Hemorrhoids, anal fissure and urinary leakage after childbirth: 5 intimate problems and their solutions

During pregnancy, hormones soften the blood vessel walls and connective tissue, and the growing uterus presses on the veins in the pelvis. The bowel works more slowly and constipation becomes more common. During delivery, the baby's head strongly stretches the pelvic floor muscles, the vagina and the perineum (the tissue between the vagina and the anus). Sometimes the perineum tears, or an episiotomy is performed, which is a small cut made to make delivery easier.

In the weeks after delivery, lack of sleep, drinking too little water, pain from stitches and fear of the first bowel movement make constipation worse. Women who deliver by cesarean can also face some of these problems, because pregnancy itself affects the pelvic floor and the bowel.

How can you get through the first bowel movement after childbirth more comfortably?

Being afraid of the first bowel movement is natural, but putting it off makes the stool harder and the situation worse. These simple steps help:

• don't wait when you feel the urge, and drink enough water through the day;
• put a small stool under your feet: when your knees are higher than your hips, the bowel empties more easily;
• if you have stitches in the perineum, gently hold a clean pad against them; this reduces the pulling feeling;
• don't hold your breath or strain hard; breathe calmly;
• afterward, wash with warm water and carefully pat dry with a soft towel.

Why does it happen? In pregnancy, blood pooling in the veins and constipation set the stage for hemorrhoids. Pushing during labor can then make the lumps larger and force them outside.

What is normal in the first weeks? Swollen, somewhat painful lumps at the edge of the anus and a small amount of bright red blood on toilet paper are often seen. In most cases, these symptoms ease within a few weeks.

What helps at home?

• keeping the stool soft: enough water, vegetables, fruit and fiber-rich food;
• not straining on the toilet and not sitting there for more than 5 minutes;
• a warm sitz bath for 10–15 minutes several times a day;
• using ointments and suppositories only when a doctor prescribes them, especially while breastfeeding.

When should you see a doctor? If the bleeding is heavy or won't stop, the lumps won't go back in, or your symptoms last beyond 6–8 weeks. If a lump suddenly becomes hard, turns bluish and hurts a lot, this may be thrombosis of the lump (a blood clot forming inside it): in that case, don't wait; seek care within the first few days. Treatment options are explained on our hemorrhoid treatment page.

Why does it happen? When the first bowel movements after childbirth involve hard stool, the lining of the anal canal can tear. Women put off going to the toilet because of pain from stitches or fear, the stool becomes even harder and a fissure develops.

What is normal in the first weeks? Mild discomfort during the first bowel movements is possible because of stitches and swelling. But a sharp, burning pain that starts during a bowel movement and continues afterward is not normal. It is the typical sign of a fissure and is often accompanied by bright red blood on the paper.

What helps at home?

• if your doctor has prescribed a stool softener after delivery, take it and don't put off the first bowel movement out of fear;
• don't hold in the urge, drink enough water and eat fiber-rich food;
• a warm sitz bath: it reduces spasm of the sphincter (the ring-shaped muscle that closes the anus) and eases pain;
• use only the ointment your doctor has prescribed.

When should you see a doctor? If the pain doesn't ease within one to two weeks, if there is blood after every bowel movement, or if you are avoiding food and the toilet because you fear the pain. An acute fissure heals without surgery in most cases. A fissure that lasts longer than 6–8 weeks is considered chronic and needs different treatment: anal fissure treatment.

Why does it happen? The thin wall between the rectum and the vagina can weaken after a difficult delivery, the use of forceps or perineal tears. The wall of the rectum then bulges toward the vagina, and stool gets stuck in this "pocket."

What is normal in the first weeks? A feeling of heaviness and weakness in the pelvic floor is normal for a while after childbirth and fades as the tissues heal. But pressing on the vagina or perineum with a finger in order to have a bowel movement is not normal. This is the most typical sign of a rectocele.

What helps at home? Preventing constipation, not straining and doing pelvic floor exercises regularly. A mild rectocele may cause no symptoms for a long time with these measures.

