Relationship between perianal diseases and toilet habits

Abstract

AimIn this study, we aimed to examine the relationship between perianal diseases and body mass index, smoking status, alcohol consumption, dietary and exercise habits, and toilet habits and to compare individuals with and without perianal diseases.MethodsThis case-control study was conducted by administering a questionnaire to 280 individuals, 140 patients and 140 controls, who presented to the General Surgery Training Outpatient Clinic of Konya City Hospital for any reason between November 1, 2021, and January 1, 2022.ResultsOf the participants, 43.5% were female and 56.5% were male. While 70.7% of the participants were aged 18-55 years, 29.3% were aged 56 years and older. The rate of smokers was statistically significantly higher in the patient group than in the control group. Individuals who consumed fiber-rich foods every day were 0.279 times less likely to have perianal diseases than those who consumed high-fiber foods once a month. In addition, those consuming high-fiber foods several times a week were 0.049 times less likely to have perianal diseases than those consuming high-fiber foods once a month.ConclusionHemorrhoidal disease and anal fissure are common diseases that can be easily diagnosed and followed up in primary healthcare services. The most important step in the diagnosis of these diseases is anamnesis and physical examination, and sometimes inspection alone can be sufficient. Primary health care providers evaluating their patients with a biopsychosocial approach and making recommendations will significantly contribute to the quality of life of patients.

Keywords

Introduction

The most common perianal diseases (PADs) are hemorrhoidal disease, anal fissures, and perianal fistulas. Hemorrhoids occur when the cushions containing venous structures in the anal canal prolapse distally and undergo venous distension. Anal fissures are usually caused by midline ruptures distal to the dentate line. Anal fissures can be acute or chronic, and are often located in the posterior midline, sometimes anteriorly, and rarely laterally.^1-2 Perianal fistulas usually emerge in the acute phase of sepsis or within six months after the first treatment. These fistulas mostly originate from the infected crypt and pathways opening outward, usually from a previous site of drainage. Abscess drainage is effective in the treatment of approximately 50% of those with anorectal abscesses, with the remaining 50% developing persistent anal fistulas.³
The normal defecation process is considered to have three components: spontaneous phasic rectal contractions that begin during filling (autonomic process), relaxation of the anal canal through an enlarged anorectal angle (mostly somatic process), and straining (somatic process). Disorders in these processes are thought to play a role in the emergence of PADs.^4-5 In addition, anal fissures and hemorrhoidal disease are affected by many environmental factors, such as constipation, dietary habits, obesity, pregnancy, psychosocial status, smoking, and alcohol consumption.^6-7
One of the parameters affecting the defecation process is the body position during defecation. The squatting position is common in Asian, African, and Eastern countries, and the sitting position is common in Western countries. The literature also indicates that the length of time spent in the toilet may be associated with PADs.^2,5,8
The determination of common sociodemographic characteristics in patients with PADs and the causes of these diseases can assist in the identification of risky individuals. This will help prevent PADs by changing the attitudes and behaviors of individuals while they are still healthy. Considering the physiological and psychosocial problems that PADs can cause individuals, it is extremely important to apply protective measures. In the current study, we aimed to compare individuals with and without PADs (hemorrhoidal disease and anal fissures) in relation to sociodemographic characteristics, body mass index (BMI), smoking status, alcohol use, constipation, presence of irritable bowel syndrome (IBS) and functional constipation (FC) diagnoses, and dietary, exercise, and toilet habits. With this study, we aimed to contribute to the literature in terms of the etiological data on PADs and the sociodemographic characteristics of this patient group.

