Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study

Hemorrhoidal disease: Epidemiological study and analysis of predictive factors for surgical management

INTRODUCTION

There are very few French studies on hemorrhoidal disease and its management.

PATIENTS AND METHODS

Prospective single-center study from July to December 2021 including 472 patients.

RESULTS

Bleeding, prolapse and pain were the main reasons for consultation. Treatment modalities were medical (44%),±instrumental (72%), and surgical (17%). After treatment, the bleeding score and prolapse score decreased significantly (P=0.002 and P≤0.0001, respectively), but improvement was more marked in the surgery group with a better rate of "very good satisfaction" (73% vs. 54%, P=0.003). Factors associated with likelihood of surgical treatment were: age>44years, hypertrophic perianal skin tags, high scores (Bristol>5, bleeding>5, prolapse>2), severe impact on quality of life, smoking and reading during bowel movements. We have developed an online application, which aims to assess the risk of requiring hemorrhoidal surgery.

CONCLUSION

Less than 20% of patients who present with hemorrhoidal disease require surgical treatment, but it is associated with better effectiveness despite more complex postoperative consequences that sometimes motivate patient refusal. We have highlighted factors associated with surgical management, which can guide the practitioner in their therapeutic choices.

Haemorrhoidal disease in pregnancy: results from a self-assessment questionnaire administered by means of a social network

BACKGROUND

The anal symptoms occurring during pregnancy and post-partum, mainly related to Haemorrhoidal Disease (HD), have been reported with in a wide range of incidence in the literature. Although in many cases the course of the disease is mild and self-limiting, sometimes it is severe enough to affect quality of life.

METHODS

Our study has been conducted through a questionnaire administered via social media with the aim of obtaining epidemiologic data on the incidence of the symptoms of HD in an unselected population of pregnant women. In addition, we looked for the presence of those factors notoriously predisposing or associated to HD (constipation, straining on the toilet, low dietary fibres and fluid intake).

RESULTS

Out of 133 patients 51% reported symptoms of HD during pregnancy, mainly in the second and third trimester. Constipation, straining on the toilet, low dietary fibres and fluid intake were not significantly related to incidence of HD. Only a previous history of HD was correlated to onset of symptoms of HD in pregnancy and reached a statistical significance (odds ratio = 5.2, p < 0.001).

CONCLUSION

Although with the limitations posed by the nature of our retrospective study via a self-assessment interview, our results suggest that the occurrence of HD in pregnancy seems not sustained by the classical risk factors observed in the general population. At the moment, specific therapeutic measures are lacking and treatment relies on empiric suggestions concerning diet, fluid intake, bowel care, local ointment. Further studies are needed in order to identify a targeted etiologic treatment.

Incidence and Risk Factors of Perianal Pathology during Pregnancy and Postpartum Period: A Prospective Cohort Study

OBJECTIVE

We aimed to identify the incidence and risk factors of perianal pathology during pregnancy and the postpartum period.

METHODS

A prospective cohort study was conducted in three institutions in Lithuania. A total of 190 patients were examined and interviewed three times (<12, 18-20 weeks of gestation, and during the first 2 months after delivery). They completed a questionnaire including demographic, obstetric, coloproctological, and birth data.

RESULTS

A total of 73 (34.59%) women developed hemorrhoidal disease after delivery, and 120 (56.87%) developed perianal pathology. Multivariate analysis identified a neonatal birth weight ≥3380 g (OR 4.22; 95% CI 1.83-9.71, p < 0.001) and consumption of eggs (OR 3.10; 95% CI 1.13-8.53, p = 0.028) or cereals (OR 2.87; 95% CI 1.32-6.25, p = 0.008) several times per week as significant risk factors for hemorrhoidal disease. Neonatal birth weight ≥3380 g (OR 3.95; 95% CI 1.47-10.59, p = 0.006), maternal BMI ≥ 21.48 (OR 3.58; 95% CI 1.51-8.47, p = 0.004), the duration of the second labor period ≥38 min (OR 2.81; 95% CI 1.09-7.23, p = 0.032), and consumption of flour products several times per week (OR 2.77; 95% CI 1.10-6.98, p = 0.030) were associated with a higher risk of perianal pathology. Daily consumption of fruits and vegetables (OR 0.35; 95% CI 0.15-0.81, p = 0.014) and less frequent consumption of eggs were protective factors (OR 0.18; 95% CI 0.06-0.56, p = 0.003).

CONCLUSIONS

Perianal diseases, especially hemorrhoidal disease, are common during pregnancy and the postpartum period. A neonatal birth weight ≥ 3380 g, a maternal BMI of ≥21.48, duration of the second labor period of ≥38 min, and consumption of flour products and cereals several times a week are risk factors for developing these diseases.

