A "rectal rocket" is an informal compounding term for a multi-ingredient rectal suppository molded with a flared external end, so that one portion sits inside the anal canal and the flared portion rests against the skin outside it. Prescribers order them for hemorrhoid symptoms, anal fissure and proctitis. There is no FDA-approved product of this design, so a rectal rocket is a compounded preparation by definition, and every ingredient in it is specified by the prescriber who writes the order.
What is a rectal rocket suppository?
The name describes the shape, not a drug. A conventional suppository is inserted entirely; a rectal rocket is molded so that a narrower body sits above the anal verge while a wider flange stays outside it, which places the same preparation against internal and perianal tissue at once. That geometry is the only thing the term reliably tells you.
The dose form is chosen because the target tissue is local. A suppository softens at body temperature and stays in contact with the anal canal and perianal skin, which is the point of ordering one rather than something taken by mouth. When and how often to use it, and for how long, are instructions that come from the prescriber and appear on your label.
Because no manufacturer makes this dose form, there is no package insert, no approved indication and no standard strength attached to it. Two suppositories called rectal rockets by two different prescribers can contain different drugs at different concentrations. This is one of the practical differences between a compounded preparation and a commercial one, a distinction covered in more depth in our explainer on how compounding and retail pharmacies differ.
What goes into a compounded rectal rocket?
The ingredient list is the prescriber's decision, not the pharmacy's. A pharmacy prepares what the prescription specifies and will not substitute drugs or alter strengths on its own. If you want to know why a particular combination was chosen for you, the prescriber who wrote it is the person who can answer.
The components that appear most often in these orders fall into a few pharmacologic classes: a local anesthetic such as compounded lidocaine, a corticosteroid such as hydrocortisone, and in fissure-directed orders a smooth muscle relaxant such as nifedipine, diltiazem or nitroglycerin.
The suppository base matters as much as the actives. Non-sterile preparations of this kind are prepared under USP 795 non-sterile compounding standards, in a fatty base such as cocoa butter or in a water-soluble polyethylene glycol base, depending on what the prescriber orders and how the preparation needs to behave at body temperature.
The reason the order goes to a compounding pharmacy at all is that no manufacturer sells these drugs together in this dose form. A prescriber who wants an anesthetic and a steroid in one rectal suppository, or a calcium channel blocker at a strength no commercial product offers, has no off-the-shelf equivalent to reach for. Compounding is the mechanism for filling that gap, one prescription at a time.
Which conditions is a rectal rocket prescribed for?
Three come up repeatedly: symptomatic hemorrhoids, chronic anal fissure and proctitis. Each is a different problem with a different mechanism, and the fact that one dose form is used across all three does not mean the same ingredients are appropriate for each.
Chronic anal fissure is the indication with the most published work behind it, because the target is specific: a fissure is associated with raised internal sphincter tone, and the drugs directed at it are agents that lower that tone. That is the reasoning behind orders for compounded rectal nifedipine.
Proctitis is inflammation of the rectal lining and has its own set of causes, including inflammatory bowel disease, radiation and infection. Rectal preparations ordered for it are usually anti-inflammatory rather than anesthetic, which is why a prescriber may order a compounded tacrolimus rectal preparation rather than a rectal rocket.
What does the evidence actually show?
There are no controlled trials of the multi-ingredient rectal rocket combination itself. What exists in the literature is evidence about individual drugs given by the rectal route, and that evidence does not transfer automatically to a compounded blend of several of them in one base.
The strongest of it sits with the smooth muscle relaxants in chronic anal fissure. Topical calcium channel blockers have been examined in randomized trials, and reviews of non-surgical therapy for anal fissure include them alongside nitrate preparations, which is the background to orders for rectal diltiazem.
Nitrates have been studied in the same setting, and an FDA-approved nitroglycerin rectal ointment for chronic anal fissure exists. Those trials tested that approved single-ingredient product; they say nothing about a compounded rectal nitroglycerin preparation combined with an anesthetic and a steroid in one suppository.
Absence of trials is not the same as evidence of harm, and it is not evidence of benefit either. It means the combination has not been measured, so its effect, its failure rate and its interactions between ingredients are not quantified in the published literature. That uncertainty is part of what a prescriber is weighing when choosing between a compounded blend and a single-ingredient product that has been studied.
How do compounded rectal preparations compare?
| Preparation | Usual target | Status | Evidence |
|---|---|---|---|
| Rectal rocket suppository | Hemorrhoid, fissure symptoms | Compounded, not FDA-approved | No trials |
| Nifedipine, rectal | Chronic anal fissure | Compounded, off-label | Small trials |
| Diltiazem, rectal | Chronic anal fissure | Compounded, off-label | Small trials |
| Nitroglycerin, rectal | Chronic anal fissure | Compounded, off-label | RCT, approved form |
| Diazepam / baclofen suppository | Pelvic floor spasm | Compounded, off-label | Case series |
| Tacrolimus, rectal | Proctitis | Compounded, off-label | Small trials |
Every row marked off-label describes a use or a route that sits outside an approved product label. Off-label prescribing is lawful and common, and the decision to prescribe that way, at what strength and for how long, belongs to the prescriber. Nothing in this table is a dosing instruction.
