Constipation, Hemorrhoids, and Anorectal Disorders in Pregnancy

INTRODUCTION Lower gastrointestinal (GI) problems, in particular constipation and anorectal disorders, are common during pregnancy and can be very disruptive, although nausea and vomiting are more widely reported (1,2). These symptoms frequently extend into the postpartum period and subsequent pregnancies (3). Despite their high prevalence, many pregnant people fail to mention these issues to their providers for a variety of reasons including those related to cultural differences (3). These disorders negatively affect quality of life both during pregnancy and postpartum period and may affect the mother's physical and social health and impair relationships with their newborn (4–6). Accordingly, healthcare providers need to be aware of the high prevalence of these disorders and how to manage them appropriately. In this monograph, we provide an up-to-date review of these topics together with current best practice recommendations. Constipation in pregnancy Prevalence. Constipation is the second most commonly reported GI symptom in pregnancy (2). Earlier studies indicated that 11%–38% of pregnant people suffer from constipation (7). Despite this high frequency, constipation during and after pregnancy is often neglected (8). A recent survey study involving 1,078 participants from Finland used modified Rome IV criteria (symptoms with 25% of defecations over 3 months) and reported a prevalence of constipation in 40% of pregnant and 52% of postpartum women, compared with only 21% in nonpregnant and similarly aged controls (9). Rates were not significantly different between the second and third trimesters. At 1 month postpartum, there was rapid recovery from constipation, with a prevalence of 9% and 15% after either vaginal or caesarean deliveries, respectively. When prevalence was assessed based on survey respondent self-reporting, 61% reported constipation in the second trimester, 55% in the third trimester, and 77% and 88% a few days after vaginal or caesarean deliveries, respectively. By 1 month postpartum, constipation was self-reported in approximately 30% for both delivery types, which was similar to the self-reported incidence of 37% in the control group (9). Pathophysiology The development of constipation in pregnancy is multifactorial and associated with physiologic, dietary, medication, and anatomic causes that are presented in Figure 1 as well as anorectal problems (Figure 2). Usually progesterone-driven hormonal effects on gut motility leads to constipation symptoms in the first trimester causing slow transit constipation (10,11), whereas pressure effects from the gravid uterus on the rectosigmoid colon may cause obstructive symptoms during the last trimester (12). Animal studies have demonstrated that administration of sex hormones during pregnancy produces opioid antinociception (13), and the hormone relaxin (which relaxes the symphysis pubis and cervix) also decreases ileal smooth muscle contractions, thereby slowing small bowel transit (14).Figure 1.: Pathophysiology and contributing factors for constipation during pregnancy.Symptoms and clinical evaluation Constipation during pregnancy involves symptoms of both difficulty with defecation and infrequent bowel movements and can occur at any time (15). Both occasional constipation and persistent or chronic constipation has been reported (16). Typically, any 2 of the following 6 symptoms suggest constipation: straining, lumpy or hard stools, a sensation of incomplete evacuation, a sensation of anorectal obstruction/blockage, manual maneuvers to facilitate defecation, and fewer than 3 spontaneous bowel movements per week for at least 1 month (16). Given the short length of pregnancy and the rapid hormonal and physical changes, the duration of symptoms is important to inquire in each patient. A 7-day prospective stool diary (16) and/or the constipation stool diary app (17) could provide accurate information because there is often a recall bias in patient's self-reporting. Medication history, especially iron and calcium supplements and those that affect motility, is important because certain agents may worsen constipation. In a prospective study, a history of constipation therapy and the use of iron supplements had a higher odds ratio (ORs) for association of constipation with pregnancy (16). An abdominal and rectal examination is useful and may reveal palpable stools, suggesting fecal retention.Figure 2.: Multiple potential contributing factors for pregnancy-related anorectal diseases.Investigations Unless fecal impaction is suspected or there is severe obstipation, radiologic and manometric tests of colorectal function (18) are generally avoided during pregnancy. Metabolic and electrolyte dysfunction should be assessed with standard hematology, biochemical, and thyroid function testing. In selected cases, plain abdomen x-ray and digital rectal examination may reveal significant stool burden and/or stool impaction. If constipation remains bothersome throughout pregnancy, patients should be evaluated postpartum with a colonic transit study, anorectal manometry, and balloon expulsion test to identify underlying pathophysiology and plan management (18). Treatment Treatment includes education, dietary modifications, and judicious use of pharmacologic therapies. Clinicians consulting drug manufacturer's prescribing