Chengdu Anorectal Specialist Hospital Qiao Fengni Yang Xiaomao Jiang Yan
As the saying goes: "Nine hemorrhoids in ten men and ten hemorrhoids in ten women" indicates that the clinical incidence of anorectal diseases is quite high. A census was conducted in 29 provinces, municipalities, and autonomous regions in China. Among the 76,692 people surveyed, the incidence of anorectal diseases was 51.9%, men's incidence was 53.9%, women's incidence was 67%, and women were 13.1% higher than men. Among pregnant and postpartum women, hemorrhoids, constipation, and anal fissures are the most common anorectal diseases that can occur.
Women's fetal formation to aging is a gradual physiological process. Women's life can be divided into six stages: neonatal, childhood, adolescence, sexual maturity, perimenopausal and old age according to their physiological characteristics. There are different changes in the body environment in each physiological period. Women's internal changes during menstruation, pregnancy, childbirth and menopause have a greater impact on the occurrence and aggravation of anorectal disease.
1. Menstruation and anorectal diseases
Menstruation: Refers to regular and periodic uterine bleeding.
During menstruation, due to the effect of estrogen, menstrual pelvic congestion, anorectal mucosal tissue is in a state of congestion and edema, anal pad hypertrophy, women often have anal discomfort. The rectal mucosa is easy to be injured by fecal sassafras, causing blood in the stool or mucosal erosion. The perianal perineum is immersed in blood and the friction of sanitary products can easily cause local edema and infection, causing perianal abscess and anal fistula. Blood loss during menstruation, dry stools, hard work can lead to anal fissures.
2. Pregnancy and anorectal diseases
Pregnancy: The mother bears the development and growth of the fetus in her body. The whole pregnancy is 280 days.
2.1 Blood and circulatory system: Circulating blood volume begins to increase at 6-8 weeks of gestation, and reaches a peak at 32-34 weeks of gestation, increasing by about 30%-45%, and increasing by about 1500ml on average. Maintain this level until delivery. Schoule pointed out that arterial blood flow in the pelvic cavity during pregnancy can increase by 25%. Correspondingly, the venous blood flow in the pelvic cavity also increases. Cardiac volume increases by about 10% from early pregnancy to the end of pregnancy, and cardiac output increases from about 10 weeks of gestation to a peak at 32 weeks of gestation. Femoral venous pressure began at 20 weeks of pregnancy and increased significantly in the supine, sitting or standing position. This is due to the increased blood volume of the pelvic blood returning to the inferior vena cava after pregnancy. The enlarged uterus compresses the inferior vena cava and hinders blood return. . When lying on the side, it can relieve the compression of the uterus and improve venous return. Due to the increased venous pressure of the lower limbs and rectum, coupled with the expansion of the vein wall during pregnancy, pregnant women are prone to lower limbs, vulvar varicose veins and hemorrhoids.
2.2 Reproductive system: As the uterus gradually increases, the uterus increases from non-pregnant 7-8cm×4-5cm×2-3cm
To full-term pregnancy, 35cm×25cm×22cm, the uterine cavity volume is about 5ml in non-pregnancy, to 5000ml in full-term pregnancy, an increase of 1000 times. The weight of the uterus is about 50g in non-pregnancy, and it is about 1000g in full-term pregnancy, which is increased by 20 times. The huge uterus compresses the inferior vena cava above the pelvic population, which affects the return of hemorrhoidal veins and causes hemorrhoids to control the hemodynamic force of the anal cushion. , Or make the original symptoms of hemorrhoids worse. Moreover, the enlarged uterus compresses the intestines, which makes the intestinal contents dyskinesia and also causes poor bowel movements.
2.3 Endocrine system: Women’s main sex hormones include estrogen, progesterone, relaxin, etc. In addition to maintaining the physiological characteristics of women, they also promote vascular smooth muscle expansion, promote smooth muscle relaxation of the intestinal wall, and make tissues The role of relaxation. During pregnancy, the secretion of female sex hormones will increase significantly, for example, the secretion of estrogen is 25-40 times higher than usual. Studies have shown that there are estrogen receptors and breast-like tissues in the blood vessel wall of the venous plexus of the female anal pad. During pregnancy, high levels of estrogen stimulate estrogen receptors and breast-like tissues, resulting in vasodilation, congestion, bleeding and swelling of the anal pads. . Progesterone and relaxin not only promote the expansion of blood vessels, but also make tissues softer. When progesterone and relaxin increase, they act on the supporting tissues of the pelvic floor and anal canal, providing favorable conditions for the lowering of the anal cushion.
