*Małgorzata Kołodziejczak1, Przemysław Ciesielski1, 2
When a postpartum patient needs a proctologist
Kiedy pacjentce po porodzie potrzebny jest proktolog
1Warsaw Proctology Centre, Saint Elisabeth Hospital, Warsaw
2Department of General Surgery, County Hospital in Wołomin
Ciąża i poród sprzyjają występowaniu dolegliwości proktologicznych u kobiety. Wpływa na to nasilenie zaparć u ciężarnych, co związane jest z czynnikami hormonalnymi, częstym przyjmowaniem przez kobiety w ciąży preparatów żelaza, ograniczeniem aktywności fizycznej i wzrostem wagi ciała. Powyższe czynniki sprzyjają wystąpieniu choroby hemoroidalnej, zakrzepów żył okołoodbytowych i przerostom fałdów brzeżnych anodermy. Pacjentka ciężarna i pacjentka w połogu skarżąca się na dolegliwości proktologiczne jest pacjentką interdyscyplinarną z pogranicza dwóch specjalności: ginekologii i koloproktologii. Większość chorób proktologicznych w tym szczególnym dla kobiety okresie życia można leczyć zachowawczo i tylko niektóre z nich wymagają operacji. Jeśli więc wiedza i doświadczenie ginekologa-położnika w zakresie rozpoznawania i leczenia podstawowych chorób proktologicznych są dostatecznie duże, może on leczyć te choroby sam, nie kierując od razu pacjentki do proktologa. Są jednak sytuacje kliniczne, w których konsultacja proktologiczna jest niezbędna ze względów zarówno medycznych, jak i prawnych. W poniższym artykule opisane zostaną najczęściej występujące choroby proktologiczne, na które cierpią pacjentki po porodzie, oraz wskazane zostaną sytuacje, w których konieczna jest konsultacja proktologiczna.
Both pregnancy and delivery increase the risk of rectal symptoms in women. This is due to the increased severity of constipation in pregnant women, which is associated with hormonal factors, higher iron intake, limited physical exercise and weight gain during pregnancy. These factors promote haemorrhoidal disease, perianal venous thrombosis and hypertrophy of marginal anodermal folds. A pregnant or a postpartum patient reporting rectal symptoms becomes a multidisciplinary patient, with the overlap of two specialities, i.e. gynaecology and coloproctology. Most rectal conditions that occur in this special period of life may be managed conservatively and only some of cases require surgical approach. Therefore, obstetrician-gynaecologists with sufficient knowledge and experience in the diagnosis and treatment of the most common rectal conditions may implement treatment on their own instead of referring the patient to a proctologist. However, there are clinical situations when proctological consultation is necessary for medical and legal reasons. The paper describes the most common rectal conditions affecting postpartum patients, with an emphasis on situations requiring proctological consultation.
Both pregnancy and delivery increase the risk of rectal symptoms in women. There are several factors responsible for this increased risk, such as elevated intra-abdominal pressure during labour and the associated venous blood stasis in the perianal region, microtrauma to the rectal mucosa during labour and, most of all, increased constipation during pregnancy. Constipation in pregnancy occurs due to hormones, frequent intake of iron preparations, limited physical exercise and weight gain. The two latter are particularly pronounced in the third trimester, when the uterus reaches its maximum size, compressing the intestines, which consequently leads to the lowering of pelvic floor muscles. The above mentioned factors may promote haemorrhoidal disease, perianal venous thrombosis and, consequently, hypertrophy of marginal anodermal folds (which are often identified as haemorrhoids by patients) and postpartum fissure. There are many reports confirming the increased incidence of rectal conditions in pregnant women. Abramowitz and Batallan (1) found that anal fissure or perianal venous thrombosis, which according to the authors are most likely to result from increased constipation during pregnancy, occur in up to 1/3 of pregnant women, and that perianal venous thrombosis is often seen in cases of difficult labour. Rectal conditions such as abscess and fistula occur at a rate similar to that in the general population.
The paper discusses the method of rectal examination in a pregnant patient as well as treatment approaches for the most common rectal conditions in pregnant and postpartum patients. Symptoms of gas and stool incontinence associated with complicated childbirth should be discussed separately.
Medical history and physical examination
In general, the method of collecting medical history and performing physical examination in a pregnant patient is the same as in other patients. Each patient should be ensured intimacy during medical history collection and physical examination, which is a typical feature of proctological examination. In addition to routine questions about symptoms, particular attention should be paid to obstetric history, including previous natural childbirths, birth weight, perineal trauma or instrumental delivery, and the obtained data should be related to the symptoms reported with particular emphasis on gas and stool incontinence. Increased itching and burning sensation around the anus are not necessarily symptoms of haemorrhoidal disease, but may result from reduced sphincter tone. There are cases, when a decision to terminate pregnancy by Caesarean section needs to be made to avoid putting the patient at a risk of increased incontinence after another delivery. An important element of the interview is its active form. Young patients are not always ready to openly talk about intimate symptoms such as stool incontinence in a clinical setting. Also, patients may fail to report venereal diseases or HIV infection if not asked. However, this information may help diagnose the aetiology of rectal symptoms.