information should be aware that the FDA replaced its former drug risk categories in 2015 with the pregnancy and lactation labeling final rule requirement, for data and plain language risk-benefit assessments (19). Table 1 summarizes prospective clinical trials for the treatment of constipation in pregnancy. Seven compounds have been assessed: fiber supplements, senna, dioctyl sodium succinate, lactulose, Glucomannan and lactulose, polyethylene glycol (PEG), and 2 different probiotics. The duration and trimester of study, outcome measures, and safety assessments were quite variable across the different studies.Table 1.: Summary of prospective clinical trials for the treatment of constipation in pregnancyFiber supplementation, preferably with mixed soluble/insoluble fiber (20), along with adequate fruit and vegetable intake is often the first-line recommendation, albeit with limited evidence. Two studies evaluated fiber supplements in the second/third trimester, reporting an increased stool frequency and softer stools (21,22). Senna and dioctyl sodium sulfosuccinate led to improvement when compared with a bulking agent sterculia (Table 1), but there was no difference between senna and stool softener (23). Lactulose resulted in increased stool frequency and normalization of bowel habit by 2 weeks in 2 studies (24,25). PEG significantly increased stool frequency and defecatory pain in an open-label study of 2 weeks (26). PEG was also compared with lactulose in a 3-week RCT, and both drugs improved constipation scores and had similar adverse effects but without any differences in outcomes (27). A 4-week open-label trial of a probiotic mixture improved stool frequency, straining effort and pain without side effects (28). Another probiotic study with VSL3 for 15 days compared with clindamycin showed that constipation improved with probiotics (29). These recommendations are based on the quality of the available evidence at the time of writing. Table 2 summarizes a list of all the available over-the-counter and prescription therapies for constipation, including their suggested dose, mechanism of action, brief summary of studies, and recommendations for use in pregnancy. Overall, there is sparse evidence to support their use in pregnancy because most of the agents listed in Table 2 have not been studied in pregnancy or have only been the subject of case reports. Because of the lack of good-quality safety information, the perceived risk-to-benefit ratio should be assessed for each pregnant patient, before the use of these agents. A Cochrane review in 2015 only included 4 quasirandomized studies in a total of 180 women and found significant risk of bias (30). Stimulant laxatives were more effective than bulk-forming ones but with an increased risk of diarrhea and discomfort. Fiber supplementation increased stool frequency compared with no intervention. Overall, there is insufficient evidence to comprehensively assess benefits and risks of pharmacological or other interventions in the management of constipation in pregnancy, and further studies are needed.Table 2.: Summary of a list of commonly used over-the-counter and prescription therapies for constipationCommon anorectal disorders in pregnancy Anorectal disorders are common during pregnancy and include hemorrhoids, fissures, and prolapses. From an overall management perspective, it is critical to accurately diagnose and time any intervention aimed at mitigating the patient's symptoms. Hemorrhoids Hemorrhoids are common during pregnancy and frequently persist postpartum. One study of 835 pregnant women reported a prevalence of 86% (31). Another study found 33% had thrombosed external hemorrhoids or anal fissures during pregnancy and/or postpartum (32). Prevalence A prospective observational cohort study of 94 patients from the second trimester to 3 months postpartum (3) found that anal symptoms were reported by 50% during pregnancy, 56.2% immediately postpartum, and 62.9% at 3 months postpartum. Sequentially, anal fissure prevalence in the second trimester was 10.6%, hemorrhoidal prolapse in the third trimester 14.4%, hemorrhoidal thrombosis immediate postpartum 14.6% (prolapse 13.5%), and postpartum anal fissure at 3 months 9.6%. Another prospective cohort study evaluated 290 women at 4 time points and reported that overall 43.9% developed perianal disease (hemorrhoids 40.7%, anal fissure 0.7%, and both in 2.5%). Of these, 1.6% developed symptoms in the first trimester, none in the second trimester, 61% in the third trimester, and 37.4% during or after delivery (32). Multivariate analysis identified specific risk factors: straining during delivery for more than 20 minutes (OR 29.75; 95% confidence interval [CI], 4.00–221.23), birth weight of newborn >3,800 g (OR 17.99; 95% CI, 3.29–98.49), history of constipation (OR 18.98; 95% CI, 7.13–50.54), and personal history of perianal diseases (OR 11.93; 95% CI, 2.18–65.30). Pathophysiology Hemorrhoids usually develop in the third trimester because of the enlarging uterus causing vascular engorgement, venous stasis, and increased intra-abdominal pressure. In addition, extrinsic compression of the rectum causes excessive straining and constipation. Furthermore, prolonged pushing during the second stage of labor can aggravate hemorrhoids. Symptoms and signs Hemorrhoids commonly present with bleeding, discomfort, pruritus, or prolapse. Severe