As the saying goes, “nine out of ten men and ten out of ten women have hemorrhoids”, which means that the incidence of anal diseases is quite high in clinical practice. The incidence of anorectal diseases was 51.9% among 76,692 people surveyed in 29 provinces and autonomous regions, 53.9% among men and 67% among women, 13.1% higher among women than men. Among the anorectal diseases that can occur in pregnant and postpartum women, hemorrhoids, constipation, and anal fissures are the most common.
Women’s life can be divided into six stages according to their physiological characteristics: neonatal period, childhood, adolescence, sexual maturity, perimenopause and old age. Each physiological period has different changes in the internal environment. In women, menstruation, pregnancy, childbirth and menopause are special physiological periods in which the internal changes of the body have a greater impact on the occurrence and aggravation of anorectal diseases.
1. Menstruation and anorectal diseases
Menstruation: refers to regular, cyclical uterine bleeding.
During menstruation, due to the role of estrogen, the pelvic cavity is congested during menstruation, the anorectal mucosa is congested and edematous, the anal cushion is enlarged, and women often have anal swelling and discomfort. The rectal mucosa is easily injured by the fecal block and blood in the stool or mucosal erosion occurs. The perianal perineum is easily infected by blood impregnation and friction of sanitary products, which can lead to local edema and perianal abscess and anal fistula. Blood loss during menstruation, dry stools, Nu earn can lead to the occurrence of anal fissures.
2, pregnancy and anal diseases
Pregnancy: the process of the mother’s body to bear the fetus in its body development and growth. The whole pregnancy is 280 days.
2.1 Blood and circulatory system: Circulating blood volume starts to increase at 6-8 weeks of gestation and reaches a peak at 32-34 weeks of gestation, with an increase of about 30%-45%, averaging about 1500 ml, and remains at this level until delivery. Schoule states that intrapelvic arterial blood flow can increase by 25% during pregnancy. This is accompanied by an increase in intrapelvic venous blood flow. Cardiac volume increases by approximately 10% from early to late gestation, and cardiac output increases from approximately 10 weeks of gestation to a peak at 32 weeks of gestation. Femoral venous pressure starts at 20 weeks of gestation and increases significantly in the supine, sitting or standing position, because of the increase of pelvic blood flow back to the inferior vena cava after pregnancy and the obstruction of blood flow due to the compression of the inferior vena cava by the enlarged uterus. When lying on the side, the compression of the uterus can be released and the venous return can be improved. Due to the increased venous pressure in the vulva and rectum of the lower limbs and the expansion of the venous wall during pregnancy, pregnant women are prone to varicose veins and hemorrhoids in the lower limbs and vulva.
2.2 Reproductive system: With the gradual enlargement of the uterus, the uterus increases from 7-8 cm × 4-5 cm × 2-3 cm in non-pregnancy
The volume of the uterine cavity is about 5 ml in non-pregnancy and 5000 ml in full-term gestation, an increase of 1000 times. The weight of the uterus is about 50g when it is not pregnant, but about l000g at full term, an increase of 20 times. The huge uterus presses on the inferior vena cava above the pelvic population, affecting the reflux of the hemorrhoidal veins, leading to impaired hemodynamic control of the anal cushion and the development of hemorrhoids, or aggravating the symptoms of existing hemorrhoids. Moreover, the enlarged uterus compresses the intestinal canal, making the movement of intestinal contents impaired, which also causes poor defecation.
2.3 Endocrine system: The main sex hormones in women are estrogen, progesterone, relaxin, etc. They usually have the role of maintaining female physiological characteristics, but also promote the role of vascular smooth muscle dilation, promote the role of intestinal wall smooth muscle diastole, as well as the role of making tissue relaxation. During pregnancy, women’s sex hormone secretion will increase significantly, such as estrogen secretion is 25-40 times higher than usual. Studies have shown that the walls of the anal cushion plexus are lined with estrogen receptors and mammary gland-like tissue. During pregnancy, high levels of estrogen stimulate estrogen receptors and mammary gland-like tissue, resulting in dilatation, congestion, bleeding and swelling of the anal cushion vessels. While progesterone and relaxin not only have the effect of promoting vasodilatation, but also can make the tissues loose. When progesterone and relaxin increase, they act on the pelvic floor and anal canal supporting tissues, providing favorable conditions for the anal cushion to move down.