Thrombosed external hemorrhoids during pregnancy: surgery versus conservative treatment

The management of thrombosed external hemorrhoids (TEH) during pregnancy is still under debate because of the fear of potential adverse effects on the fetus. This study aims to compare efficacy and safety of conservative versus surgical treatment of acute TEH in pregnant women. Furthermore, the outcome of two different surgical approaches was evaluated. This is a prospective observational study including a sub-analysis on two randomized groups of pregnant women affected by TEH. The primary outcome measured was the impact of conservative and surgical treatment defined in terms of VAS, clinical patient grading assessment scale (CPGAS) and the SF-12 questionnaire. In a randomized sub-analysis of the surgical treatment, the outcome of local excision (LE) versus thrombectomy (TE) was compared. Fifty-three patients entered the study. Twenty-six patients had conservative treatment and 22 underwent surgery. Within the surgical group, 8 were randomized for TE and 14 for LE. VAS, SF-12 and CPGAS improved in both groups after 3 and 10 days from the treatment. However, physical (PCS) and mental health (MCS) domains of the SF-12 and CPGAS showed a significant difference in favor of surgery on the 10th day (PCS: p < 0.002 and MCS: p = 0.03; CPGAS: p = 0.002). The surgical group showed an earlier significant reduction of pain on the 3rd day (p = 0.0004). In the surgical group, randomization was halted due to ethical concerns arising from a notable difference in the primary end point between subgroups during interim analysis. Specifically, the re-thrombosis rate was 38% (3/8) after TE and 7% (1/14) after LE. No complications occurred for either mothers or fetuses. Both surgical and conservative treatments are safe and effective. However, surgery allows a faster relief of anal pain. Thrombectomy is associated with higher risk of re-thrombosis when compared to local excision (clinicaltrials.gov ID number NCT04588467).

Belgian consensus guideline on the management of anal fissures

Introduction

Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred.

Methods

A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023.

Results

Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks.

Conclusions

The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

Anal disorders in pregnant and postpartum women: epidemiological, diagnostic and therapeutic aspects in 10 maternities of Bamako in Mali

Bowel transit disturbances favored by pregnancy and injuries during childbirth would be triggering or aggravating factors for anal pathologies. The objective of this work was to study the epidemiology, diagnosis, and treatment of anal pathologies during pregnancy and 6 weeks after delivery. We carried out a prospective, multi-centric, and analytical study in 10 obstetric units in Bamako from June 1st, 2019, to May 31st, 2020. After informed consent, we enrolled all first-trimester pregnant women admitted to the hospitals and who were followed up through the postpartum. We conducted a rectal examination in each participant and an anoscope in those with an anal symptom. Hemorrhoidal diseases were diagnosed in the case of external hemorrhoids (thrombosis or prolapse) or internal hemorrhoids. During the study period, we followed up 1,422 pregnant women and we found 38.4% (546) with anal pathologies (hemorrhoidal diseases in 13% (192), anal fissure in 10.5% (150) and anal incontinence in 8.6% (123). Risk factors for the hemorrhoidal disease were age of patient ≥30 years old aRR=5.77, 95% CI 4.57-7.34; p=0.000; a existence of chronic constipation aRR=2.61, 95% CI 1.98-3.44; p=0.000; newborn weight >3500 g aRR= 1.61, 95% CI 1.25-2.07; p=0.000 and fetal expulsion time >20 minutes aRR= 6.04, 95% CI 5.07-7.27; p=0.000. The clinical signs observed were constipation, anal pain, bleeding, and pruritus. The treatment was based on counseling on hygiene and diet, the use of laxatives, local topicals, and analgesics along perineal rehabilitation. Anal pathologies were common during pregnancy and 6 weeks after delivery. Pregnant women must be screened systematically for such pathologies. Early diagnostic and appropriate treatment would reduce serious complications.

Haemorrhoids and Anal Fissures in Pregnancy: Predictive Factors and Effective Treatments

Introduction Haemorrhoids and anal fissures (HAF) are common in pregnancy and can severely affect the quality of life of those suffering from them. Despite the condition being common, there is limited evidence, formal guidelines or recommendations on treatment, and little is known about the natural course during pregnancy. Methods This was a prospective, observational cohort study conducted at a tertiary-referral university maternity hospital (The National Maternity Hospital, Dublin), conducted over a nine-month period. The first part of the study was a case-control study of antenatal patients over 34 weeks' gestation. The second part of the study involved a cohort of postnatal patients. Anonymous patient surveys were performed and analysed. Results Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021. Of the antenatal patients, 82/184 (45%) of these patients had symptoms of HAF and 102/184 (55%) antenatal patients were unaffected, acting as controls. In addition, 74 affected postnatal patients were also included. In the affected antenatal group, 36/82 (44%) of patients had self-reported HAF (symptoms or signs of HAF); 50/82 (61%) of patients diagnosed with HAF on their own. 12/82 (15%) noticed symptoms in the first trimester, 25/82 (30%) in the second and 45/82 (55%) in the third. 142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre. 144/184 (78%) used medical treatments including suppositories. Only one patient had surgery. 70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months. Conclusion HAF affect almost half of the pregnancies. Age over 35 was significantly associated with antenatal haemorrhoids or anal fissures. Concerningly, the majority of patients (64%) self-diagnose and manage the condition without either seeking or receiving guidance from medical professionals. In terms of the natural course of the disease, it was encouraging that 45% of patients' symptoms resolved within a few days. This will help when counselling patients with distressing symptoms. Conservative measures such as increased dietary fibre, increased fluid intake and bath salts were effective in relieving symptoms for the majority of patients.

