A suppository is a ‘solid or semi-solid, bullet-shaped pellet’ (Dougherty and Lister, 2015) that is a mix of medication and a ‘wax-like’ substance that melts following insertion into the rectum (Galbraith et al, 2013). Suppositories are used for a local or systemic effect to empty the bowel prior to surgery, investigations or examinations, to administer medications, to soothe and treat haemorrhoids or anal pruritus (Dougherty and Lister, 2015). Suppositories may also be considered when oral medications cannot be used, in palliative care, if a patient has swallowing difficulties or has severe nausea and cannot retain oral medication. For the complete list of medicines available for rectal administration as suppositories refer to the British National Formulary (Joint Formulary Committee, 2019a).
Most commonly, suppositories are used to empty the bowel to relieve constipation when other less invasive treatments have failed. Constipation is defined by the National Institute for Health and Care Excellence (NICE) (2017a) as a symptomatic disorder that describes unsatisfactory defecation due to infrequency or difficulty in passing stools that is less frequent than the individual's normal bowel pattern. Chronic constipation is defined as symptoms that present for at least 12 weeks in the last 6 months (NICE, 2017a). Complications of constipation include faecal loading or impaction, haemorrhoids, anal fissure, faecal retention, rectal distension and loss of sensory and motor function (NICE, 2017b). Early assessment and treatment of constipation are necessary to prevent long-term implications (Mitchell, 2019). Individuals with constipation often experience a reduction in their quality of life compared with the general population (Norton, 2006). In the short term individuals can experience pain, discomfort and bloating. The long-term effects of constipation can lead to diverticular disease, chronic back pain, hernia or recurrent urinary tract infections.
Suppository types and mode of action
There are various types of suppositories used for constipation. Nurses must be aware of any potential harm associated with their practice and reduce this whenever possible (Nursing and Midwifery Council (NMC), 2018). Nurses should understand how each type of suppository works, the anatomy of the rectum and only administer medicines within their training and competence (Peate, 2015; NMC, 2018).
There is currently no conclusive evidence to support the most effective way to insert a suppository. Abd-el-Maeboud et al (1991) suggested that the blunt end should be inserted first to prevent anal irritation and rejection of the suppository. However, this was a very small piece of research and other studies have subsequently challenged this work (Kyle, 2009). Due to the lack of conclusive evidence, it is important that nurses always follow the manufacturer's instructions and local policies.
Glycerine suppositories work as a lubricator, softener and a weak stimulant by lowering the surface tension of faeces, allowing water to penetrate and soften the stool (Dougherty and Lister, 2015; NICE, 2017c). They can be used for both hard and soft stools and are licensed for occasional use only (NICE, 2017c). Glycerine suppositories should be moistened before use to aid insertion and must be placed along the bowel wall, where heat from the body causes them to dissolve and distribute around the rectum (NICE, 2017c). This technique requires accuracy and therefore insertion of the suppository apex first may be better (Kyle, 2009).
Bisacodyl suppositories act as a stimulant. They are often used for bowel clearance before radiological procedures and surgery (NICE, 2017c; Joint Formulary Committee, 2019b). Bisacodyl suppositories have no softening effect and should be used only for soft stools, avoid administration into large, hard stools. Sodium phosphate and sodium bicarbonate suppositories are used for bowel clearance and work by an effervescent action (NICE, 2017c). The chemical reaction leads to a liberation of carbon dioxide, which causes an evacuation of the bowel within 30 minutes. All suppositories must be prescribed for each individual prior to administration.
Suppositories are contraindicated if the patient is suffering from chronic constipation (which would require repeated use), a chronic obstruction or malignancy, a paralytic ileus, low platelet levels or following any gastrointestinal or gynaecological operations unless prescribed by the surgeon/doctor (Dougherty and Lister, 2015). Glycerine suppositories should not be administered if an individual is allergic (hypersensitive) to glycerol or any of the other ingredients in the suppositories.
Suppositories for systemic use are best absorbed by the lower rectum. Venous drainage avoids the portal circulation and moves quickly to the inferior vena cava, resulting in a more rapid therapeutic effect (Kyle, 2009). There are some instances when a suppository may be prescribed for administration via a stoma. Nurses should seek additional advice before undertaking this procedure (Peate, 2015).
Administration
Elimination is a sensitive issue and must be handled respectfully at all times by the nursing team. The privacy and dignity if the patient must be respected and it is essential that the procedure is clearly explained to ensure informed consent is granted (NMC, 2018). Nurses should ensure that a moving and handling risk assessment is completed prior to treatment to establish if additional equipment such as hoists are required.
Before administration of suppositories, it is essential to correctly assemble all the necessary equipment. This should include:
Procedure
Conclusion
Administration of suppositories is an invasive technique. Nurses need to carry out a full assessment of the patient prior to this procedure and only administer a suppository if they have the appropriate knowledge and skills. Respect for the patient's privacy and dignity should be maintained at all times and a full reassessment must take place following the procedure.