of the drug. There were already indications that artesunate, given rectally, was effective in severe malaria. Significant work with artemisinin suppositories in severe malaria was conducted in Viet Nam in the early 1990s,^[1][2][3] and clinical trials of rectal artesunate followed by mefloquine treatment in moderately severe malaria were conducted in Thailand.^[4][5]

A major placebo-controlled clinical trial published in 2009 found that "if patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability.

Enema:

An enema (pronounced /ˈɛnəmə/; plural enemata or enemas) is the procedure of introducing liquids into therectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and complete evacuation of the lower intestinal tract. An enema has the advantage over any laxative in its speed and certainty of action, and some people prefer it for this reason.

Enemas can be carried out as treatment for medical conditions, such as constipation and encopresis, and as part of some alternative health therapies. They are also used to administer certain medical or recreationaldrugs. Enemas have been used for rehydration therapy (proctoclysis) in patients for whom intravenous therapyis not applicable.

History:

Enema comes from Greek ἔνεμα (énema), from ἐνίημι (eníēmi), "(I) inject".

Clyster, also spelled glister in the 17th century, comes from Greek κλυστήρ (klystḗr), from κλύζω (klýzo), "(I) wash". It is an archaic word for enema, more particularly for enemas administered using a clyster syringe – that is, a syringe with a rectal nozzle and a plunger rather than a bulb. Clyster syringes were used from the 17th century (or before) to the 19th century, when they were largely replaced by enema bulb syringes, bocks, and bags.

The patient was placed in an appropriate position (kneeling, with the buttocks raised, or lying on the side); a servant or apothecary would then insert the nozzle into the anus and depress the plunger, resulting in the liquid remedy (generally, water, but also some preparations) being injected into the colon.

Because of the embarrassment a woman might feel when showing her buttocks (and possibly her genitals, depending on the position) to a male apothecary, some contraptions were invented that blocked all from the apothecary's view except for the anal area. Another invention was syringes equipped with a special bent nozzle, which enabled self-administration, thereby eliminating the embarrassment.

Clysters were administered for symptoms of constipation and, with more questionable effectiveness, stomach aches and other illnesses. In his early-modern treatise, The Diseases of Women with Child, François Mauriceau records that both midwives and man-midwives commonly administered clysters to labouring mothers just prior to their delivery.

Lysters were a favourite medical treatment in the bourgeoisie and nobility of the Western world up to the 19th century. As medical knowledge was fairly limited at the time, purgative clysters were used for a wide variety of ailments, the foremost of which were stomach aches and constipation. Molière, in several of his plays, introduces characters of incompetent physicians and apothecaries fond of prescribing this remedy, also discussed by Argan, the hypochondriac patient of Le Malade Imaginaire. More generally, clysters were a theme in the burlesque comedies of that time. According to Claude de Rouvroy, duc de Saint-Simon, clysters were so popular at the court of KingLouis XIV of France that the duchess of Burgundy had her servant give her a clyster in front of the King (her modesty being preserved by an adequate posture) before going to the comedy. However, he also mentions the astonishment of the King and Mme de Maintenon that she should take it before them.

Medical usage:

The main medical usages of enemas are:

§ As a bowel stimulant, not unlike a laxative – the main difference being that laxatives are commonly thought of as orally administered while enemas are administered directly into the rectum, and thereafter, into the colon. When the enema injection into the rectum is complete, and after a set "holding time", the patient expels feces along with the enema in the bedpan or toilet.

§ Enemas may also be used to relieve constipation and fecal impaction, although in the U.S.A. and some other parts of the world, their use has been replaced in most professional health-care settings by oral laxatives and laxative suppositories. In-home use of enemas for constipation and alternative health purposes is somewhat harder to measure.

§ Bowel stimulating enemas usually consist of water, which works primarily as a mechanical stimulant, or they may be made up of water with baking soda (sodium bicarbonate) or water with a mild hand soap dissolved in it; buffered sodium phosphate solution, which draws additional water from the bloodstream into the colon and increases the effectiveness of the enema – which often can be rather irritating to the colon, causing intense cramping or "griping" – or mineral oil, which functions as a lubricant and stool softener, but which often has the side effect of sporadic seepage from the patient's anus which can soil the patient's undergarments for up to 24 hours. Other types of enema solutions are also used, including equal parts of milk and molasses heated together to slightly above normal body temperature. In the past, castile soap was a common additive in an enema, but it has largely fallen out of use because of its irritating action in the rectum and because of the risk of chemical colitis as well as the ready availability of other enema preparations that are perhaps more effective than soap in stimulating a bowel movement. At the opposite end of the spectrum, an isotonic saline solution is least irritating to the rectum and colon, having a neutral concentration gradient. This neither draws electrolytes from the body – as can happen with plain water – nor draws water into the colon, as will occur with phosphates. Thus, a salt water solution can be used when a longer period of retention is desired, such as to soften an impaction.