Prevalence, Characteristics, and Treatment of Hemorrhoids During Pregnancy: A Nationwide Population-Based Cohort Study in Taiwan

Background: Hemorrhoids, a gastrointestinal tract disorder, are common during pregnancy. However, large-scale epidemiological studies on hemorrhoids during pregnancy are limited. Therefore, this study used analyzed data from a nationwide population-based database to investigate the prevalence, characteristics, and treatment of hemorrhoids in Taiwan. Materials and Methods: This retrospective population-based study used data from the National Health Insurance Research Database and Taiwan Birth Certificate Application to collect the medical records of women who were pregnant at any time during 2009-2018. Hemorrhoids was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (455. X) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) (K64.X, O22.4X) with related treatment. Results: We enrolled 1,608,804 deliveries in 1,070,708 women. The proportion of hemorrhoids increased with age in both primipara and multipara women. Of the pregnant women, 31% received oral medication, and 93.2% used the topical ointment to treat their hemorrhoids. Few patients (1.8%) required procedure or surgery during pregnancy, and 41.4% of those patients underwent procedure or surgery in their first trimester. The cumulative incidence of hemorrhoids during pregnancy was significantly higher in women with a history of hemorrhoids and those with multifetal pregnancies. No significant difference in the incidence of hemorrhoids was observed between multiparous and primiparous women. Conclusion: Women with a history of hemorrhoids or those carrying multiple fetuses had an increased risk of hemorrhoids during pregnancy. The most commonly used treatment for hemorrhoids during pregnancy was topical ointments, with only a small proportion (1.8%) of patients requiring procedure or surgery.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Preventing hemorrhoids during pregnancy: a multicenter, randomized clinical trial

Background

To compare specific dietary and behavioral recommendations for hemorrhoids prevention during pregnancy.

Methods

This was a randomized, single-blind, multicenter trial conducted in three different clinical centers. Patients were randomly allocated into two groups in a ratio of 1:1. Intervention consisted of specific dietary and behavioral counseling. The primary outcome of this study was the rate of hemorrhoids at the time of discharge from the obstetrics unit. Categorical variables were compared by the Chi-Squared or Fisher exact tests, as appropriate. Continuous variables were compared using either the Student's t-test or the Mann–Whitney U test. Binary logistic regression model was used to identify independent predictors of hemorrhoids after delivery. This analysis was performed on factors with a p-value < 0.10 in univariate analysis. Statistical analysis was performed using IBM SPSS 23.0 and GraphPad Prism 9 software. A P-value of less than 0.05 was considered significant for all tests.

Results

We observed a significantly lower hemorrhoids rate in the intervention group at the time of discharge from the obstetrics unit after delivery (intention-to-treat (ITT) (the relative risk (RR) 0.38; 95% the confidence interval (CI) 0.24–0.59; p < 0.001) per-protocol (PP) (RR 0.42; 95% CI 0.27–0.64; p < 0.001). There was no significant difference in spontaneous miscarriage rate between the groups for both ITT and PP analysis. Additional binary logistic regression analysis revealed that the intervention applied in this study was the only protective factor. Both, the history of hemorrhoids before pregnancy and the increase of newborn height was associated with a higher risk of hemorrhoids.

Conclusions

Our suggested intervention, aimed to modify dietary and behavioral habits, significantly reduces the rate of hemorrhoids after pregnancy and can be safely recommended to pregnant women.

Trial registration

Date of registration: 2016–05-09; Date of initial patient enrollment: 2016–06-02; Trial registration number: 158200–16-843–357; Trial registration site URL: https://www.mf.vu.lt/mokslas/vilniaus-regioninis-biomedicininiu-39tyrimu-etikos-komitetas#isduoti40vrbtek-leidimai. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04688-x.

Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods

Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.

Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults

Hemorrhoidal disease is a highly prevalent anorectal condition causing substantial discomfort, disability, and decreased quality of life. Evidence on preventable risk factors for hemorrhoidal disease is limited. We conducted a cross-sectional study of 194,620 healthy men and women who completed a health screening exam including colonoscopy in 2011–2017. We evaluated potential risk factors of hemorrhoidal disease, including lifestyle factors, medical history, birth history, gastrointestinal symptoms, and anthropometric measurements. The prevalence of hemorrhoidal disease was 16.6%, and it was higher in females than in males (17.2 vs. 16.3%; P < 0.001). Compared to men, the prevalence of hemorrhoidal disease was higher in parous women (adjusted odds ratio [OR] 1.06; 95% confidence interval [CI] 1.02–1.10), and lower in nulliparous women (adjusted OR 0.92; 95% CI 0.86–0.98). In the adjusted analyses, older age, female sex, smoking, overweight, and being hypertensive were independently associated with the presence of hemorrhoidal disease. The prevalence of hemorrhoidal disease was positively associated with body mass index and waist circumference in parous women. The prevalence of hemorrhoidal disease was higher in older age, females, ever-smokers, and hypertensive participants. The association of excess adiposity with the prevalence of hemorrhoidal disease differed by sex and parity.