throbbing anal pain likely represents acute thrombosis, whereas a “knife-like” sharp perianal pain during stool passage likely represents anal fissure. Hemorrhoids are graded based on the patient's description and visual inspection (Table 3). Figure 3a is an example of Grade 3 hemorrhoids. It is important to differentiate rectal prolapse from prolapsing hemorrhoids. Rectal prolapse is the intussusception of the rectal wall through the anal canal, presenting with circular folds of pink rectal mucosa because of loss of normal rectal attachments. Prolapsed internal hemorrhoids have radial folds and engorged blood vessels.Table 3.: Goligher classification for the severity of hemorrhoids (62)Figure 3.: (a) Grade 3 hemorrhoids. (b) Posterior anal fissure.Diagnosis Distinguishing internal from external hemorrhoids requires careful perianal and digital rectal examination. External hemorrhoids arise below the dentate line and are covered by the anoderm and sensitive to pain. Internal hemorrhoids arise above the dentate line, are covered by mucosa, and are not painful unless prolapsed or thrombosed. Anoscopy is useful to confirm the diagnosis but not a requisite. Sigmoidoscopy or colonoscopy is rarely necessary for hemorrhoid management in pregnancy (33). Treatment Hemorrhoids in pregnancy should be treated initially by increasing dietary fiber, administering stool softeners, increasing liquid intake (hydration), and timed toilet training particularly in the first trimester. If symptoms persist, topical medication with analgesics and anti-inflammatory agents provide short-term local relief while having limited systemic absorption. Their safety in pregnancy has not been studied (34). Most symptomatic disease presents in the third trimester, so teratogenic risk is unlikely. Most cases can be managed in an outpatient office setting (35). Other options include office-based, endoscopic banding, diathermy, or, in the worst cases, hemorrhoidectomy. The obstetrician should be involved in all decisions before initiation of anorectal disease treatment. Topical agents Topical agents are safe and effective and are best applied after a bowel movement and at bedtime, to maximize mucosal contact time. A few examples of currently available products are listed below. All have no reported pregnancy-related safety concerns. Preparation H (Pfizer, New York, NY): This contains ingredients such as cocoa butter, phenylephrine, starch, or zinc oxide that form a protective barrier to prevent irritating contact with stool. Preparation H works by reducing inflammation and causing vasoconstriction and temporarily relieves burning, pain, and itching. Anusol (Johnson and Johnson, New Brunswick, NJ): The active ingredient in Anusol ointment and suppositories is zinc sulfate monohydrate, which helps to decrease the irritation and acts as an astringent. However, zinc ointments that contain a topical anesthetic (e.g., Anusol Plus ) or suppositories that contain esculin (Proctosedyl ) are not recommended during pregnancy. Acetaminophen is recommended for discomfort from hemorrhoids. Tucks pads (Blistex, Oak Brook IL): The pads contain witch hazel—glycerin compresses can be applied in pregnancy for symptomatic relief and is safe. Steroid creams and suppositories These are more effective as second-line topical therapies for hemorrhoids. Hydrocortisone 25 mg suppositories should only be used during pregnancy if the potential benefit justifies the risk to the fetus. There does not seem to be an increased risk of preterm birth, low birth weight, or preeclampsia after systemic corticosteroid use in pregnancy (36), albeit small increased risk of cleft lip with or without cleft palate associated with first-trimester corticosteroid use (37). Hemorrhoids more commonly cause symptoms in the third trimester, after organogenesis. In 1 prospective trial of 204 patients with hemorrhoids treated with hydrocortisone foam in the third trimester, adverse events were comparable with placebo, suggesting that rectal steroids were safe (38). In normal subjects, about 26% of hydrocortisone acetate is absorbed when used as a rectal suppository. Office-based therapy Given that most hemorrhoids resolve within 6 weeks after delivery, we recommend waiting until then before considering any procedures. Women with relapsing symptoms should undergo definitive treatment before subsequent pregnancies. Hemorrhoid banding Hemorrhoid banding, especially for grades 1–2 (and in selected grade 3 cases), is a very effective office-based treatment for hemorrhoids. Most office banding devices are designed to suction the hemorrhoid complex into a plastic barrel and then release a plastic band over the hemorrhoid. This is best performed about 2 cm above the dentate line. The resulting strangulation, ulceration, and fibrosis prevent prolapse and reduce the blood supply to the hemorrhoid. When performed properly, it is painless and effective with a success rate of 69%–97%. Typically, this involves 1 banding per session, separated by at least 2 weeks, to allow healing and minimize complications (39). Some patients may experience mild lower abdominal pressure or cramping lasting 2–3 hours. Infrared photocoagulation Infrared photocoagulation is performed under direct vision through an anoscope to cauterize the feeding vessels and mucosa just proximal to the internal hemorrhoid column. Unlike banding, this does