§ Cleansing the lower bowel prior to a surgical procedure such as sigmoidoscopy or colonoscopy. Because of speed and supposed convenience, enemas used for this purpose are commonly the more costly, sodium phosphate variety – often called a disposable enema. A more pleasant experience preparing for testing procedures can usually be obtained with gently-administered baking soda enemas; cleansing the lower bowel for colonoscopy and other bowel studies can be effectively achieved with water-based, or water with baking soda, enema administration.

§ The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema. Medicines for cancer, for arthritis, and for age-related macular degeneration are often given via enema in order to avoid the normally-functioning digestive tract. Interestingly, some water-based enemas are also used as a relieving agent for irritable bowel syndrome, using cayenne pepper to squelch irritation in the colon and rectal area. Finally, an enema may also be used for hydration purposes. See also route of administration.

§ Emergency blood expansion. Emergency pre-hospital treatment of haemorrhage requires immediate fluid replacement therapy. In mass casualty, remote or rural settings, the lack of sterile fluids, intravenous equipment or the knowledge to use them might limit the treatment options available. In such situations proctoclysis remains an easy and effective way to provide fluid replacement. It does not require sterile fluids, special equipment or complex training, and it is useful when alternative routes are not readily available.^[2]

§ The topical administration of medications into the rectum, such as corticosteroids and mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids having the medication pass through the entire gastrointestinal tract, therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream.

§ General anesthetic agents for surgical purposes are sometimes administered by way of an enema. Occasionally, anesthetic agents are used rectally to reduce medically-induced vomiting during and after surgical procedures, in an attempt to avoid aspiration of stomach contents.

§ A barium enema is used as a contrast substance in the radiological imaging of the bowel. The enema may contain barium sulfate powder, or a water-soluble contrast agent. Barium enemas are sometimes the only practical way to "view" the colon in a relatively safe manner. Following barium enema administration, patients often find that flushing the remaining barium with additional water, baking soda, or saline enemas helps restore normal colon activity without complications of constipation from the administration of the barium sulfate.

In certain countries, such as the United States, customary enema usage went well into the 20th century; it was thought a good idea to cleanse the bowel in case of fever; also, pregnant women were given enemas prior to labor, supposedly to reduce the risk of feces being passed during contractions. Under some controversial discussion, pre-delivery enemas were also given to women to speed delivery by inducing contractions. This latter usage has since been largely abandoned, because obstetricians now commonly give pitocin to induce labor and because women generally found the procedure unpleasant.

Now obsolete, the tobacco smoke enema was the principal medical method for resuscitating victims of drowning during the 18th century.

Home usage:

Many self-given enemas used at home are the pre-packaged, disposable, sodium phosphate solutions in single-use bottles sold under a variety of brand names, or in generic formats. These units come with a pre-lubricated nozzle attached to the top of the container. Some enemas are administered using so-called disposable bags connected to disposable tubing (despite the names, such units can commonly be used for many months or years without significant deterioration).

Patients who want easier, more gently-accepted enemas often purchase combination enema syringes which are commonly referred to as "closed top" syringes, and which can also be used as old-fashioned hot water bottles, so as to relieve aches and pains via gentle heat administrations to parts of the body. Cost for each enema can be as little as the cost of baking soda added to ordinary tap water.

In Asian countries, particularly in Japan, commercially available disposable enemas typically contain glycerin (at concentrations varying from 30-50%) or sodium chloride. They are not pre-lubricated and the amount of liquid contained in them may vary, although most contain about 20-40ml of diluted glycerin.

In medical or hospital environments, reusable enema equipment is now rare because of the expense of disinfecting a water-based solution. For a single-patient stay of short duration, an inexpensive disposable enema bag can be used for several days or weeks, using a simple rinse out procedure after each enema administration. The difficulty comes from the longer time period (and expense) required of nursing aides to give a gentle, water-based enema to a patient, as compared to the very few minutes it takes the same nursing aide to give the more irritating, cold, pre-packaged sodium phosphate unit.

For home use, disposable enema bottle units are common, but reusable rubber or vinyl bags or enema bulbs may also be used. In former times, enemas were infrequently administered using clyster syringes. If such commercially-available items are not at hand, ordinary water bottles are sometimes used.

Alternative medicine:

The term "colonic irrigation" is commonly used in gastroenterology to refer to the practice of introducing water through a colostomy or a surgically constructed conduit as a treatment for constipation. The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for the purpose of general well-being] and has taken action against many distributors of this equipment, including aWarning Letter. The use of enemas for reasons other than the relief of constipation is currently regulated in some parts of the United Stateswhile practitioners in other states may go through a voluntary certification process.

Rectal drug administration:

An enema might be used to clean the colon of feces first to help increase the rate of absorption in rectal administration of dissolved drugs, including alcohol.