Evaluation and management of rectal bleeding in pregnancy

Rectal bleeding occurs in about 40% of pregnant women, and is predominantly attributed to benign perianal pathology (haemorrhoids or anal fissures). More sinister causes of rectal bleeding may be heralded by key red flag clinical and biochemical features. These features should be evaluated in all women with rectal bleeding. Imaging investigations or flexible sigmoidoscopy may be warranted. The latter can be performed safely by experienced operators in pregnant women. Women with evidence of haemodynamic compromise, elevated inflammatory markers, significant anaemia, signs of intestinal obstruction or compromise to the fetus should be evaluated urgently. Providers must be mindful of the changes in normal ranges for common haematological and biochemical parameters in pregnancy compared with the non-pregnant state. Faecal calprotectin is an established tool for identification of intestinal inflammation and is valid in pregnancy. An elevated faecal calprotectin level (≥ 50 µg/g) signifies a need for further diagnostic evaluation. Inflammatory bowel disease may present initially, or with worsening disease activity, in pregnancy. Expedient diagnosis with the use of faecal calprotectin, sigmoidoscopy with or without intestinal ultrasound, exclusion of alternative or compounding infective aetiologies, and institution of appropriate therapy are critical. Medical therapies for management of inflammatory bowel disease can be safely instituted in pregnancy. Colorectal cancer incidence is increasing in younger age groups, but fortunately remains rare. When diagnosed in pregnancy, colorectal cancer can be successfully and safely managed with a collaborative multidisciplinary team approach. Early diagnosis is key to optimising outcomes.

Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management

Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.

Influence of Bowel Habit and Hormonal Changes on the Development of Hemorrhoidal Disease During Pregnancy and the Postdelivery Period: A Prospective Cohort Study

BACKGROUND

Hemorrhoidal disease in women during pregnancy is common in clinical practice. However, prospective data on its real prevalence and women's demographics are scarce.

OBJECTIVE

The aim of this study was to determine the prevalence of hemorrhoidal disease during pregnancy and to assess its impact on quality of life. In addition, this study aimed to identify the relationship between patients' characteristics, bowel habits, hormonal changes, and the presence of symptomatic hemorrhoids.

DESIGN

This is a prospective longitudinal cohort study.

SETTING

This study was conducted in the Obstetrics Department for pregnancy follow-up.

PATIENTS

The patients evaluated were a cohort of pregnant women.

INTERVENTION

The study was designed to follow a homogeneous cohort of women for 15 months. Visits took place in the first and third trimesters of pregnancy, and 3 and 6 months after delivery. Women's demographics (age, medical history, bowel habit, Bristol stool scale) and serum determination of pregnancy-related hormones (estrogen, progesterone, and relaxin) were determined.

MAIN OUTCOME MEASURES

The primary outcome was the development of hemorrhoidal disease.

RESULTS

Overall, 109 women (mean age, 31.2 ± 5.4 years) were included in the study. The prevalence of symptoms and physical findings of hemorrhoidal disease was present in 11% in the first trimester, 23% in the third trimester, 36.2% at 1 month after delivery, and 16.9% at 3 months after delivery. A medical history of hemorrhoidal disease was significantly associated with the diagnosis of hemorrhoids in the first trimester (p < 0.0001) and third trimester (p = 0.005). Symptoms of constipation were associated with this clinical disorder in the first trimester (p = 0.011) and the third trimester of pregnancy (p = 0.022). No association was found between hormonal changes and the development of hemorrhoidal disease.

LIMITATIONS

A larger sample would provide more information.

CONCLUSIONS

The prevalence of women with hemorrhoidal disease increases during pregnancy and after delivery. A history of hemorrhoidal disease and constipation is significantly associated with the diagnosis of symptomatic hemorrhoidal disease. See Video Abstract at http://links.lww.com/DCR/B504.

