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A Pain in the Butt: haemorrhoids, fissures and rectal pain

Chronic constipation is a common source of both physical and emotional distress, and the straining can often lead to other issues including pelvic floor dysfunction, haemorrhoids, prolapse (either rectal or vaginal), anal fissures, and pain. Without managing the constipation, other treatments are often a short-term, band-aid solution at best. Very commonly, we see procedures for haemorrhoids, prolapse correction and fissures prove to be unsuccessful as the underlying causes continue to be unaddressed.


What are haemorrhoids, anal fissures, and rectal prolapse?


Haemorrhoids (also sometimes referred to as “piles”) are stretched-out veins around the anus that cause a pooling of blood, sometimes felt as painful or itchy lumps or seen as purplish bulges. They can be either internal or external, and can often bleed if aggravated by hard or frequent bowel movements, repeatedly sitting on the toilet too long, or from straining. They are common around pregnancy and childbirth due to the increased pressure from the baby in the pelvis and the associated pushing and straining. They will often resolve on their own once the straining and pressure has resolved, but sometimes they can persist, especially if there is a genetic predisposition to more mobile connective tissues.


Rectal prolapse can often be confused with haemorrhoids. This is when the internal lining of the rectum starts to telescope downwards towards the anus. This is also often caused by chronic constipation or straining. Fissures, on the other hand, are tears in the lining of the anal canal, often feeling like intense stinging or a “paper cut”-type pain. This can also be caused by constipation, straining and other bowel issues.

Does my pelvic floor have anything to do with this?


Yes! We want a pelvic floor that's toned, well co-ordinated and relaxes well to allow easy evacuation of stools. We often see problematic pelvic floors contribute to bowel symptoms. Often there can be an over-engagement of the muscles (often due to fear of pain or discomfort) that stall the emptying process, causing a vicious cycle of more straining, then more problems. There's even a condition where the anal sphincter muscles can go into spasm and cause rectal pain directly - ouch!


Another big issue is our maladaptive Western-style toilets. We are actually designed to squat on the ground to poop (and those who don't use Western toilet actually have far fewer of these bowel problems!). By sitting upright on a toilet, we aren't allowing the natural mechanics and pelvic floor relaxation that's necessary for easy defaecation to occur. To rectify this (no pun intended!) we will often recommend you sit with your feet propped on a footstool and lean forward with your elbows resting on your knees to make yourself into more of a squat-like position.


How should I manage my constipation?


There are a variety of causes for constipation. Some common contributors include:

  • A lack of dietary fibre

  • Inadequate food intake frequency or quality

  • Not enough water/hydration

  • Being sedentary

  • Poor toileting behaviours, including withholding the urge to go for too long or sitting on the toilet in a suboptimal position

  • Certain medications and supplements, like pain killers and iron tablets.

Simple lifestyle changes to address some of these issues can make a big difference, like drinking more water, eating more fruit (think prunes, pears and kiwi fruit), having breakfast rather than racing straight out the door, and trying to get more physical activity into your daily routine. There are some people who respond well to a morning cup of coffee to kick-start their gastrointestinal tract, too!


There are also fibre supplements, stool softeners and other laxatives available if you're still struggling - speak to your health care provider if you're unsure what's safe for you to try. The goal for most people to to achieve a Type 3-4 on that Bristol Stool Chart - soft enough that you don't have to strain, but not so soft you have to hurry to get there in time (or need to wipe a dozen times to feel clean - not fun when you have a sore bum!).


Can a physio help me with these problems?


Sure can! We help people with bowel issues all the time in our clinic, and will generally recommend lifestyle changes, optimal positioning on the loo, and guide you with optimising your pelvic floor muscles. If we're concerned things are not getting better as anticipated, sometimes a review with your doctor will be encouraged to help you better manage pain or for further testing if needed. Very few people require surgery for these problems if the basics are done well.


Get in touch to find out more or book yourself in online to get that pain in the butt sorted!

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