When should you see a clinician instead?
Rectal bleeding is a symptom that warrants evaluation rather than self-treatment. It is common in benign conditions, and it is also how colorectal disease can first present, so a preparation that quiets the symptom without a diagnosis behind it can delay the assessment that matters.
Hemorrhoid symptoms also overlap heavily with conditions that need a diagnosis to separate them: fissure, abscess, fistula, pruritus ani, inflammatory bowel disease and anal or rectal neoplasm can all present with pain, itching or bleeding around the anus. An examination is what distinguishes them, and self-diagnosis from symptoms alone is unreliable.
Some circumstances make an assessment more pressing: bleeding that is new, changing or persistent, a change in bowel habit, unintended weight loss, fever, a hard lump or discharge, or symptoms in anyone with a personal or family history of colorectal disease. None of these are reasons to reach for a suppository first.
Pelvic floor muscle spasm is another cause of anorectal pain that does not respond to hemorrhoid-directed ingredients, and it is a different prescribing decision. Where a clinician identifies it, they may order compounded diazepam and baclofen suppositories instead.
What does Bayview compound for this?
Bayview prepares rectal suppositories, ointments and creams on a prescriber's order, in the strengths and ingredient combinations that order specifies, using USP 795 non-sterile compounding. The rectal preparations kept as standing formulations include nifedipine, diltiazem and nitroglycerin for the fissure indication, tacrolimus rectal preparations, and a diazepam and baclofen suppository in a vaginal or rectal form, starting at $154.
Diazepam is a controlled substance. It is dispensed only against a prescription written for a named patient, and controlled substances are not shipped to New York addresses.
Compounded preparations are not billed through insurance, so they are paid for directly, and pricing varies with the drug, strength and quantity the prescriber orders. Questions about cost, ordering and the states where Bayview is licensed are answered on our frequently asked questions page.
The full range of rectal, oral and topical preparations in this area is listed under pain and palliative care compounding.
Preparations outside that area, including the dermatology and digestive listings that hold several of the rectal items named above, are indexed in the searchable catalog of compounded medications.
Where a patient cannot swallow reliably, the rectal route is sometimes chosen for reasons that have nothing to do with hemorrhoids, a situation described in our piece on compounding in palliative care.
How do you raise this with your prescriber?
Bring the symptom, not the product name. Describe what you feel, where, for how long, and whether there has been bleeding, and let the clinician examine you before any preparation is chosen. If a rectal rocket comes up, ask which drugs are in it, at what strengths, and why those were selected for your situation.
Ask also what the plan is if the symptom does not change, and what would prompt further investigation. Non-opioid options for local pain are discussed in our overview of compounded alternatives to opioids.
Prescribers can send an order directly to the pharmacy, and the clinical background on anorectal and other local preparations is set out on our pain management compounding page.
Frequently asked questions
Do these suppositories work?
Benefit is not established. In the best-designed study, nightly 10 mg vaginal diazepam over four weeks produced no difference in resting pelvic floor EMG at any time point and no difference on any validated questionnaire compared with placebo, and a second double-blind, placebo-controlled trial also failed to show benefit.
Pelvic floor physical therapy is the intervention with actual evidence for hypertonic pelvic floor dysfunction. If you are considering these, ask your prescriber how they fit alongside physical therapy rather than in place of it.
How are they used?
Use them exactly as your prescriber directs. As commonly prescribed, one suppository is inserted vaginally or rectally at bedtime, or twice daily, often as a defined two-to-four-week trial timed around pelvic floor physical therapy rather than as open-ended refills. Wash your hands before and after. Because sedation is expected, do not drive until you know how it affects you, and a panty liner helps with base leakage.
Is this a local-only treatment?
No. Vaginal diazepam is not confined to the pelvic floor, pharmacokinetic studies show measurable diazepam in the bloodstream after vaginal dosing. That means the ordinary systemic effects of a benzodiazepine apply, including sedation, impaired driving and coordination, and interactions with alcohol and opioids. Any description of these suppositories as acting locally only, or as having minimal systemic absorption, is not accurate.
What side effects should I expect?
Expect sedation. Drowsiness, dizziness, impaired coordination, falls, and problems with memory or concentration are the most common, and alcohol and opioids make them worse. Baclofen adds drowsiness and muscle weakness and must be tapered rather than stopped suddenly. Locally, vaginal irritation, discharge, and leakage or staining from the suppository base are common. Extra caution applies in older adults.
Is diazepam a controlled substance?
Yes. Diazepam is a Schedule IV controlled substance and the benzodiazepine boxed warnings apply. Taken with opioids it can cause profound sedation, life-threatening respiratory depression, coma, and death. Abuse, misuse, and addiction are risks, and continued use can cause physical dependence, so stopping abruptly can cause withdrawal including seizures. Do not stop on your own, ask your prescriber about tapering.
