Should a suppository be inserted with the blunt end or the pointed end first, or does it not matter?

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Q Should a suppository be inserted with the blunt end or the pointed end first, or does it not matter?

A The rectal mucosa has a rich blood and lymph supply that aids systemic absorption. Suppositories are medicated solid preparations primarily for insertion into the rectum. They may be used for both local and systemic effect.

This route of drug delivery is relatively painless and particularly useful for patients who are fasting or nil-by-mouth before or after surgery or who are unable to tolerate oral medication due to nausea and/or vomiting. It is also useful for children who have needle phobia and require medication.

Suppositories for local effect are useful in the management of chronic constipation, in bowel preparation prior to bowel investigations and for the treatment of itching and pain caused by haemorrhoids.

Suppositories are manufactured in a torpedo shape with a pointed end (apex) and a blunt end (see picture above). The blunt end is often concave, forming a useful indentation for the fingertip to push against.

Historically suppositories were inserted pointed end first but the publication of one study (Abd-El-Maeboud et al, 1991) changed nursing practice overnight. The authors suggested retention is more easily achieved if suppositories are inserted blunt end first because the squeezing action of the anal sphincter against the apex pushes (sucks) them into the rectum.

Since the authors made no particular reference to clinical need, arguably the study can be interpreted to include suppositories for either a systemic or local action or both.

However, there has been a lack of critical appraisal of this research, which has never been replicated and has the limitations inherent with any small study. The research analysis used simple descriptive statistics, which further brings into question the validity and robustness of the research and the conclusions drawn.

The lack of critical appraisal is in itself disconcerting as publication of the research had a cascading effect on nursing practice. Articles (Moppett, 2000) and textbooks on practical procedures (Mallett and Dougherty, 2005; Baillie, 2001) all support the view that suppositories should be inserted blunt end first, citing Abd-El-Maeboud et al (1991).

Does it matter?

If a suppository is for the management of chronic constipation, it must be placed against the bowel wall so the way it is inserted does seem to matter. Insertion is usually required because the patient is experiencing extreme discomfort from constipation. An incorrect insertion will subject the patient to an undignified and invasive procedure that is also ineffective.
Suppositories need body heat in order to dissolve and become effective - placed in the middle of faecal matter they will remain intact. If a suppository is inserted blunt end first using the anal sphincter to assist with insertion there is no guarantee it will come into contact with the bowel wall. However, if it is inserted apex end first the fingertip is able to guide and place the suppository against the bowel wall.

Patients self-administering suppositories may find the blunt end more acceptable as, owing to the sucking action, there is no need to insert the finger into the anal canal (Abd-El-Maeboud et al, 1991). This lends weight to inserting the blunt end first - especially if the suppository is for a systemic effect, as rectal absorption is more effective lower in the rectum as veins draining from this part of the rectum join the internal iliac veins. This means medication returns directly to the inferior cava, bypassing the portal circulation (Waugh and Grant, 2007).

Conclusion

In the absence of conclusive evidence to recommend one particular method of suppository insertion, it seems that a common-sense approach is required (Bradshaw and Price, 2006).

Although the idea that a patient might receive clinical care that is not based on best practice is unacceptable, recommendations on suppository insertion in nursing textbooks and articles were radically changed following suggestions made in one small research trial. There is an ambiguity as to what constitutes ‘best evidence-based practice’ in the administration of suppositories. If their insertion pointed or blunt end first really does matter then arguably more extensive research is urgently required.

Author
Gaye Kyle, MA, DipEd, BA, RGN, is honorary lecturer, Thames Valley University, London, and recognised teacher at University of Ulster.

• Related article on NursingTimes.net Administration of a suppository

References

Abd-El-Maeboud, K.H. et al (1991) Rectal suppository: commonsense and mode of insertion. The Lancet; 338: 8770, 798-803.

Baillie, L. (ed) (2001) Developing Practical Nursing Skills. London: Hodder Arnold Headline Group.

Bradshaw, A., Price, L. (2006) Rectal suppository insertion: the reliability of the evidence as a basis for nursing practice. Journal of Community Nursing; 16: 1, 98-103.

Mallett, J., Dougherty, L. (2005) Bowel care. In: Mallett, J. Dougherty, L. (eds) Royal Marsden Hospital Manual of
Clinical Nursing Procedures (6th ed). London: Blackwell.

Moppett, S. (2000) Which way is up for a suppository? Nursing Times; 96: 26, 196-197.

Waugh, A., Grant, A. (2007) Anatomy and Physiology in Health and Illness (10th ed). London: Elsevier.

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