INFLUENCIA DEL HBITO INTESTINAL Y LOS CAMBIOS HORMONALES EN EL DESARROLLO DE LA ENFERMEDAD HEMORROIDAL DURANTE EL EMBARAZO Y EL PERODO POSTERIOR AL PARTO UN ESTUDIO DE COHORTE PROSPECTIVO

ANTECEDENTES:La enfermedad hemorroidal en mujeres durante el embarazo es común en la práctica clínica. Sin embargo, hay escasos datos prospectivos sobre su prevalencia real y la demografía de las mujeres.OBJETIVO:El objetivo fue determinar la prevalencia de enfermedad hemorroidal durante el embarazo y evaluar su impacto en la calidad de vida. Además, identificar la relación entre las características de los pacientes, los hábitos intestinales, los cambios hormonales y la presencia de hemorroides sintomáticas.DISEÑO:Estudio prospectivo de cohorte longitudinal.AJUSTE:Este estudio se realizó en el Departamento de Obstetricia para el seguimiento del embarazo.PACIENTES:Una cohorte de mujeres embarazadas.INTERVENCIÓN:El estudio se diseñó para realizar un seguimiento de una cohorte homogénea de mujeres durante 15 meses. Las visitas se realizaron en el primer y tercer trimestre del embarazo, y a los 3 y 6 meses después del parto. Se determinaron los datos demográficos de las mujeres (edad, antecedentes médicos, hábito intestinal, escala de heces de Bristol) y la determinación sérica de hormonas relacionadas con el embarazo (estrógeno, progesterona y relaxina).PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el desarrollo de enfermedad hemorroidal.RESULTADOS:Se incluyó en el estudio a 109 mujeres (edad media, 31,2 ± 5,4 años). La prevalencia de síntomas y hallazgos físicos de enfermedad hemorroidal estuvo presente en 11% en el primer trimestre, 23% en el tercer trimestre, 36,2% 1 mes después del parto y 16,9% 3 meses después del parto. Un historial médico previo de enfermedad hemorroidal se asoció significativamente con el diagnóstico de hemorroides en el primer trimestre (p <0,0001) y tercer trimestre (p = 0,005). Los síntomas de estreñimiento se asociaron con este trastorno clínico en el primer trimestre (p = 0,011) y el tercer trimestre del embarazo (p = 0,022), respectivamente. No se encontró asociación entre los cambios hormonales y el desarrollo de enfermedad hemorroidal.LIMITACIONES:Una muestra más grande proporcionaría más información.CONCLUSIONES:La prevalencia de mujeres con enfermedad hemorroidal aumentó durante el embarazo y el posparto. El antecedente de enfermedad hemorroidal y estreñimiento se asociaron significativamente con el diagnóstico de enfermedad hemorroidal sintomática. Consulte Video Resumen en http://links.lww.com/DCR/B504.

A flexible silicone patch for treatment of hemorrhoids after birth: a pilot study of HEMOCIN® Patch

PURPOSE

To test a non-pharmacological silicone patch for treatment of symptomatic hemorrhoids with focus on usability, safety, and self-reported short-term effect.

METHODS

Puerperal women in a Danish maternity ward were cluster randomized to treatment with the HEMOCIN® patch (intervention) or no systematic treatment (control group). On inclusion and after 2 weeks, they completed a questionnaire regarding history and hemorrhoid symptoms scored from 0 to 10. Women in the intervention group also reported on the usability of the patch and any side effects.

RESULTS

We included 31 women in the intervention group and 33 in the control group. Twenty-eight (90.3%) women in the intervention group and 27 (81.8%) women in the control group responded to follow-up. Except from a difference in the severity of swelling at inclusion, there were no differences between the two groups for any symptoms, neither at inclusion, nor at follow-up, or in the change of symptoms during the two weeks (p > 0.05). Twenty-three women (85.2%) in the control group used medical treatment vs. one woman in the intervention group. The patch was used on an average of 9.3 days, 15.5 h/day and for 7.1 h before changing the patch. No severe side effects were reported.

CONCLUSION

This pilot study finds that the HEMOCIN® patch is a safe and feasible treatment option for hemorrhoids. However, we did not detect any significant effect on hemorrhoid symptoms. The patch could be an option for people who seek non-pharmacological treatment for symptomatic hemorrhoids or need long-term treatment without steroid side effects.

Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is common in adults. Treatment is largely conservative, although more invasive procedures may be required. Venoactive drugs such as micronized purified flavonoid fraction (MPFF) are widely used, but a recent and comprehensive review of supporting evidence is lacking. In acute HD, MPFF can reduce HD symptoms such as bleeding, pain, anal discomfort, anal discharge and pruritus. In patients undergoing surgery, postoperative adjunct MPFF consistently reduces pain, bleeding duration and use of analgesia. MPFF treatment is appropriate and effective both as a first-line conservative treatment and as a postoperative adjunct treatment. MPFF reduces the duration of hospital stay following surgery, facilitating a return to normal activity and improving quality of life. MPFF may also prevent HD recurrence.

Epidemiology of haemorrhoids and publicly funded excisional haemorrhoidectomies in New Zealand (2007-2016): a population-based cross-sectional study

AIM

Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand.

METHOD

This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location.

RESULTS

A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence.