When should you see a doctor? If, several months after delivery, you still can't empty your bowel completely, you have to help with your finger, or you feel a bulge in the vagina. A rectocele does not go away on its own. More: what is a rectocele and rectocele treatment.

Why does it happen? Childbirth stretches the muscles and ligaments that support the urethra. When you cough, sneeze, laugh or lift something heavy, pressure inside the abdomen rises, and the weakened support can't hold the urine. This is called stress urinary incontinence.

What is normal in the first weeks? A small amount of leakage in the first weeks and months after delivery happens in many women and often eases gradually.

What helps at home? Pelvic floor exercises (below), preventing constipation and not lifting heavy loads. Drinking less water does not help: the urine becomes concentrated and can irritate the bladder.

When should you see a doctor? If, despite regular exercises, the leakage continues about 3 months after delivery, or you feel a bulge in the vagina. Burning or pain when urinating may be a sign of infection; have it checked without delay. Urinary leakage is not "fate" after childbirth or with age; it can be treated: cystocele and urinary incontinence.

Why does it happen? In a vaginal delivery, the vagina and the pelvic floor muscles are stretched a great deal. Several deliveries, a large baby, a long pushing stage and tears increase these changes.

What is normal in the first weeks? In the first months, the vagina may feel wider and weaker. While breastfeeding, dryness and discomfort during sex are also common because of hormones. As the tissues recover, these feelings often ease.

What helps at home? Pelvic floor exercises and, if you have dryness, a lubricant. Return to sex only after your postpartum check-up and when you feel ready.

When should you see a doctor? If, several months after delivery, looseness, air escaping from the vagina during sex, reduced sensation or a vaginal opening that stays open bothers you. In such cases, surgical repair options such as vaginoplasty are available.

About the scar from a birth tear. The scar from a repaired perineal tear or an episiotomy sometimes causes pulling, pain and discomfort during sex for months. Such scars can be corrected with perineal plastic surgery (perineoplasty). If you have trouble holding in gas or stool, don't hide it: this may be a sign of damage to the anal sphincter and needs a specialist's examination.

Pelvic floor (Kegel) exercises are the main non-surgical treatment for urinary leakage, a mild rectocele and vaginal weakness. Ask your doctor when it is safe to start after delivery, especially if you had stitches or a cesarean.

1. Find the muscles. Imagine that you are holding in gas and urine at the same time. To check, you can try to stop the flow of urine once, briefly, but don't do this as an exercise.
2. Empty your bladder. The exercises are done with an empty bladder.
3. Choose a comfortable position. At first, lie on your back with your knees bent.
4. Squeeze and hold. Pull the muscles in and up, hold for 5 seconds, then fully relax for 5 seconds.
5. Work only the pelvic floor. Don't tighten your abdomen, buttock or thigh muscles, and don't hold your breath.
6. Build up gradually. Increase the hold to 10 seconds and the repetitions to 10. Three times a day is enough.
7. Then do them anywhere. Once you have learned them, you can do the exercises sitting or standing, at any time of day.

Be patient: the difference is usually felt after several months of regular exercise. If you can't feel the muscles or the exercises cause pain, get examined.

Don't wait; seek urgent care:

• heavy or non-stop bleeding from the anus;
• a painful swelling near the anus or perineum with a fever;
• a very painful, hard, bluish lump that has suddenly appeared at the anus;
• gas or stool coming from the vagina;
• being unable to urinate.

If you have heavy bleeding from the vagina or a fever, contact the obstetrician-gynecologist who delivered your baby right away.

Get a planned examination if:

• pain during bowel movements lasts more than 1–2 weeks;
• there is blood after every bowel movement;
• you help empty your bowel with a finger;
• urinary leakage continues about 3 months after delivery;
• you have a bulge in the vagina or a feeling that "something is dropping down";
• you have trouble holding in gas or stool (in this case, don't delay the examination);
• looseness or a painful scar bothers you several months after delivery.

At your appointment, a female surgeon examines you, and the examination is confidential. If several problems are found together, it is possible, when indicated, to treat them in one session under one anesthesia: combined ("bouquet") surgery. You can find the overall picture of postpartum changes on our aesthetic proctology page.