Epidemiological and Therapeutic Aspects of Proctological Pathologies in Pregnant and Postpartum Women at the Reference Health Center of Commune IV of Bamako District ()
1. Introduction
While pregnancy and childbirth are generally considered happy episodes in women's lives, these events can be marred by painful proctological conditions that are far less pleasant. Less than 50% of women are aware of these potential postpartum discomforts [1] . While all proctological emergencies can be observed during pregnancy and postpartum, the most frequent pathologies are hemorrhoids and anal fissures, which are causes of acute anal pain [1] . The prevalence of the disease increases with age and is not related to gender. Women suffering from this condition have frequently had one or more pregnancies and often chronologically link the onset of their pathology to these episodes in their lives [2] . The prevalence of hemorrhoidal disease in pregnant women and parturients varies in the literature from 7.9% to 38% depending on whether it occurs during pregnancy or postpartum and depending on the series [3] [4] .
The immediate postpartum period is the most likely period for thrombosis (20% of parturients versus 8% of women during the third trimester of pregnancy) [4] . In 91% of cases, thrombosis occurs within 24 hours of delivery, and is more frequently observed in cases of macrosomia and when the delivery is complicated by a superficial perineal tear [4] . In the USA (2004), Dixon MR et al. found that 50% of the general population after 50 years of age had hemorrhoidal disease [5] [6] . In France, in 2004, the estimated frequency was approximately 4% of the general population [7] [8] . In Mali, (in 2006), Dicko M L found an annual frequency of 21.4% over seven years in the general surgery department at the Gabriel Touré University Hospital Center (CHU) [9] .
Early management of proctological pathologies in pregnant women and in the postpartum period allows a better quality of life for the fetus and/or the child and the woman and/or the pregnant woman, and therefore a better prognosis. If left untreated, it can develop into complications. Medical treatment is the first line of treatment for uncomplicated hemorrhoids (bleeding and/or procidence). The treatment of proctological disorders in pregnant women must be cautious because of the potentially iatrogenic effects of drugs on the fetus [10] . In all cases, surgical treatment should be considered as a last resort or immediate in case of complications. Incision or excision under local anaesthesia is the rule [11] . The anal canal is the terminal part of the digestive tract. It is 4 cm long, follows the rectum and ends in the anus which is located 20 mm from the apex of the coccyx. In the occluded state, the anus is a slit or a simple point from which skin folds radiate that fade on opening. [12] In the formation of the anal canal, the cloaca intervenes, which is of endoblastic origin and gives rise to the urogenital sinus and the rectum. It is formed by the cloacal membrane that becomes the anal membrane and disappears towards the end of the seventh week of embryonic development.
Pregnancy: This is the period of time between fertilization and delivery (or abortion) during which the embryo and then the fetus develops in the mother's uterus. Hemorrhoids: Hemorrhoids are complex vascular formations normally present in all individuals [13] . It is the onset of clinical manifestations that transforms this normal anatomical state into “hemorrhoid disease”. A distinction is made between internal hemorrhoids (located above the pectineal line) and external hemorrhoids (located below the pectineal line, at the anal margin). Anal fissure: is a tear in the epithelium and dermis of the distal part of the anal canal. Anal incontinence: It is defined by the inability to voluntarily delay the passage of intestinal contents through the anus until it is possible to do so or/and when socially possible. It is therefore an involuntary emission of gas and/or liquid and/or solid stools. Fecal incontinence: is defined as the involuntary emission of liquid and/or solid stool through the anus, excluding isolated losses of gas or mucus. Anal abscess: It is a pus-filled cavity located near the anus or rectum.
In Mali, few studies have been carried out on proctological pathologies in pregnant women and in the post-partum period. This explains the orientation of our study toward this pathology which is expanding in our country. Our aim would be to study the epidemiological and therapeutic aspects of proctological pathologies in pregnant women and in the post-partum period at the Reference Health Center of Commune IV of the District of Bamako Mali.
2. Methodology
2.1. Study Setting
Our prospective, analytical, cross-sectional cohort study was conducted in the Obstetrics and Gynecology Department of the Health Center of Commune IV of the District of Bamako between January 1, 2020 and September 30, 2020, a period of nine (09) months. The study population included all pregnant women who had completed their pregnancy and postpartum follow-up at the gynecological-obstetric service of the Health Center of Reference of Commune IV of the District of Bamako.
2.2. Inclusion and Exclusion Criteria
The inclusion criteria concerned all women who had started their pregnancy follow-up from the first trimester and who had given birth in our department. The exclusion criteria concerned all women who had consulted for the first time after the first trimester of pregnancy, all women who had consulted in the first trimester but who had not accepted to participate in the study, all women who had been followed up in another department for their pregnancy and all women who had had an abortion for their current pregnancy.