CONCLUSION

There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

The prevalence, characteristics and treatment of hemorrhoidal disease: results of an international web-based survey

Background: This international study assessed the characteristics and treatment of individuals with hemorrhoids. Materials & methods: Online survey among nationally representative populations of adults from Brazil, Czech Republic, France, Hungary, Italy, Romania, Russia and Spain, that identified participants who self-reported having hemorrhoidal disease. Results: Hemorrhoid prevalence was 11% (1725/16015); most respondents had low-severity disease (71%). Compared with the general population, participants with hemorrhoidal disease had more comorbidities (mean 3.1 vs 1.3) and included more women who had been pregnant (81 vs 68%). Common initial signs/symptoms were pain (60%), bleeding (47%) and discomfort (43%). Hemorrhoid respondents who consulted a physician were more likely to undergo interventions and take medications. Conclusion: The prevalence of hemorrhoidal disease in the adult population is 11%, mostly low-severity disease.

Hemorrhoids Are Associated with Urinary Incontinence

Background: Hemorrhoids are a common anal disorder and are more frequent in women than in men. Urinary incontinence (UI) also occurs more frequently in women than in men. Although both diseases share similar risk factors, research on the association between the two diseases is lacking. This study aimed to investigate the relationship between hemorrhoids and UI in adult Korean women. Methods: This study was based on the data of the 2008-2009 Korean National Health and Nutrition Examination Survey. Logistic regression test was performed to determine the relationship between hemorrhoids and UI after adjusting for age, body mass index (BMI), smoking, heavy drinking, physical activity, education level, income, diabetes mellitus, and hypertension. Results: Analysis of the data of 8,139 adult women revealed that the prevalence of hemorrhoids, which were self-reported and diagnosed by a physician, was 17.5% and 7.9%, respectively. Both types of hemorrhoids were more prevalent in older women with spouses, those with a large waist circumference, and those with a high BMI. The prevalence of UI was significantly high in the hemorrhoid group, regardless of whether it was self-reported or diagnosed by a physician. Multiple logistic regression analyses revealed a significant association between the prevalence of UI and hemorrhoids, both of which were found to peak at 19-39 years of age. Conclusions: Our findings demonstrate that hemorrhoids are significantly correlated with UI in adult Korean women. When treating adult women with hemorrhoids, it is, therefore, necessary to consider other pelvic floor diseases such as UI.

S3-Leitlinie: Analfissur

Die Analfissur ist eine der häufigsten Pathologien, welche sich dem Proktologen präsentiert. Entsprechend ist es wichtig, verlässliche Leitlinien dazu zu entwickeln. Die aktuelle Leitlinie wurde anhand eines systematischen Literaturreview von einem interdisziplinären Expertengremium diskutiert und verabschiedet.

Die akute Analfissur, soll auf Grund ihrer hohen Selbstheilungstendenz konservativ behandelt werden. Die Heilung wird am besten durch die Einnahme von Ballaststoff reicher Ernährung und einer medikamentösen Relaxation durch Kalziumkanal-Antagonisten (CCA) unterstützt. Zur Behandlung der chronischen Analfissur (CAF), soll den Patienten eine medikamentöse Behandlung zur „chemischen Sphinkterotomie“ mittels topischer CCA oder Nitraten angeboten werden. Bei Versagen dieser Therapie, kann zur Relaxation des inneren Analsphinkters Botulinumtoxin injiziert werden. Es ist belegt, dass die operativen Therapien effektiver sind. Deshalb kann eine Operation schon als primäre Therapie oder nach erfolgloser medikamentöser Therapie erfolgen. Die Fissurektomie, evtl. mit zusätzlicher Botulinumtoxin Injektion oder Lappendeckung, ist die Operation der Wahl. Obwohl die laterale Internus Sphinkterotomie die CAF effektiver heilt, bleibt diese wegen dem höheren Risiko für eine postoperative Stuhlinkontinenz eine Option für Einzelfälle.

Portuguese Society of Gastroenterology Consensus on the Diagnosis and Management of Hemorrhoidal Disease

Hemorrhoidal disease (HD) is a frequent health problem with considerable repercussions on patients' quality of life. However, much of the clinical practice related to HD is based on knowledge without scientific evidence and supported largely by empirical experience of the physician who deals with this pathology. As in other countries, the goal of this consensus is to establish statements supported by solid scientific evidence and whose purpose will be to standardize and guide the diagnosis and management of HD both in the general population and in some particular groups of patients.

Factors Influencing Quality of Life during the First Trimester of Pregnancy: A Prospective Cohort Study

Introduction: Pregnancy, delivery and postpartum periods are associated with fast changes leading to decreased self-confidence, anxiety, stress or even maternal depression impairing their quality of life (QOL). Although considered important, QOL of women during pregnancy is poorly understood. The aim of our study was to assess factors influencing QOL during first trimester of pregnancy. The secondary goal of our study was to evaluate whether QOL during first trimester of pregnancy is associated with newborn weight. Materials and methods: A prospective cohort study was performed including pregnant women during the first trimester visit. Our questionnaire consisted of the SF-36 QOL questionnaire, Wexner fecal incontinence scale, and other additional information. The SF-36 questionnaire mental (MCS) and physical (PCS) health scores were used in order to evaluate QOL of women during first trimester of pregnancy. Two multiple logistic regression models were created in order to determine independent variables that influence the QOL. Results: 440 pregnant women were included in the study. The two main domains that were used in the study were MCS and PCS, their medians were 50.0 (25.0; 50.0) and 50.1 (39.4; 59.0) points respectively. From the two logistic regression models we determined several independent factors that influence QOL of women during the first trimester of pregnancy. Additionally, we determined that women who reported worse QOL tended to give birth to newborns large for their gestational age. Conclusions: We found several significant variables that influence QOL of women during the first trimester of pregnancy. We also found that that lower MCS and PCS scores during the first trimester are associated with newborns large for gestational age.