2.4 Digestive system: Affected by a large amount of estrogen, stomach acid is reduced during pregnancy, motilin level is lower, gastrointestinal smooth muscle tension is reduced, cardia sphincter relaxes, acidic contents in the stomach can reflux to the lower esophagus to produce a feeling of "heartburn". The secretion of gastric acid and pepsin is reduced. Prolonged gastric emptying time, prone to a feeling of fullness in the upper abdomen, so pregnant women should prevent full meals. Intestinal peristalsis is reduced, feces accumulate in the large intestine for a long time, and water is reabsorbed, causing constipation to dry up the feces. Dry stool stays in the intestine for a long time. On the one hand, long-term pressure on the intestinal wall causes obstruction of rectal venous return, which increases the chance of anorectal diseases. On the other hand, it is difficult to defecate during constipation, defecation is hard, and abdominal pressure increases, which further increases the rectum. The venous return is blocked.
3. Puerperal and anorectal diseases
Puerperium: The period from the birth of the placenta to the period required for all organs of the mother's body to return to a normal non-pregnant state, except for the breast, becomes the puerperium, usually 6 weeks.
3.1 Blood and circulatory system: blood volume returns to non-pregnant state in 2 to 3 weeks postpartum. In the early part of the puerperium, a large amount of blood enters the systemic circulation due to the cessation of the uterine-placental circulation and the contraction of the uterus. At the same time, the compression of the uterus during pregnancy is relieved, the venous blood flow of the lower limbs increases, and the excessive interstitial fluid absorption during pregnancy , The blood volume increases by 15%-25%, the blood is further diluted, and the circulating blood volume gradually returns to normal 2-6 weeks after delivery. The coagulation system is in a hypercoagulable state in the early part of the puerperium, and the platelet declines in the late pregnancy and quickly rises during the puerperium. The fibrinogen in the blood is still at a high level, and the prothrombin and thromboplastin system are also enhanced, but the hypercoagulable state and lower cavity during the puerperium Slow venous blood flow can also be a factor in thrombosis. This hypercoagulable state needs to be restored 4 weeks after delivery.
3.2 Reproductive system: As the muscle fibers continue to shrink, the uterus gradually shrinks. The uterus shrinks to the size of about 12 weeks of gestation 1 week after delivery. It can be palpated above the pubic symphysis. At 10 days to 2 weeks after delivery, the uterus drops to the pelvic cavity. Internally, the fundus of the uterus is not palpable in the abdominal examination, and the uterus returns to the size of the non-pregnancy until 6-8 weeks postpartum. During childbirth, due to long-term compression and expansion of the fetal head, compression and injury to the birth canal, perineum and rectum, damage to the perineal nerve, and postpartum pelvic floor relaxation, the anal cushion moves down, and the abdominal pressure increases due to repeated exertion during labor. , Aggravate hemorrhoid venous congestion.
3.3 The endocrine system: a series of changes in the pituitary gland, thyroid and adrenal cortex during pregnancy, and gradually return to an unpregnant state during the puerperium. After childbirth, the levels of estrogen and progesterone dropped sharply, and by 1 week after childbirth, they had dropped to the level of not pregnant.
3.4 Digestive system: As the progesterone level drops and the motilin level rises after delivery, the digestive function is gradually restored. Postpartum gastrointestinal muscle tone and peristaltic motility and gastric acid secretion will take about 1 to 2 weeks to return to normal. Therefore, within a few days after childbirth, women still have poor appetite and prefer to eat soup. In addition, due to the relaxation of the abdominal wall and pelvic floor muscles after delivery, constipation is prone to occur.
4. Menopause and anorectal diseases
Menopause: Women's menopause refers to the period when ovarian function further declines and finally disappears. The ovaries stop ovulating every four weeks, and menopause usually occurs in women aged 45-55. There are premenopausal, perimenopausal, menopausal, menopausal, and post-extreme stages.