2.3. Sampling
The minimum sample size was calculated using the Schwartz formula below:
Ideal sample size:
n = sample size;
Z = point of the normal distribution corresponding to the significance level of 1.96;
P = prevalence of anal pathology in pregnant women and newborns obtained in previous studies (10%);
A confidence interval of 95% will be used;
E = maximum probable error of 5%.
Therefore the minimum sample size was
2.4. Data Collection
In order to facilitate the study, we developed a survey form with the variables to be studied. Our data were collected on the survey forms from: Obstetrical records; Antenatal consultation books (CPN); Anesthesia registers; and Delivery registers.
2.5. Variables Studied
The variables studied included socio-demographic variables (age, marital status, education level, dietary habits), medico-clinical variables (parity, body mass index (BMI), transit disorders, history of proctological disease, duration of expulsion, route of delivery, weight of the newborn, perineal tears, episiotomy, type of delivery and twin pregnancy).
2.6. Conduct of the Study
The methodology used for this study will be the search for anal pathologies in pregnant women. Each of them benefited from an obstetrical and proctological examination in the 1st, and 3rd trimester of pregnancy and postpartum. The clinical proctological examination was performed on a patient examination table in the knee-pectoral or left lateral decubitus position. The first step of the examination was the observation of the anus (inspection) which was done by unfolding the radial folds allowing observing a fissure; a fistula; a swelling; a hemorrhoidal thrombosis; a condyloma. We asked the patients to push to reveal possible ano-perineal pathologies such as internal hemorrhoids that prolapsed; swelling or a rectal prolapse. The second part of the examination included palpation of the anal verge and an anorectum to look for an abnormality such as swelling; pain; or an anal fistula opening. This also allowed evaluating the tone of the anal sphincters. The third step was anoscopy to visualize internal hemorrhoids in the anal canal; an endo-canal fissure; an endo-canal cancer and the lower rectum. This third step was done for women who had a proctological pathology at the end of the clinical examination.
2.7. Data Analysis and Processing
The data were entered in Excel and analyzed with the Epi info 7 Software. The statistical test used was Fisher’s exact test and the Mantel Haenszel test with a significance threshold set at 5%.
3. Results
During our study period, we collected data from the obstetrics and gynecology department of the Health Center of Commune IV of the District of Bamako on 3358 monitored pregnancies, of which 150 were eligible. The latter was followed up during prenatal consultations, in the post-partum period and proctological, both during pregnancy and in the post-partum period from the first trimester of pregnancy to six (6) weeks after delivery. Thus, 36 incident cases of anal diseases occurred in these patients, i.e. a frequency of 24% (36/150) among which hemorrhoidal disease represented 6.67%, anal fissures 10%, anal incontinence 5.33% and multiple anal pathologies 2%. Among the patients who had developed only hemorrhoidal disease, 0.6% (n = 6) were internal hemorrhoidal disease and 0.4% (n = 4) had external hemorrhoidal disease (Tables 1-8).
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Table 1. Distribution of patients according to socio-demographic characteristics
The age range of 20 - 29 years was the most represented, i.e. 56.66% of the cases. The average age was 39 ± 5.75 years. Other: Dyer (n = 1) Teacher (n = 1) Obstetric nurse (n = 1). Housewives were the most represented with 50.67% of cases. Primary education level was the most represented with 40.67% of cases.
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Table 2. Distribution of patients according to the time of diagnosis of anal pathology for the first time.
The anal fissure was the most represented with 10% of the cases (15/36).
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Table 3. Distribution of women by functional signs according to periods of gravido-puerperium.
The main symptoms found were constipation followed by anal pain, anal pruritus and rectal discharge.
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Table 4. Distribution of women according to the data of the proctological examination according to the periods of gravido-puerperium.
Hemorrhoidal marks, rectal pain on touch and fissure were the most common signs found on proctological examination.
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Table 5. Univariate analysis of risk factors for hemorrhoidal disease.
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Table 6. Univariate analysis of risk factors for anal fissure.
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Table 7. Univariate analysis of risk factors for anal incontinence.
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Table 8. Frequency of anal pathologies according to the authors.
4. Discussion
From a methodological point of view, the studies carried out on anal pathologies during pregnancy and postpartum are very few in the world because of their complexity. The methodology adopted was advantageous because we had examined the patients ourselves, which allowed us to have exploitable results. It was a prospective and analytical study, a single-center cross-sectional cohort survey from January 1 to September 30, 2020, i.e., a duration of 9 months. During this study, we encountered certain difficulties, including the limited financial means of the patients for the realization of certain complementary examinations such as anorectoscopy; sociocultural factors such as modesty had influenced certain patients, particularly pregnant women who were not educated. This made their physical examination difficult.