2.4 Digestive system: influenced by a large amount of estrogen, stomach acid decreases during pregnancy, the level of gastrin is low, the tension of gastrointestinal smooth muscle decreases, the cardia sphincter relaxes, and the acidic contents of the stomach may reflux to the lower esophagus, resulting in a feeling of “heartburn”. The secretion of gastric acid and pepsin is reduced. The gastric emptying time is prolonged, and the feeling of fullness in the upper abdomen is easy to occur, so pregnant women should prevent full meals. Intestinal peristalsis is then reduced, and the stool stays in the large intestine for a long time, and water is reabsorbed, making the stool dry and causing constipation. Dry stool stays in the intestine for a long time, on the one hand, long-term compression of the intestinal wall, resulting in obstruction of rectal venous reflux, increasing the chance of anorectal disease, on the other hand, constipation when defecation is difficult, defecation force, increased abdominal pressure, further increasing the obstruction of rectal venous reflux.
3, puerperium and anorectal diseases
Puerperium: The period from the delivery of the placenta to the time when all organs of the mother’s body, except the mammary glands, return to the normal state of non-pregnancy, becomes the puerperium, usually for 6 weeks.
3.1 Blood and circulatory system: Blood volume returns to the non-pregnant state in 2-3 weeks after delivery. In the early puerperium, due to the cessation of the uterine-placental circulation and the contraction of the uterus, a large amount of blood enters the body circulation from the uterus, and at the same time, due to the release of the compression of the pregnant uterus, the increase of venous blood flow in the lower extremities and the absorption of excessive inter-tissue fluid during pregnancy, the blood volume increases by 15%-25% and the blood is further diluted, and the circulating blood volume gradually returns to normal only in 2-6 weeks after delivery. The coagulation system is in a hypercoagulable state in the early puerperium, platelets fall in late pregnancy and quickly rise in the puerperium, fibrinogen in the blood is still at a high level, and prothrombin and prothrombin systems are also enhanced, but the hypercoagulable state in the puerperium and slow inferior vena cava blood flow can also be a factor in the formation of thrombus. This hypercoagulable state needs to be restored only 4 weeks after delivery.
3.2 Reproductive system: With the continuous shrinkage of muscle fibers, the uterus gradually shrinks, and the uterus shrinks to the size of about 12 weeks of gestation in 1 week after delivery, which can be retrieved on the pubic symphysis, and in 10 days-2 weeks after delivery, the uterus descends to the pelvic cavity, and the fundus cannot be retrieved during abdominal examination until 6-8 weeks after delivery, when the uterus returns to the size of unpregnant. In the process of delivery, due to the prolonged compression and dilatation of the fetal head, the compression and injury to the birth canal, perineal rectum, injury to the nerves in the perineum and the relaxation of the pelvic floor after delivery, the anal cushion shifts downward, and the repeated straining during delivery, the abdominal pressure increases, which aggravates the hemorrhoidal venous stasis.
3.3 Endocrine system: The pituitary gland, thyroid gland and adrenal cortex undergo a series of changes during pregnancy and gradually return to the non-pregnant state in the puerperium. After delivery, the levels of estrogen and progesterone drop sharply, and by 1 week after delivery, they have already dropped to the level of non-pregnancy.
3.4 Digestive system: After delivery, the level of progesterone decreases and the level of gastric motility increases, which promotes the gradual recovery of digestive function. The muscle tone and peristaltic force of the gastrointestinal tract and the secretion of gastric acid take about 1 to 2 weeks to return to normal after delivery. Therefore, within a few days after delivery, the mother still has poor appetite and prefers to eat soup. In addition, because of the postpartum abdominal wall and pelvic floor muscle relaxation, less activity, so easy to constipation.
4.Menopause and anorectal diseases
Menopause: Menopause in women is the period when ovarian function further declines and finally disappears. The ovaries stop ovulating once every four weeks, and menopause usually occurs at the age of 45-55. There are several stages: pre-menopause, perimenopause, over-menopause, menopause, and late menopause.