Both physical examination and surgical procedures should be performed in a pregnant patient lying on her left side. Proctological examination involves visual inspection of the perianal region, palpation and anoscopy. Each of these elements should be appropriately documented, with particular emphasis on passive and active tone of the anal sphincter prior to childbirth. Thorough obstetric and proctological history along with the evaluation of muscle tone helps make decisions on the method for pregnancy termination. A detailed description of the prenatal examination may be also an important element of doctor’s legal protection against the consequences associated with potential postpartum complications. Anoscopy and rectoscopy are invasive procedures and should be performed during pregnancy only in justified cases, when there is a need for diagnosis (e.g. a bowel tumour) or treatment (e.g. massive haemorrhoid bleeding) (2).
It is estimated that haemorrhoidal disease occurs in 1 in 5 pregnant women (1). Constipation, which affects 11 to 38% of pregnant women, is one of the primary risk factors for haemorrhoidal symptoms (3-5). It was found that large-sized uterine compression on the intestines is not as important as previously thought as there are no significant differences in the incidence of constipations between the first and the third trimester. Most patients with haemorrhoidal disease receive conservative treatment after delivery. Pregnancy is a relative contraindication to surgical treatment of haemorrhoids. Patients with massive haemorrhoid bleeding, secondary anaemia or acute haemorrhoidal thrombosis are an exception. Therapeutic recommendations include anti-constipation diet (high-fibre diet with high intake of water) and pharmacotherapy that is not toxic for the child. Since most women breastfeed after childbirth, pharmacotherapy is used carefully, considering the fact that each agent, including those in the form of suppositories, may enter bloodstream and, consequently, breast milk. Diosmin derivatives or Butcher’s broom (Ruscus aculeatus), which are present in breast milk in trace amounts, may be used in the acute phase of haemorrhoidal disease. It should be emphasised that papers on pharmacotherapy in pregnant women are sparse. A large retrospective study in 2,092 pregnant patients assessing the safety of Butcher’s Broom preparations was conducted in France; however the study is considered “old” as it was conducted in 1985 (6). Currently, no such studies are conducted in pregnant patients for ethical reasons. In cases of mild haemorrhoidal disease, the treatment is limited to diet and lubrication of the anal canal with hyaluronic acid or herbal preparations. Invasive procedures also play a role in the treatment of haemorrhoidal disease in postpartum women. Barron’s rubber band ligation may be used in the case of mild, yet persistent haemorrhoid bleeding, while surgical approach should be used in rare cases of massive bleeding causing secondary anaemia. In her clinical practice, the author of this paper performed several surgical procedures in postpartum patients due to haemorrhoidal bleeding via classical Milligan Morgan haemorrhoidectomy with good clinical effect (the risk of hypoxia in the child outweighed the risk of surgery). Therefore, patients with advanced haemorrhoidal disease (grade IV, massive bleeding, extensive inflammation) should be referred to a proctological surgeon. Patients with mild haemorrhoidal disease may be successfully conservatively treated by their gynaecologist.
Perianal venous thrombosis
The treatment of perianal venous thrombosis in a postpartum patient does not differ significantly from the one used in other patients. Large painful clots should be evacuated under local anaesthesia, diffuse thrombosis manifesting with oedema of the entire anal circumference is treated conservatively with diosmin derivatives. Hot sitz baths should be avoided due to a fresh perineal wound. Streptodornase and streptokinase derivatives in the form of suppositories should be also avoided due to unknown effects on the child. Warm soda compresses may be applied on the anoderm. Most of clots are absorbed spontaneously after a few days, sometimes with hypertrophied anoderm folds left behind.
To conclude, patients requiring an incision to drain the clot should be referred to a proctological surgeon, whereas other patients may be treated with diet and pharmacotherapy by their gynaecologists.
Hypertrophied anodermal folds
This is not a disease, but only a “residue” after a disease, which usually occurs after marginal clot absorption. Marginal folds should not be removed immediately after delivery. It should be explained to the patient that the size of folds may decrease significantly over a few weeks. Surgical removal may be offered to patients with frequently inflamed folds or folds causing significant psychological discomfort during sexual encounters; however such cases are rare. There is no need to hurry with this surgical procedure. Preferably, it should be performed after the breastfeeding period. The decision and the procedure should be left to a proctologist. Zinc ointment, which has regenerating action and protects against stool penetration and retention between the folds, may be used to reduce discomfort or itching that may be caused by swollen folds.
Postpartum anal fissure
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