In our study, 36 women or 24% had developed anal disease. Our result was lower than those of Abramowitz et al. [11] , Poskus T et al. [14] and Poudiougo A.M et al. [15] who found respectively 44.4% and 43.9% and 45.5% cases of anal disease. This difference could be related to the methodological approach in particular with the size of the sample and the diversity of risk factors in the patients. In our study anal fissure was the most frequent anal pathology with 10%, followed by hemorrhoidal disease and anal incontinence with 6.67% and 5.33% respectively; while Poskus T et al. [14] reported 53.9% of hemorrhoidal disease and 3.21% of anal fissures.
4.1. Socio-Demographic Characteristics
The average age of the women was 26 years with extremes of 14 and 39 years. The age range of 20 to 29 years was the most represented with 56.6% of the cases. Our patients were relatively younger. Our result was close to that of Poskus et al. [14] who found a mean age of 28.7 years with extremes of 18 and 45 years. On the other hand, Ferdinand K et al. [15] found a mean age of 31 years with extremes of 20 and 40 years. This can be explained by the young age at pregnancy of the African population in general and Mali in particular.
4.2. Risk Factors
A univariate analysis was performed with a suspected risk factor for each type of anal pathology. We identified that chronic constipation (p = 0.003), newborn weight > 3500 g (p = 0.000), age 30 years (p = 0.048), body mass index at 25 kg/m2 (p = 0.006), instrumental vacuum extraction (p = 0.001) and fetal expulsion time > 20 minutes (p = 0.000) were significantly associated with the occurrence of hemorrhoidal disease. For anal fissure, we identified that the weight of the newborn > 3500 g (p = 0.002) and a duration of fetal expulsion > 20 minutes (p = 0.000) were significantly associated with the occurrence of anal fissure.
Finally, we also identified that a weight of the newborn > 3500 g (p = 0.000), an age up to 30 years (p = 0.001), a duration of fetal expulsion > 20 minutes (p = 0.000) and the instrumental extraction by suction cup (p = 0.044) were significantly associated with the appearance of anal incontinence.
The mean duration of fetal expulsion was 12 minutes with extremes of 5 minutes and 40 minutes, standard deviation = 10.13. The average weight of the newborn was 3079 g with extremes of 2090 and 4102 g, standard deviation = 319.52.
Poskus T et al. [14] identified constipation, birth weight > 3800 g, prolonged expulsion time > 20 minutes and personal history of anal disease as risk factors for the development of anal disease in pregnant women. In the literature, the risk factors for the occurrence of hemorrhoidal disease, and anal fissure in pregnancy or postpartum, are traumatic delivery (birth weight greater than 3800 g and soft tissue tear) or duration of expulsion of more than 20 minutes, and history of anal pathology [11] [16] [17] . The main risk factors for postnatal anal incontinence are: advanced maternal age (to 30 years); high parity; maternal obesity; prolonged second stage of labor; median episiotomy; obstetric anal sphincter injury; forceps delivery [18] [19] .
4.3. Clinical Aspects
1) Hemorrhoidal disease
· Functional signs
Anal pain was the main symptom found. Its frequency in our study was 50%. It was the most frequent symptom in the study by Poskus T et al. [14] who recorded 98.3% of patients with anal pain. The frequency of rectal bleeding in our study was 50%. It was of variable intensity, appearing during or after the stool [14] . Our result was lower than that reported by Ollende C et al. [20] in 2010 89.5% of functional signs (p = 0.000010). This could be explained by the fact that rectal discharge was mostly occult due to the use of traditional latrines in our
context. Pruritus and oozing were found in 20% of our patients. Our result is lower than that reported by Poskus T et al. [14] 74%. This difference could be explained by the size of the samples. They usually occurs secondary to hemorrhoidal procidence [20] .
· Physical signs
Proctological examination at the digital rectal exam allows the diagnosis of hemorrhoidal disease. Hypertonicity of the anal sphincter was an important sign of hemorrhoidal disease [11] [14] [20] . We observed a significant sphincter tone in 40% of the patients when touched. However, this hypertonicity could not be evaluated because we did not have a manometer
Anal fissure
· Clinical signs
Anal pain was more frequently found in our study (88.2%), as well as in those of Siproudhis et al. in France and Keita KI et al. in Mali [21] [22] , with 100% and 100% respectively. It was the most common clinical manifestation of anal fissure, regardless of its location. It was a pain like a tear or a sensation of broken glass in the anus, provoked and punctuated by defecation [23] . The three-stroke pain characterizes the anal fissure. It was a pain triggered by the passage of stool, calmed down for a while after the stool and then resumed for several hours (4 to 6 hours). Sometimes it was replaced by simple discomfort [15] [20] [21] [23] . Jaundice was frequently found in our study (35.3%) as well as in those of Siproudhis et al. [21] and Keita CO et al. [22] with a rate of 85% and 71.5% respectively. It was generally made of red blood, emitted from the anus but coming from the anal canal as evidenced by the traces of blood on the stool. Anal pruritus was found in more than half of our patients (52.9%). Siproudhis et al. [21] recorded it in 60% of cases.