Menopause: Ovarian atrophy, which causes a continuous decline in estrogen levels and progesterone levels, vaginal atrophy, low resistance to senile vaginitis, urinary tract infections, tension urinary incontinence in some women, and decreased pelvic floor muscle tone. Commonly mixed hemorrhoids, prolapse, internal hemorrhoids, with anal foreign body prolapse, with anal flaccidity, constipation are common. The reasons may be: (l) endocrine disorders during menopause, which inhibit intestinal peristaltic function; (2) perineal rectal compartment relaxation, some patients form rectal protrusion, defecation difficulties, prolonged squatting and straining, hemorrhoidal venous plexus paralysis blood or anal cushion downward; (3) perineal rectal muscle aging relaxation, so that the anal cushion and other tissues downward; (4) old age and weakness or outdoor activities reduce, affecting intestinal peristaltic function.
5, diet and anorectal disease
The study shows that long-term drinking and eating spicy food can increase the chance of anal diseases, the relative risk of drinking alcohol is 3.055, and the relative risk of eating spicy food is 2.014. And in China, it is generally believed that women have a deficiency of energy and blood after pregnancy and childbirth, and need to make up for it, and the more they eat, the better, and mostly eat chicken and duck meat and sweet food. Sweet food, while vegetables and fruits eat relatively less. The survey shows that the intake of cereals and leafy vegetables is high, and the incidence of anorectal disease is low in women who often change their recipes.
6.Differences in delivery methods
The occurrence of anorectal disease is also related to the mode of delivery. The survey showed that the incidence of anorectal disease in those who gave birth by cesarean section was lower than that in those who gave birth vaginally. Qin Ting et al. showed that vaginal delivery and premature application of abdominal pressure contributed to the occurrence and aggravation of hemorrhoids, acute thrombosis of the original hemorrhoid nucleus, hemorrhoid edema, hemorrhoid prolapse out of the anus or impaction. Vaginal delivery
When the fetal head passes through the true pelvis after contraction, the fetal head squeezes the intestinal canal, the blood return of the middle and lower rectal arteries is impaired, the vascular plexus of the anal cushion is bruised and dilated, the microcirculation of the anal cushion and surrounding tissues is impaired, the tissue is hypoxic resulting in anal cushion edema, degenerative changes in the elastic fibers of the pits muscle, degeneration and necrosis of the elastic fibers and connective tissue; the pressure in the rectum and anal canal increases significantly when the mother holds her breath during the second stage of labor. At the end of the second stage of labor, anal dilatation is seen, the anal flap catenary is ectropion, the supporting tissue treitZ muscle and elastic fibers of the anal cushion are elongated or torn, and the direct extrusion of the fetal head pushes down, so that the anal cushion which loses support is displaced.
7.The relationship between pregnancy and abortion times
According to the survey by Lin Guoqiang and Li Xia, the prevalence of anal diseases was positively correlated with the number of pregnancies and abortions, with statistically significant differences, indicating that each pregnancy and delivery would aggravate the symptoms and signs of anal diseases. The study of Sun Deli and Yan Shiying also pointed out that the prevalence rate of menstrual disease was significantly higher than that of primigravida.
8. Psychological effects
Due to family, social and biological factors, women have different degrees of psychological changes after pregnancy and childbirth, such as depression, anxiety, pain and other emotions. After delivery, most women feel relieved, however, women with introverted personality, conservative and stubborn, their dependence, passivity, depression and lack of confidence are more obvious. Some of these women can further develop into postpartum depression and anxiety after delivery, which is known as postpartum depression syndrome. The main manifestations are mental disorders with crying, depression and boredom as the main signs. Some studies have shown that depression can cause prolongation of the first and second stage of labor, and prolonged breath-holding and exertion during labor can cause the occurrence and aggravation of hemorrhoid disease. In addition, emotional changes can also affect the vegetative nervous system, which is closely related to gastrointestinal motility disorders, gastrointestinal dysfunction, which indirectly leads to the occurrence of anorectal diseases.
In short, various changes in the special physiological period of women have a certain influence on the occurrence and development of anal diseases, especially during pregnancy and childbirth, and anal diseases are most common in internal and external hemorrhoids, mixed hemorrhoids and anal fissures, while infectious diseases and anal cryptitis, anal carbuncle and anal dwarf are less common.