Can hemorrhoids (piles) influence pelvic floor disorders?

Relationship Between Hemorrhoids and Pelvic Floor Disorders

Yes, hemorrhoids can influence pelvic floor disorders, as both conditions share common risk factors and pathophysiological mechanisms related to increased intra-abdominal pressure and pelvic floor muscle dysfunction.

Pathophysiological Connection

• Hemorrhoids consist of connective tissue cushions surrounding arteriovenous communications in the anal canal, contributing approximately 15-20% of resting anal pressure and serving as a conformable plug to ensure complete closure of the anal canal 1
• The pathogenesis of enlarged, prolapsing hemorrhoidal cushions involves abnormal swelling of anal cushions, stretching of suspensory muscles, and dilation of the submucosal arteriovenous plexus 1
• Multiple studies have shown elevated anal resting pressure in patients with hemorrhoids compared to controls, which may affect pelvic floor muscle function 1
• Chronic straining during defecation, a common factor in hemorrhoid development, also contributes to pelvic floor dysfunction by increasing stress on pelvic floor muscles and fascia 1

Epidemiological Evidence

• A 2020 study demonstrated a significant correlation between hemorrhoids and urinary incontinence in adult women, with the association being strongest in women aged 19-39 years 2
• Both hemorrhoids and pelvic floor disorders share common risk factors including:
  • Advanced age
  • Pregnancy and vaginal childbirth
  • Obesity
  • Chronic straining
  • Conditions that result in chronic increased intra-abdominal pressure 1

Clinical Implications

• When patients present with hemorrhoids, clinicians should consider evaluating for concurrent pelvic floor disorders, as both conditions frequently coexist 2
• Patients undergoing concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery have higher risk of:
  • Postoperative urinary tract infections (33.3% vs 10.6%)
  • Need for discharge with urinary catheter (42.4% vs 18.2%)
  • Severe rectal pain (33.3%)
  • Unplanned office visits (27.2% vs 12.6%) 3
• Hemorrhoidectomy may affect continence mechanisms, as hemorrhoidal tissue plays a role in anal continence (corpus cavernosum) 4

Management Considerations

• Conservative measures for both conditions include:
  • Increasing dietary fiber and water intake
  • Avoiding straining during defecation
  • Proper toilet posture with buttock support, foot support, and comfortable hip abduction 5, 6
• Pelvic floor physiotherapy should be considered as first-line treatment for patients with pelvic floor dysfunction, which may also benefit those with hemorrhoids 5
• Aggressive management of constipation is crucial for both conditions and should be maintained long-term 5

Diagnostic Approach

• A careful anorectal evaluation is warranted for patients reporting hemorrhoids, as symptoms caused by other conditions are frequently misattributed to hemorrhoids 1
• When pelvic floor dysfunction is suspected, global assessment of all pelvic compartments may be necessary using:
  • Radiologic tests such as fluoroscopy, MRI, and ultrasound
  • Focused clinical diagnostic tests such as urodynamic studies for urinary incontinence and anal manometry for defecatory dysfunction 1, 7

Pitfalls and Caveats

• Pain is generally not associated with hemorrhoids unless thrombosis has occurred; anal pain suggests other pathology and mandates closer investigation 1
• Incontinence is a complex phenomenon; isolated injury is normally not a sufficient cause 4
• Pelvic floor abnormalities often involve multiple compartments, requiring comprehensive assessment 5
• Constipation management is crucial and often discontinued too early; treatment may need to be maintained for many months 5