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This practice has been questioned by Abd-el-Maeboud et al. 1991 who suggest that suppositories should be inserted blunt end first. This advice is based on anorectal physiology; if a suppository is inserted apex first, the circular base distends the anus and the lower edge of the anal sphincter fails to close tightly. The normal squeezing motion (reverse vermicular contraction) of the anal sphincter therefore fails to drive the suppository into the rectum. These factors can lead to anal irritation and expulsion of the suppository (Moppett 2000). The study by Abd-el-Maeboud et al. 1991 remains the only research evidence supporting this practice. Whilst their work demonstrated that patients found insertion and retention of suppositories much easier and more comfortable using the base-first method, the isolated nature of this research means that manufacturers’ instructions continue to recommend apex end first. Therefore this area of practice remains somewhat unclear: the Abd-el-Maeboud et al. 1991 study, coupled with the anatomical and physiological rationale, would imply that blunt end first is preferable.

Types of suppository

There are several different types of suppository available. Retention suppositories are designed to deliver drug therapy, for example analgesia, antibiotic, non-steroidal anti-inflammatory drug (NSAID). Those designed to stimulate bowel evacuation include glycerine, bisacodyl and sodium bicarbonate. Lubricant suppositories, for example glycerine, should be inserted directly into the faeces and allowed to dissolve. They have a mild irritant action on the rectum and also act as faecal softeners (BNF 2011). However, stimulant types, such as bisacodyl, must come into contact with the mucous membrane of the rectum if they are to be effective as they release carbon dioxide, causing rectal distension and thus evacuation.

Procedure guideline 6.11 Suppository administration

Essential equipment

Disposable incontinence pad

Disposable gloves

Topical swabs or tissues

Lubricating jelly

Suppository(ies) as required (check prescription before administering a medicinal suppository, e.g. aminophylline)

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. If you are administering a medicated suppository, it is best to do so after the patient has emptied their bowels. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008a, C). To ensure that the active ingredients are not prevented from being absorbed by the rectal mucosa and that the suppository is not expelled before its active ingredients have been released (Moppett 2000, E).

2 Wash hands. To ensure the procedure is as clean as possible and for infection control reasons (Fraise and Bradley 2009, E).

3 Ensure privacy. To ensure privacy and dignity for the patient (NMC 2008b, C).

4 Ensure that a bedpan, commode or toilet is readily available. In case of premature ejection of the suppositories or rapid bowel evacuation following their administration. P

Procedure

5 Assist the patient to lie on the left side, with the knees flexed, the upper higher than the lower one, with the buttocks near the edge of the bed. This allows ease of passage of the suppository into the rectum by following the natural anatomy of the colon. Flexing the knees will reduce discomfort as the suppository is passed through the anal sphincter (Moppett 2000, E).

6 Place a disposable incontinence pad beneath the patient’s hips and buttocks. To avoid unnecessary soiling of linen, leading to potential infection and embarrassment to the patient if the suppositories are ejected prematurely or there is rapid bowel evacuation following their administration. E

7 Wash hands. For infection prevention and control (Fraise and Bradley 2009, E).

8 Place some lubricating jelly on the topical swab and lubricate the blunt end of the suppository if it is being used to obtain systemic action. Separate the patient’s buttocks and insert the suppository blunt end first, advancing it for about 2–4 cm. Repeat this