2) Anal incontinence
In the female population, it has been shown that less than 20% of women affected by anal incontinence symptoms tell their doctor [24] (Table 9, Table 10).
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Table 9. Authors and functional signs.
Of the 9 cases of anal incontinence, 8 were gas and 1 was fluid. We did not note any cases of AI to solids. In the literature [22] [24] , it is most often gas leakage with a repercussion that can be very disabling in professional life, during leisure activities or intimate relations. In 1 to 2% of cases, it involves loss of liquid stools with an even greater impact on quality of life.
4.4. Treatment
1) Hemorrhoidal disease
During our study, all patients with hemorrhoidal disease were put on a bowel regulator. We agreed with other authors, Abramowitz L et al., Holzheimer RG et al. [11] [25] , that transit regulation was the most important element in the treatment of hemorrhoidal disease. In our study, the rate of symptomatic improvement was 45% after the regularization of the transit and a cessation of rectal bleeding in 25%.
Holzheimer RG et al. [25] found an improvement of the symptomatology in 47% after the regularization of the transit and a stop of the rectal bleeding in 50%. In addition, other drugs were used in the department as adjunctive treatment, in particular those improving venous circulation (venotonics and phlebotonics) per os, topicals (ointments and suppositories) and analgesics. Dietary recommendations were given such as the avoidance of spices, continuous sitting (long car journeys) and dietary excesses, the recommendation in case of overweight a restrictive diet, of general hygiene. None of our patients had benefited from an instrumental treatment (injection of botulinum toxin) or surgical treatment (hemorrhoidectomy) during our study.
In the literature, instrumental treatments and surgery should be re-discussed at a distance from the delivery according to the usual indications [11] .
2) Anal fissure
During our study, all patients with anal fissure were put on bowel regulator. It was used in all 17 cases of anal fissure. Other drugs were used as treatment to lubricate the anal canal, heal the anal fissure and calm the pain (local topical suppository cream). In the literature, the treatment of anal fissure in pregnant women consists of a combination of regulation of intestinal transit (almost exclusively constipation to be treated with osmotic or oily laxatives or mucilage) and lubrication of the anal canal (local topical in the form of suppositories and ointments) [26] .
3) Anal incontinence
Of the 9 cases of anal incontinence during the entire study, 84.2% had been put on laxatives. Another important data was collected during this study, that of post-partum perineal rehabilitation. The first line treatment of incontinence combines specific perineal rehabilitation of the anus with dietary measures and drug prescriptions to regulate intestinal transit Damon H et al. [27] . During counseling during pregnancy, 30 women agreed to undergo perineal rehabilitation after delivery; and during the postpartum period, the majority of them mentioned the lack of time, hence the low rate of rehabilitation. It is therefore essential to inform future mothers from the time of pregnancy of the interest of post-partum rehabilitation, whatever the weight of the child and the mode of delivery.
5. Conclusions
Anal pathologies are frequent during pregnancy and in the post-partum period. They touch on intimacy and are part of the many taboos that are difficult to discuss in our society. One-third of women suffer from them during their pregnancy. Their diagnosis is easy.
The occurrence of these anal pathologies is linked to the existence of numerous risk factors in pregnant women. The treatment is based on the regulation of the intestinal transit and simple gestures allowing fast relief, it is medical in all cases.
6. Recommendations
It will be necessary to promote and train doctors specialized in proctology in order to create a close relationship between gynecologist and proctologist. An adequate technical platform of specialized proctology is needed. Finally, it is necessary to intensify the communication for the change of behavior in order to inform the population about anal pathology during pregnancy and in the postpartum.
Contributions of the Authors
Adégné Togo and Amaguiré Saye were the designers of this study. Adégné Togo, Youssouf Traore, and Amadou Bocoum validated the previously established questionnaire. Fanta Doumbia and Moussa Samaké collected and analyzed the manuscript. Seydou Mariko and Amaguiré Saye were the editors of the manuscript. All authors had reviewed and approved the final version of the manuscript prior to its submission.
Ethical Approval
All patients had given their consent to participate in our study.