Relationship between parity and the problems that appear in the postpartum period

Parity is associated with the incidence of problems in pregnancy, delivery and the puerperium. The influence of parity in the postpartum period has been poorly studied and the results are incongruous. The objective of this study was to identify the association between parity and the existence of distinct discomfort and problems during the postpartum period. Cross-sectional study with puerperal women in Spain. Data was collected on demographic and obstetric variables and maternal manifestations of discomfort and problems during the postpartum period. An ad hoc online questionnaire was used. Crude odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were estimated by conditional logistic regression. 1503 primiparous and 1487 multiparous participated in the study. 53.4% (803) of the primiparous women affirmed to have feelings of sadness, as opposed to 36.2% (539) of multiparous women (aOR: 1.60; 95% CI: 1.35-1.89). 48.3% (726) of primiparous had lactation problems vs 24.7% (367) of multiparous (aOR: 2.46; 95% CI: 2.05-2.94). 37.2% (559) of primiparous reported anxiety, while the percentage in multiparous was 25.7% (382) (aOR: 1.34; 95% CI: 1.12-1.61). 22.2% (333) of primiparous had depressive symptoms, and 11.6% (172) of multiparous (aOR: 1.65; CI 95%: 1.31-2.06). Faecal incontinence was more present in primiparous than in multiparous, 6.5% (97) and 3.3% (49) respectively (aOR: 1.60; 95% CI: 1.07-2.38). Parity is associated with the presence of certain problems in the postpartum period. Thus, primiparous are more likely to have lactation problems, depressive symptoms, anxiety, sadness, and faecal incontinence.

Benign Anal Disease: Implementation of an Educational Program Across Specialties

BACKGROUND

Benign anal diseases, including hemorrhoids, fissures, abscesses, fistulas, and anal condylomata, affect 10%-15% of our population. Most patients seen by nonsurgical providers experience delayed treatment. We examined at our institution whether an educational session on anorectal diseases would benefit trainees from medical and surgical specialties.

MATERIALS AND METHODS

The study took place at Oregon Health & Science University, a primary institutional practice with 130 resident participants. An exploratory study using a 10-point pretest and posttest regarding these diseases was designed and administered to medical subspecialties, including general surgery (GS), emergency medicine, internal medicine, and family medicine, obstetrics/gynecology, and pediatric residents. Intervention was a 50-min presentation highlighting anatomy, history and physical findings, and disease treatment. The posttest was repeated after 6 mo to evaluate retention and overall satisfaction, and differences were evaluated.

RESULTS

With the exception of GS, posttest scores improved. Internal medicine improved most significantly. GS residents scored better on the pretest than other specialties; their posttest scores, however, declined. The survey demonstrated residents with prior education scored better on the pretest. PGY-1 and PGY-2 residents improved most on their posttest. On 6-mo retest, 17.6% of residents responded and posttest performance was 72%.

CONCLUSIONS

Nonsurgical residents have limited knowledge about benign anal diseases but demonstrate improvement after educational intervention. Surgery residents performed well, but demonstrate regression to the mean, common in test taking, but may also require a more advanced lecture. Formal institutional, regional, and national educational interventions are needed to improve the understanding of these diseases.

Is round ligament varicosity in pregnancy a common precursor for the later development of inguinal hernias? The prospective analysis of 28 patients over 9 years

Purpose

Short-term effects of round ligament varicosity (RLV) in pregnancy have been investigated in small-scale studies. The long-term effects are unknown. This study aims to evaluate the risk of groin hernia manifestation after RLV in pregnancy, to delineate possible risk factors and to analyze the natural course of pregnancy and post-partum period with regard to RLV.

Methods

In a prospective analysis 28 pregnant women with RLV presented to the hernia clinic over 9 years. After clinical and ultrasound examination during pregnancy and publication of early results in 2013 a second structured follow-up was conducted. Demographic data, hernia-specific risk factors, comorbidities, pregnancy and birth-related data as well as post-partum period were documented without loss of follow-up. In these women, all pregnancies that occurred, including the ones without RLV, were analyzed.

Results

Median follow-up was 68 months (11.4–104.9). Only one groin hernia was found. No risk factors could be identified. After uncomplicated childbirth complaints subsided spontaneously in all but one patient within 4 weeks. Recurrence rates in subsequent pregnancies are up to 89%.