Materials and Methods

Ethical approval was obtained from the Health Sciences University Hamidiye Scientific Research Ethics Committee, with the decision numbered 29/13 taken at the meeting dated September 17, 2021, and numbered 2021/29.
This research was designed as a case-control study and was conducted using the questionnaire method with n = 280 individuals, n = 140 patients and n = 140 controls, who presented to the General Surgery Training Outpatient Clinic of Konya City Hospital from November 1, 2021, through January 1, 2022. The questionnaire was administered to the individuals who met the study criteria and agreed to respond to the face-to-face questionnaire.
The questionnaire consisted of a total of 51 questions presented in two sections. The first section included 30 questions concerning the participants’ sociodemographic characteristics, height-weight and BMI, smoking status, alcohol consumption habits, dietary and exercise habits, IBS and FC diagnoses according to the Rome IV criteria, and toilet habits. In the second section, the 21-item Beck Anxiety Inventory (BAI) was used to examine the psychiatric background of the patients. Before the administration of the data collection instrument, informed consent was obtained from all participants. The study was conducted in accordance with the principles of the Declaration of Helsinki.
The patient group consisted of individuals who presented to the outpatient clinic with the diagnosis of hemorrhoids and anal fissures. Perianal fistulas were excluded from the study because they mainly contain cryptoglandular abscesses in their etiology. Therefore, in this paper, the term “PADs” refers to both hemorrhoids and anal fissures.
The control group consisted of patients who presented to the outpatient clinic with other diagnoses (gallstones, multinodular goiter, breast disease, etc.) and were confirmed to have no history of hemorrhoidal disease or anal fissures. Patients with previous PADs were not included in the study. In addition, to reveal the effect of other factors, especially toilet habits in a more objective manner, patients with conditions that could increase intra-abdominal pressure or were caused by increased intra-abdominal pressure were excluded from the sample.Ethical ApprovalEthics Committee approval for the study was obtained.Statistical AnalysisThe statistical analysis of the data was performed using SPSS v 27.0 (IBM SPSS, Chicago, IL, USA). Numbers and percentages were used to summarize categorical data. The chi-square (χ²) test was used to demonstrate the relationship between categorical variables. A model was constructed using participants’ age, presence of IBS, presence of FC, frequency of fiber-high food consumption, duration of defecation, and toilet time to examine the effect of these variables on the presence of PADs. In the logistic regression analysis of this model, the Forward-LR method was used, and the Hosmer-Lemeshow test was conducted to examine the model fit. In all statistical tests, p < 0.05 was accepted as the significance level.

Results

The study included a total of n = 280 individuals, n = 140 (50%) patients and n = 140 (50%) controls. Table 1 shows the comparison of the sociodemographic characteristics and general characteristics of the participants according to the presence of PADs. Bad habits such as smoking and alcohol consumption were similar between the patient and control groups (p>0.05). The rate of individuals evaluated to have minimal anxiety using BAI was statistically significantly higher in the control group than in the patient group (p<0.001). There was no statistically significant difference between the patient and control groups in relation to the rate of individuals with occupations considered risky for PAD development, namely farmers, drivers, students, and civil servants (p>0.05). Concerning dietary preferences, the rate of vegetarians was similar between the patient and control groups (p>0.05, χ² = 1.098). However, the rates of individuals with daily consumption of high-fiber foods and those with daily water consumption of ≥ 2 liters were statistically significantly higher in the control group (χ² = 52.142 and χ² = 25.583, respectively; p<0.001 for both). Lastly, the patient group had a significantly higher rate of individuals who did not walk regularly on a weekly basis (p<0.001, χ² = 17.367). Numerical data and comparisons concerning toilet habits are given in Table 2. The type of toilet preferred, position during defecation, cleaning method after defecation, and preferences related to warm or cold water use for cleaning were similar between the patient and control groups (p>0.05). A model was created using age, presence of IBS, presence of FC, frequency of high-fiber food consumption, duration of defecation, and toilet time to determine risk factors affecting PAD development. The logistic regression model explained 71.0% of the disease status (Nagelkerke’s R² = 0.710) and had an accuracy rate of 87.1% in identifying individuals with PADs (Table 3).