How should I store them?
Follow your label, because storage depends on the base: PEG-based suppositories are generally kept at controlled room temperature, while cocoa butter and other fatty bases are generally refrigerated at 2 to 8 °C, or at least below 25 °C, so they do not melt. Because diazepam is a controlled substance, keep them secured and out of the reach of children and others, and never share them.
What is nifedipine rectal ointment?
It is a compounded, prescription medication applied to the anal area. Nifedipine is a calcium channel blocker, and used this way it relaxes the ring of muscle around the anus. Providers most often prescribe it for anal fissures, small tears in the skin of the anal canal that cause sharp pain and bleeding with bowel movements. Bayview compounds it at 0.3% strength as an ointment.
What is diltiazem rectal ointment?
It is a compounded, prescription medication applied to the anal area. Diltiazem is a calcium channel blocker, and used this way it relaxes the ring of muscle around the anus. Providers most often prescribe it for anal fissures, small tears in the skin of the anal canal that cause sharp pain and bleeding with bowel movements. Bayview compounds it at 2% strength as an ointment and as a gel.
How does diltiazem compare with nitroglycerin or nifedipine for an anal fissure?
All three are applied to the anal area, and all three are compounded, since none is available as an FDA-approved topical product in the United States. The 2023 clinical practice guideline from the American Society of Colon and Rectal Surgeons reports that topical calcium channel blockers such as diltiazem and nifedipine heal chronic fissures about as well as topical nitroglycerin while causing fewer side effects such as headache, and that either class may be used first-line. Which one suits a particular person is your prescriber's decision.
How long does diltiazem take to work on a fissure?
Pain often eases within the first week or two, but healing takes longer. Chronic fissures are usually treated for six to eight weeks, and prescribers generally direct patients to finish the full course even after the pain improves, since stopping early is a common reason a fissure returns. Supportive care such as fiber, fluids, and sitz baths is usually part of the plan. If your symptoms are not improving after several weeks of use, contact your provider.
What is nitroglycerin ointment used for?
Applied to the anal area, nitroglycerin relaxes the internal anal sphincter and improves blood flow to the tissue. That eases the pain and spasm of a chronic anal fissure and gives the tear the circulation it needs to heal. It treats the muscle spasm behind the problem, and is a recognized non-surgical option for chronic fissures.
Why are the ear, rectal, and scalp forms compounded?
No manufacturer makes a tacrolimus ear drop, rectal enema, gel, foam, or shampoo, so each one is compounded to the prescriber's order and used off-label. These routes are supported mainly by small studies and case series rather than large trials, so the evidence behind them is limited. Compounded preparations are not FDA-approved, and your prescriber decides whether one is appropriate for you.
How do providers send a prescription to Bayview?
Providers can submit a prescription three ways:
- E-prescribe: Search Bayview Pharmacy, Warwick, RI (NCPDP 4106882) in your EHR. For compounds, use the compound, custom, or free-text option and include the full formulation, strength, quantity, refills, and directions.
- Fax: Send a signed order to 401-284-4506 (alt. 401-210-2757) with patient and prescriber details, medication, quantity, refills, directions, signature, and date.
- Phone: Call 401-284-4505 to submit, clarify, or coordinate refills.
A valid prescription is required, and compounded medications are not FDA-approved.
Do you accept insurance?
Most compounded medications are not covered by insurance. We can always try and run your insurance prior to compounding your prescription if you wish.
What Bayview compounds for this
Important: Compounded medications are prepared to a prescriber's order for an individual patient. They are not FDA-approved, and the FDA has not evaluated them for safety, effectiveness, or manufacturing quality. This article is educational and is not a substitute for advice from your prescriber or pharmacist.
This preparation contains a controlled substance. Controlled-substance prescriptions carry refill limits, must be e-prescribed, and can only be shipped to states where Bayview holds the required licensure.
Uses discussed here may be off-label, meaning they are not part of any FDA-approved labeling. Off-label use is a decision for you and your prescriber, based on the available evidence.
Veterinary preparations are compounded to a veterinarian's order for a specific animal and are not FDA-approved animal drugs. Never give a compounded human medication to an animal without veterinary direction.
Compounded prescriptions are paid for directly rather than billed through insurance. Most are HSA/FSA-eligible, and many patients submit the receipt to their plan for possible reimbursement. Pricing depends on the strength, dose form and quantity your prescriber orders. Read more about cost and insurance.
Compounded rectal preparations are not billed through insurance, because a compounded preparation has no NDC for a plan to adjudicate against. They are paid for directly at the time of dispensing. A diazepam and baclofen suppository starts at $154, and the price of any rectal preparation varies with the drugs, strengths and quantity the prescriber orders.
Bayview Pharmacy is an NABP-accredited compounding pharmacy in Warwick, Rhode Island, licensed to fill and ship compounded prescriptions for patients in Rhode Island, Massachusetts, Connecticut, New Jersey, New Hampshire, Florida, New York and Maine. Controlled substances are not shipped to New York addresses. See where we ship and how to get started.
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