Conclusion

Temporary RLV-induced dilation of the deep inguinal ring in pregnancy is not a common precursor for the development of inguinal hernias later in life. All findings support the theory that the hindrance of venous blood flow caused by the gravid uterus is an important contributing factor for RLV in pregnancy, which is self-limited but has a high risk of recurrence and is not an indication for surgery before or after delivery or for cesarean section.

Anorectal symptoms during pregnancy and postpartum: a prospective cohort study

AIM

The aim was to determine the prevalence and risk factors of anal symptoms prepartum and postpartum.

METHOD

A prospective observational cohort study was carried out in Ghent University Hospital, Belgium. Ninety-four pregnant women between their 19th and 25th week of pregnancy were included. An anal symptom questionnaire was filled in at four different times: in the second and third trimester, immediately postpartum and 3 months postpartum. Descriptive data were obtained from patient files. A proctological diagnosis was presumed on the basis of combined symptoms (i.e. rectal bleeding, anal pain and swelling). Constipation was defined by the Rome III criteria. Risk factors were identified using multivariate analysis.

RESULTS

Sixty-eight per cent of the patients developed anal symptoms. The most prevalent symptom was anal pain. Constipation was reported by 60.7% during the study period. Seven women (7.9%) suffered from faecal incontinence. The most prevalent diagnoses were haemorrhoidal thrombosis (immediately postpartum), haemorrhoidal prolapse (in the third trimester and immediately postpartum) and anal fissure (not episode related). The two independent risk factors for anal complaints were constipation, with a 6.3 odds ratio (95% CI 2.08-19.37), and a history of anal problems, with a 3.9 odds ratio (95% CI 1.2-13). The Bristol Stool Chart was shown to be a reliable indicator in pregnancy and postpartum as significant correlations were observed in all study periods.

CONCLUSION

Two-thirds of pregnant women have anal symptoms during pregnancy and postpartum, especially haemorrhoidal complications and anal fissure. The most important risk factor is constipation. The prevention of constipation in pregnant women is therefore highly recommended.

Haemorrhoids - A neglected problem faced by women after birth

OBJECTIVE

To investigate the prevalence and severity of haemorrhoids after birth among first-time mothers in relation to management during the second stage of labour and to describe the women's experiences with haemorrhoids.

METHOD

A mixed method explanatory sequential design was used. Nulliparous women were allocated to an intervention group for whom the second-stage of labour practice followed the MIMA model (Midwives management during second stage of labour) or to a control group for whom standard-care practice was followed. Data were collected three weeks and 1.5 years after birth.

RESULT

A total of 496 (82.1%) women responded to the questionnaire three weeks after birth, 120 (70%) responded to the questionnaire 1.5 years after the birth. The women in the intervention group had fewer symptoms from haemorrhoids three weeks after birth compared to the women in the control group (adj. OR 0.6 95% CI 0.4-0.9). Half of the women in the intervention and control group (50.8%) who reported problems with haemorrhoids three weeks after birth still experienced problems after 1.5 years. The majority of all women did not seek medical care due to their symptoms. The women who described that they experienced haemorrhoids as a problem after birth felt neglected by the healthcare system.

CONCLUSION

A substantial percentage of women had symptoms from haemorrhoids after birth. Many of these women felt that their problems were neglected. Women who experienced a slow birth of the baby's head and spontaneous pushing suffered less from haemorrhoids 3 weeks after birth.

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Zusammenfassung. Der auf Höhe der Linea dentata gelegene Corpus cavernosum recti spielt eine tragende Rolle bei der Regulierung der Feinkontinenz. Kommt es zu einer pathologischen Vergrösserung des Corpus cavernosum verbunden mit Symptomen, spricht man von einem Hämorrhoidalleiden. Das Hämorrhoidalleiden ist eine Volkskrankheit mit einer Inzidenz von ca. 40 %, wobei die Rate an Selbsttherapien hoch ist. Im klinischen Alltag fällt der stadienadaptierten Therapie eine wichtige Rolle zu: Hämorrhoiden Grad I sind die Domäne der konservativen Therapie, Hämorrhoiden Grad II können in Abhängigkeit der Schwere der Symptome konservativ oder operativ angegangen werden. Hämorrhoiden Grad III und Grad IV sollten einer Operation zugeführt werden.

Skin disease in pregnancy

Skin manifestations during pregnancy are common and diversified. This review will focus on the most important entities to be recognized by obstetricians. These are, on the one hand, physiological changes, where unnecessary investigations should be avoided, and on the other, the specific dermatoses of pregnancy. These develop electively in pregnancy, and they are currently grouped into three disorders: polymorphic eruption of pregnancy, atopic eczema of pregnancy, and pemphigoid gestationis. Arguments for recognition of these are presented including detection of anti-BP180 antibodies. Follow-up and treatment depend on the precise diagnosis. Risks in fetal prognosis may occur in rare pemphigoid gestationis cases.