Discussion

In this study, there was a statistical difference between the groups with and without PADs according to gender, resulting from the significantly higher rate of women in the patient group. In addition, the rate of participants aged 18–55 years was statistically significantly higher in the patient group. In the literature, there are studies showing whether women or men are more likely to be diagnosed with PADs. Therefore, further studies with larger groups are needed. Consistent with our findings, previous researchers found that the rate of PADs was generally higher in individuals aged below 40 years and decreased after 65 years.^9-10-11-12 There are also publications reporting that low socioeconomic status and decreased physical activity may be associated with PADs, which supports our results. Despite publications indicating that some occupational groups constitute risk factors for PAD, we found no significant difference in relation to occupation in our study. This can be attributed to different working conditions of individuals with the same occupation or the effect of other confounding factors.^9,11,13
In contrast to previous research reporting a relationship between high BMI and PADs, we observed no significant difference between the patient and control groups in terms of BMI. This may be related to the generally high BMI values in our participants.^14-15
The rate of smokers was significantly higher in the patient group with PADs. Although there is evidence in the literature showing that alcohol consumption is as high as smoking in PADs, we did not determine a relationship between alcohol consumption and PADs.^11,16
Concerning the relationship of PADs with FC and IBS, similar results have been reported in many studies. Our findings revealed that individuals with IBS were 3.324 times more likely and those with FC were 21.943 times more likely to have PADs than those without these conditions. We found no significant relationship between toilet type and position and PADs; however, the literature suggests that constipated individuals may have different defecation positions. Constipation and functional bowel disease, which we also detected, are known causes of anal fissures and recurrent anal fissures, and prolonged straining may trigger hemorrhoids.^{17-18-19-20-21}
Important findings were obtained concerning toilet habits and PADs. Patients with PADs spent more than five minutes in the toilet for defecation. The rate of defecation less than three times a week was also significantly higher in the patient group. The most common preoccupations of participants in the toilet were smoking and phone/tablet use, but other habits such as reading books, newspapers, and smartphone use have also been reported in the literature, especially among young people. Similar to our study, the literature contains evidence that time spent in the toilet is associated with PADs.^11,20,22
Many studies have examined the relationship of PADs with dietary habits and physical activity. High-fiber food consumption is reported to be protective against PADs, and increasing daily water intake reduces related symptoms. In our study, individuals who consumed ≥ 2 liters of water per day were fewer in the patient group. Individuals who consumed high-fiber foods daily were 0.279 times less likely to have PADs than those who consumed them once a month, and those who consumed high-fiber foods a few times a week were 0.049 times less likely to have PADs than those who consumed them once a month. Similarly, the patient group included fewer individuals who walked regularly on a weekly basis, confirming literature suggesting that physical activity accelerates food passage.^19,23
Among participants, the rate of those with minimal anxiety according to BAI scores was statistically significantly higher in the control group than in the patient group. Many studies have reported a relationship between PADs and personality types, anxiety, and depression. Considering that IBS and constipation are also affected by anxiety and depression, the question is whether anxiety and depression are predisposing factors for PADs or cause PADs through these digestive disorders.^6-7 Regardless, it is clear that positive changes that help reduce anxiety will also produce positive results in PADs.
The small number of patients is an important limitation of our study. However, strengths include the diversity of data obtained and evaluation of many factors. We consider this study an important step in guiding further studies with larger patient groups.
Hemorrhoidal disease and anal fissures are problems experienced by many people of all ages. Primary healthcare providers are expected to diagnose these diseases and begin medical or conservative treatment. Considering that a significant portion of individuals with PADs have never attended a hospital, it is important for primary healthcare providers to evaluate the population they are responsible for in this respect. This depends on proven predisposing factors and the follow-up of related symptoms and factors by primary healthcare providers.

Conclusion

We consider that our study will contribute to the literature by presenting factors that are effective in PADs and creating a model showing the importance of predisposing factors in the formation of these diseases. This model will assist primary health care providers in identifying which predisposing factor(s) to prioritize. This way, they can play an important role in reducing the prevalence of PADs by encouraging their patients to modify their dietary, exercise, and toilet habits through information and recommendations.