Menopause: Ovarian atrophy, which causes estrogen and progesterone levels to drop continuously, vaginal atrophy, and low resistance, leading to senile vaginitis and urinary tract infections. Some women experience tension urinary incontinence and pelvic floor muscle tension. Common mixed hemorrhoids, prolapsed anus, internal hemorrhoids, prolapsed anal foreign body, accompanied by loose anus, constipation are more common. The reasons may be: (l) secretion disorder during menopause, inhibiting intestinal peristalsis; (2) perineal rectal septum relaxation, some patients form rectal protrusion, difficult defecation, long squatting effort, hemorrhoid venous plexus blood or anal cushion (3) The aging and relaxation of the muscles around the perineum and rectum will cause the anal cushion and other tissues to move down; (4) The frail elderly or reduced outdoor activities will affect the intestinal motility.
5. Diet and anorectal diseases
Diet plays a very important role in the incidence of anorectal diseases. Studies have shown that long-term drinking and eating spicy food can increase the incidence of anorectal diseases. Among them, the relative risk of drinking is 3.055 and the relative risk of eating spicy food is 2.014. In China, it is generally believed that women with pregnancy and postpartum qi and blood deficiency require a lot of nourishment. They think that the more they eat, the better, and they eat chicken, duck, and sweets, while vegetables and fruits are relatively small. The survey shows that the intake of grains, leafy vegetables is high, and the incidence of anorectal diseases in women who frequently change diets is low.
6. Different delivery methods
The occurrence of anorectal diseases is also related to the mode of delivery. The survey shows that the incidence of anorectal diseases in cesarean section is lower than that of vaginal delivery. The research of Qin Ting et al. showed that vaginal delivery and premature application of abdominal pressure promote the occurrence and aggravation of hemorrhoids, causing acute thrombosis of the original hemorrhoids, hemorrhoid edema, prolapse or incarceration of hemorrhoids. Vaginal delivery
When the fetal head passes through the true pelvis after uterine contraction, the fetal head squeezes the intestinal tube, the blood return of the middle and inferior rectal arteries is obstructed, the vascular plexus of the anal cushion is congested and expanded, the microcirculation of the anal cushion and surrounding tissues is impaired, and the anal cushion is caused by hypoxia. Edema, degenerative changes of elastic fibers of its muscles, degeneration and necrosis of elastic fibers and connective tissue; the internal pressure of the rectum and anal canal increases significantly when the parturients hold their breath during the second stage of labor. Anal dilation can be seen at the end of the second stage of labor. Membrane ectropion, the treitZ muscle and elastic fibers of the anal cushion are elongated or torn, and the fetal head is directly squeezed and pushed down, displacing the anal cushion without support.
7. The relationship between pregnancy times and miscarriage times
According to investigations by Lin Guoqiang, Li Xia and others, the prevalence of anorectal diseases is positively correlated with the number of pregnancy and miscarriage. There are statistically significant differences, indicating that every pregnancy and delivery will aggravate the symptoms and signs of anorectal diseases. Research by Sun Deli and Yan Shiying also pointed out that the prevalence of maternal women was significantly higher than that of primiparous women.
8. Psychological impact
Due to many factors such as family, society and biology, women have different degrees of psychological changes after pregnancy and childbirth, such as depression, anxiety, pain and other emotions. After childbirth, most parturients feel comfortable. However, for parturients with introverted personality, conservative and stubborn, dependence, passivity, depression and lack of confidence are more obvious. Some of them can further develop into postpartum depression, anxiety, etc., the so-called postpartum depression syndrome. Mainly manifested as mental disorders characterized by crying, depression and depression. Studies have shown that depression can lead to the prolongation of the first and second stages of labor, and the long-term breath-holding of the parturients during the labor process will cause the occurrence and aggravation of hemorrhoids. In addition, changes in mood will also affect the autonomic nervous system, and autonomic nerve function is closely related to gastrointestinal motility diseases, gastrointestinal dysfunction, which indirectly leads to anorectal diseases.
In short, the various changes in women's special physiological periods have a certain impact on the occurrence and development of Liu Anal Disease, especially during pregnancy and childbirth. Anal diseases are more common in internal and external hemorrhoids, mixed hemorrhoids, and anal fissures. Diseases and anal cryptitis, anal carbuncle, and anal shortness are relatively rare.