not cause any postprocedure cramping. When conservative management fails, infrared photocoagulation is an option, although data on its use and safety during pregnancy are limited. Thrombosed hemorrhoids Hemorrhoid thrombosis affects 8% of pregnant women in their third trimester and 20% during the postpartum period (40). Both internal and external hemorrhoids may thrombose, although the external ones are more common and painful. Treatment with analgesics, sitz baths, and local anesthetic ointments typically leads to resolution in 1–3 weeks. If presenting within 72 hours of symptom onset, it is best to perform incision and drainage of the blood clot using lidocaine injection-based local anesthesia. Clot removal leads to instant relief of pain and is safe and effective, albeit with limited data in pregnancy (41). Recurrence is prevented by “deroofing” the thrombosed hemorrhoid. Surgery for hemorrhoids in pregnancy Irreducible, thrombosed, or gangrenous hemorrhoids may require urgent operative intervention, but elective hemorrhoid surgery should be postponed until after pregnancy. In 1 study of 25 pregnant patients requiring hemorrhoidectomy, intractable pain, protrusion, and bleeding were the main indications. Preterm labor, postoperative bleeding, and poor healing were risk factors (42). There was no fetal loss or adverse effect. Anal fissures Anal fissures are linear tears in the anal canal that typically (85%–90%) occur midline posteriorly and involve the anoderm. Fissures off the midline should raise concerns for inflammatory bowel disease, infections, and neoplasia. A “glass-like passage, cutting pain” in the anal canal during defecation with or without bleeding is the typical symptom. A gently performed digital rectal examination will confirm the diagnosis with exquisite tenderness, and rarely anoscopy is needed (Figure 3B). The most common cause is constipation, passage of hard bulky stool, and, rarely, chronic diarrhea (43).BEST PRACTICE RECOMMENDATIONS ✓ Constipation affects 25%–40% of women during pregnancy and postpartum period and significantly affects quality of life, but bowel function mostly normalizes in puerperium. ✓ Constipation during pregnancy involves both infrequent stools and difficulty with defecation. A prospective stool diary or stool app could improve diagnosis and help with intervention strategies. Diagnostic tests are best undertaken postpartum. ✓ Treatment options include dietary fiber education and medication, including senna, lactulose, and PEG. There is a paucity of randomized clinical trials in pregnancy, and none are with the newer prescription agents. ✓ Hemorrhoids and anal fissure are seen in two-thirds of women during pregnancy and are best managed conservatively with hydration, fiber supplementation, treatment of constipation, and topical ointments. If symptoms persist postpartum or the subject is planning further pregnancies, more aggressive treatment is recommended. ✓ Thrombosed hemorrhoids, if extremely painful, should be incised and decompressed. ✓ Anal fissures can be safely treated with intra-anal topical 0.125% nitroglycerin, 0.5% nifedipine, or 2% diltiazem ointment. Treatment Initial treatment consists of increased water intake, stool softeners, high-fiber diet with psyllium, and avoidance of constipation-inducing medications. Warm sitz baths will help to sooth the associated anal sphincter spasm. Nitroglycerin 0.125%, nifedipine 0.5%, or diltiazem 2% sometimes with lidocaine 5% compounded ointment applied 3 times a day for 1–4 weeks and then twice a day for 1 week will reduce spasm, promote blood flow, and help healing. Notably, these ointments are not commercially available and require compounding with each prescription. We advise patients to use a “pea-sized amount” on the tip of a gloved/lubricated finger and massage into the anal canal, up to the first knuckle, to ensure effective sphincter relaxation. Addition of lidocaine (2.5%–5%) is effective in pain relief and can be used without compounding with nifedipine or diltiazem (as an alternative to nitroglycerin). Although nifedipine may be absorbed systemically to a small degree, it seems to be safe in pregnancy (44). Lidocaine topical ointment is also safe in pregnancy (45), but avoid long-term use because of hypersensitization. Botulinum toxin injection into the internal anal sphincter, 15 international units on either side of the fissure, is an effective treatment if ointments fail to provide relief. The botulinum does not cross the placenta passively (46). One study of 45 pregnant women who received botulinum injections for migraine headaches revealed no harmful effects on the fetus (47). Because it is not detectable systemically after intramuscular use, breast milk excretion seems unlikely with using it in this setting (22,48). CONFLICTS OF INTEREST Guarantor of article: Satish S.C. Rao, M.D., Ph.D., FRCP, FACG. Financial support: This article appeared as part of the ACG Monograph on GI Diseases and Endoscopy in Pregnancy and Postpartum Period. Unrestricted educational grants to support the monograph have been provided to the ACG Institute for Clinical Research & Education from UCB, Inc., Ferring Pharmaceuticals, Inc., and Janssen Biotech, Inc. Potential competing interests: Dr. Johnson is a consultant for HyGieCare and Aries, and sits on the Advisory Board of MedScape. All other authors report no conflicts of interest.