References

1. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Cerrahi (Sabiston Surgery). Gülçelik MA, Güven HE, eds. Güneş Tıp Kitapevleri; 2018:1400-1410.
   PubMed · Google Scholar
2. Giuliani A, Romano L, Lazzarin G, et al. Relationship between haemorrhoidal grade and toilet habits. Ann Ital Chir. 2020;91(2):192-195.
   PubMed · Google Scholar
3. Brunicardi F, Brandt M, Andersen D, et al. Schwartz Cerrahinin İlkeleri (Principles of Schwartz Surgery). Özmen MM, ed. Güneş Tıp Kitapevleri; 2016:1222-1231.
   PubMed · Google Scholar
4. Broens P, Vanbeckevoort D, Bellon E, Penninckx F. Combined radiologic and manometric study of rectal filling sensation. Dis Colon Rectum. 2002;45(8):1016-1022. doi:10.1007/s10350-004-6353-3
   Article · PubMed · Google Scholar
5. Sakakibara R, Tsunoyama K, Hosoi H, et al. Influence of body position on defecation in humans. Low Urin Tract Symptoms. 2010;2(1):16-21. doi:10.1111/j.1757-5672.2009.00057.x
   Article · PubMed · Google Scholar
6. Ravindranath G, Rahul B. Prevalence and risk factors of hemorrhoids: a study in a semi-urban centre. Int Surg J. 2018;5(2):496-499. doi:10.18203/2349-2902.isj20180339
   Article · PubMed · Google Scholar
7. Sit M, Yilmaz EE, Canan F, Yildirim O, Cetin MM. Health-related quality of life in patients with anal fissure: effect of type D personality. Prz Gastroenterol. 2014;9(2):93-98. doi:10.5114/pg.2014.42504
   Article · PubMed · Google Scholar
8. Sikirov D. Comparison of straining during defecation in three positions: results and implications for human health. Dig Dis Sci. 2003;48(7):1201-1205. doi:10.1023/a:1024180319005
   Article · PubMed · Google Scholar
9. Ali SA, Shoeb MFR. Study of risk factors and clinical features of hemorrhoids. Int Surg J. 2017;4(6):1936-1939. doi:10.18203/2349-2902.isj20172051
   Article · PubMed · Google Scholar
10. Tazeoğlu A, İdiz C, Tazeoğlu D, Sağlam F, Alemdar A. Benign anorektal hastalıklar ile yaşam tarzı ve beslenme alışkanlıkları arasındaki ilişkinin değerlendirilmesi (Evaluation of the relationship between benign anorectal diseases and lifestyle and nutritional habits). J Tradit Complement Med. 2020;3(3):361-366.
    PubMed · Google Scholar
11. Madoff RD, Fleshman JW. American gastroenterological association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126(5):1463-1473. doi:10.1053/j.gastro.2004.03.008
    Article · PubMed · Google Scholar
12. Aziz A, Cemile İ. Benign anorektal hastalıklarda beslenme ve kabızlık durumunun değerlendirilmesi (Evaluation of nutrition and constipation in benign anorectal diseases). Caucasian J Med Sci. 2020;10(1):56-59.
    PubMed · Google Scholar
13. McCrea GL, Miaskowski C, Stotts NA, Macera L, Paul SM, Varma MG. Gender differences in self-reported constipation characteristics, symptoms, and bowel and dietary habits among patients attending a specialty clinic for constipation. Gend Med. 2009;6(1):259-271. doi:10.1016/j.genm.2009.04.007
    Article · PubMed · Google Scholar
14. Mapel DW, Schum M, Von Worley A. The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterol. 2014;14:129. doi:10.1186/1471-230x-14-129
    Article · PubMed · Google Scholar
15. Yener AC, Demirel AH. Hemoroidal hastalıkta başvuru gecikmesine neden olan faktörlerin irdelenmesi (Examination of the factors that cause delay in admission in hemorrhoidal disease). Kocatepe Med J. 2015;16(3):172-177. doi:10.18229/ktd.75598
    Article · PubMed · Google Scholar
16. Pigot F, Siproudhis L, Allaert F. Risk factors associated with hemorrhoidal symptoms in specialized consultation. Gastroenterol Clin Biol. 2005;29(12):1270-1274. doi:10.1016/s0399-8320(05)82220-1
    Article · PubMed · Google Scholar
17. Remes-Troche J, Amieva-Balmori M, Coss-Adame E, et al. The use of pictograms to identify postures associated with constipation. Gastroenterology. 2015;148(4):S312. doi:10.1016/s0016-5085(15)31030-1
    Article · PubMed · Google Scholar
18. İnce M, Özdemir Y, Küçükerdönmez Ö, Akın ML. Gençlerde hemoroidal hastalık: etiyolojik risk faktörleri (Hemorrhoidal disease in young people: etiological risk factors). Anatol J Clin Investig. 2012;6(2):109-112.
    PubMed · Google Scholar
19. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009-2017. doi:10.3748/wjg.v18.i17.2009
    Article · PubMed · Google Scholar
20. Kaygısız N, Durbaş A, Karaman H, Solman ÇH, Ersoy Ö. Evaluation of toilet habits and self-awareness of constipation statuses among young adults from different faculties at Acibadem University. Turk Med Stud J. 2021;8(1):22-27. doi:10.4274/tmsj.galenos.2021.08.01.06
    Article · PubMed · Google Scholar
21. Helvaci MR, Algin MC, Kaya H. Irritable bowel syndrome and chronic gastritis, hemorrhoid, urolithiasis. Eurasian J Med. 2009;41(3):158-161.
    PubMed · Google Scholar
22. Şişik A, Başak F, Hasbahçeci M, et al. Recovery from hemorrhoids and anal fissure without surgery. Turk J Gastroenterol. 2020;31(4):289-294. doi:10.5152/tjg.2020.19183
    Article · PubMed · Google Scholar
23. Peters HP, De Vries WR, Vanberge-Henegouwen GP, Akkermans LM. Potential benefits and hazards of physical activity and exercise on the gastrointestinal tract. Gut. 2001;48(3):435-439. doi:10.1136/gut.48.3.435
    Article · PubMed · Google Scholar

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