Enemas have also been used for ritual rectal drug administration such as balché, alcohol, tobacco, peyote, and other hallucinogenic drugsand entheogens, most notably by the Mayans and also some other American Indian tribes. Some tribes continue the practice in the present day.

People who wish to become intoxicated faster have also been known to use enemas as a method to instill alcohol into the bloodstream, absorbed through the membranes of the colon. However, great care must be taken as to the amount of alcohol used. Only a small amount is needed as the intestine absorbs the alcohol more quickly than the stomach. Deaths have resulted due to alcohol poisoning via enema.

Precautions:

Improper administration of an enema may cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these occurrences are rare in healthy, soberadults. Internal bleeding or rupture may leave the individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.

The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such asbradycardia. Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of thebowel can cause an inflamed appendix to rupture.

Colonic irrigation should not be used in people with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids or tumorsin the rectum or colon. It also should not be used soon after bowel surgery (unless directed by one's health care provider). Regular treatments should be avoided by people with heart disease or renal failure. Colonics are inappropriate for people with bowel, rectal or anal pathologieswhere the pathology contributes to the risk of bowel perforation.

Recent research has shown that ozone water, which is sometimes used in enemas, can immediately cause microscopic colitis. A recentcase series^] of 11 patients with five deaths illustrated the danger of phosphate enemas

Dry enema:

A dry enema is an alternative technique for cleansing the human rectum either for reasons of health, or for sexual hygiene. It is accomplished by squirting a small amount of sterile lubricant into the rectum, resulting in a bowel movement more quickly and with less violence than can be achieved by an oral laxative.

It is called "dry" by contrast to the more usual wet enema, because no water is used.

A rudimentary form of 'dry' enema is the use of a non-medicated glycerin suppository. However, due to the relative hardiness of the suppository - necessary for its insertion into the human body - before the glycerin can act, it must be melted by the heat of the body, and hence it does not take effect for up to an hour. Often the hygroscopic glycerin irritates the sensitive membranes of the rectum resulting in forceful expulsion of the suppository without any laxative effects.

A quicker form of the dry enema utilizes the injection of a small amount of water-based lubricant such as K-Y into the rectum via a non-hypodermicsyringe, such as an oral syringe, or from some other source. Then again since the glycerin itself is an effective producer of the desired contraction of the colonic muscles it is simpler - and more easily controlled - to introduce 5 - 10 cc of glycerin into directly into the rectum. Specialist syringes are available for this purpose but are hard to find. An alternative is to use an enema nozzle which has an intake end which is compatible with a standard hypodermic syringe. This allows the immediate injection of the 5-10 ccs. required, and results can be expected in 2-4 minutes. Another alternative is to use a normal 5 or 10cc syringe inserted directly into the anus. This needs to be done carefully to avoid scratching the anal passage. The passage should be lubricated with sorbolene cream or any water-based lubricant. In addition a syringe which is made with only the normal Luer tip should be used, not the type molded to take a screw-on needle. Penetration is better performed by the patient to eliminate any pain. The patient should be encouraged to wait at least 15 minutes in order that peristalsis can reach the full length of the rectum, but many will find this impossible and this treatment should therefore be applied only when the facilities to evacuate are nearby.

The usual amount of lubricant applied is about 2 tsp (10 cc), which will produce a movement in 30 minutes or less. The movement will be produced in a compact body, rather than in the more copious liquid form produced by a wet enema; and since no water is used, none will be retained higher up in the colon, to be expelled at a later, and possibly inconvenient, time.

A further advantage of this technique for sexual hygiene is that any slight remaining traces of fecal material will - due to the presence of the lubricant - tend to adhere to the wall of the rectum rather than to any foreign object which may subsequently be inserted.

Nutrient enema:

A nutrient enema, also known as feeding per rectum, rectal alimentation, or rectal feeding, is an enema administered with the intent of providing nutrition when normal eating is not possible. Although this treatment is ancient, dating back at least to Galen, and commonly used in the Middle Ages, and still a common technique in 19th century medicine, Nutrient enemas have been superseded in modern medical care by tube feeding and intravenous feeding.

A variety of different mixes have been used for nutrient enemas throughout history. A paper published in Nature in 1926 stated that because the rectum and lower digestive tract lack digestive enzymes, it is likely that only the end-products of normal digestion such as sugars, amino acids, salt and alcohol, will be absorbed.

Notoriously, the treatment was given to U.S. President James A. Garfield after his shooting in 1881, and is asserted to have prolonged his life.

Douche:

Douche usually refers to vaginal irrigation, the rinsing of the vagina, but it can also refer to the rinsing of any body cavity. A douche bag is a piece of equipment for douching—a bag for holding the fluid used in douching. To avoid transferring intestinal bacteria into the vagina, the same bag must not be used for an enema and a vaginal douche.

References:

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