At the Francophone Days of Hepatogastroenterology and Digestive Oncology 2026, Laurent Abramowitz, from the Department of Gastroenterology and Proctology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, and Ramsay Santé, Paris, France, presented an update on anal conditions during pregnancy and the postpartum period, including hemorrhoids and anal fissures. Although these problems are common in clinical practice, they remain poorly studied in the literature, with only six publications on the topic since 1972.

Primarily External Hemorrhoidal Thromboses

As a reminder, hemorrhoidal disease consists of external hemorrhoids and internal hemorrhoids. In the first case, it involves a blood clot originating from hemorrhoids beneath the skin of the anal margin. When this clot resolves, a more or less shrunken hemorrhoid forms. In the second case, when internal hemorrhoids are severely dilated, they protrude (prolapse) and bleed.

In a systematic screening for anal pathology among women in labor and in the postpartum period (N = 165), as previously reported in 2002, the researchers found that the most common finding was external hemorrhoidal thrombosis (EHT). In the study, 13 cases were identified during the third trimester (7.9% of women in labor), and 33 cases were seen in the postpartum period within 2 months of delivery (20%), Abramowitz noted. Follow-up showed that EHT is primarily an immediate postpartum condition and can be readily diagnosed with a simple visual clinical examination in the maternity ward.

Factors contributing to the risk factors for postpartum hemorrhoidal thrombosis included traumatic delivery with prolonged labor, a large baby, labial tears (33% vs 16%), and dyschezia (36.4% vs 20.6%). Cesarean section, on the other hand, was associated with a lower risk for postpartum hemorrhoidal thrombosis (3% vs 19%).

For postpartum hemorrhoidal thrombosis and related anorectal conditions, the recommended approach is to regulate bowel movements with laxatives, with topical corticosteroids and anesthetics added when needed. Nonsteroidal anti-inflammatory drugs may be used after delivery, including during breastfeeding, but they are contraindicated in the third trimester of pregnancy, when corticosteroids are preferred instead. For pain control, acetaminophen is often not enough, so level 2 analgesics such as tramadol or codeine may be required. Surgical excision is reserved for exceptional cases and should be performed in an expert center.

Anal Fissure, Extremely Common

“In cases of pain, do not overlook the possibility of an anal fissure, as it is extremely common,” warned Abramowitz. Among the 165 women who had given birth in the previously cited study, two fissures (1.2%) were found in the third trimester, but 25 (15.2%) were found postpartum (< 2 months). “Pain triggered by a bowel movement in the weeks following childbirth should raise suspicion of an anal fissure.”

Which women are most affected? Primarily, those with dyschezia (84% vs 20.6%). Researchers have also shown that postpartum anal fissures are associated with decreased pressure in the anal canal (hypotonia).

Treatment, once again, involves regulating bowel movements for several weeks or even months, along with the use of topical agents, primarily lubricants. It should be noted that calcium channel blockers and nitrates are contraindicated in women who have recently given birth. If treatment fails after 12 weeks, a fissurectomy may be considered. “But if treatment has been properly managed, surgery remains an exception,” Abramowitz explained.

Taking into account his own research and the most recent prospective study on the topic, published in 2014, Abramowitz concluded that 35%-44% of women in labor develop anal conditions, including postpartum hemorrhoids in 20%, hemorrhoids during pregnancy in 8%, and postpartum anal fissures in 15%. “Treatment is almost always highly effective,” he said, emphasizing that it primarily centers on regulating bowel movements before, during, and after childbirth.

This story was translated from Medscape’s French edition.