Clinically reviewed by Dr. Carmen Fong, MD, FACS, Bummed's Chief Medical Officer

This article is brought to you in partnership with Bummed, the first digital health platform focused on anorectal health, providing telehealth access to prescription treatment for hemorrhoids, anal fissures, and related conditions.

Medically reviewed by Dr. Carmen Fong, MD, FACS, Bummed's Chief Medical Officer, drawing on her book Constipation Nation: What to Know When You Can't Go.

"Just relax."

It's the advice everyone gets when a bowel movement won't cooperate. It also, for a lot of bodies, feels physically impossible.

Straining seems like the natural response to a stubborn bowel movement. In reality, it's often the exact mechanism that turns a temporary inconvenience into a lasting problem, for your pelvic floor and for your hemorrhoidal veins alike.

Pelvic floor dysfunction and hemorrhoids are usually treated as separate issues. One gets referred to a pelvic floor physical therapist. The other gets a tube of cream from the pharmacy, or treatment from Bummed.

But clinically, they're closer than most people realize. Straining is the thread that ties them together, especially for two populations who deal with an outsized share of both: postpartum and perimenopausal/menopausal patients.

What Straining Actually Does to Your Body

The hemorrhoid mechanism

In Constipation Nation, Dr. Fong describes hemorrhoids simply: bundles of blood vessels everyone is born with, cushioning the anal canal and helping keep it closed.

They only become a problem when they get inflamed, swollen, or start to bleed. The pathophysiology behind that, she explains, generally comes down to increased intra-abdominal and pelvic pressure, driven by three things: constipation, sitting too much, and straining during bowel movements.

She illustrates this with what she calls "Monday morning hemorrhoids": the scenario where a weekend of dehydration, rich food, and little fiber leaves someone straining against hard stool on Monday. The perfect storm of pressure finally tips things over.

It's rarely one bad bowel movement that causes the problem. It's accumulated pressure (dehydration, inactivity, straining) that finally does.

The fissure mechanism

Fissures work through a related but distinct mechanism.

Dr. Fong explains that anal fissures are generally caused by a hypertonic, or too tight, internal anal sphincter, which reduces blood flow to the area and impairs healing. Constipation and straining are the most common triggers.

But she also points out something less discussed: fissures can happen just as easily, or become chronic, from holding in a bowel movement, because people end up holding tension in their pelvic floor muscles out of habit or anxiety about using the bathroom.

That's pelvic floor dysfunction (in this case, an overly tense, poorly relaxing pelvic floor) creating the exact mechanical conditions that produce a fissure.

A pelvic floor that doesn't relax properly during defecation forces you to strain to compensate. That straining is a direct driver of hemorrhoid and fissure symptoms. Treating one without addressing the other often means treating the same problem twice, from two different directions, without ever resolving the root cause.

The Postpartum Straining Cycle

Dr. Fong writes candidly about this connection from both sides of the exam table, as a colorectal surgeon and as a patient.

In her book, she describes a scenario she's seen repeatedly in practice: a patient's hemorrhoids worsen through pregnancy, she gives birth vaginally after a long final push, and the resulting external hemorrhoidal skin flaps, tissue left over after the swelling resolves, never fully go away. These flaps generally can't be treated with the same in-office procedures used for other hemorrhoids, and often require surgical removal if they become bothersome.

She also shares her own postpartum experience: sixteen hours of labor, six of them spent actively pushing.

No one discussed with her, before or during labor, that prolonged pushing increases the risk of pelvic organ prolapse, a form of pelvic floor dysfunction.

Looking back, she draws a clear contrast: friends who didn't push for long have had no bladder or bowel issues since. Friends who pushed extensively now deal with difficulty peeing, difficulty pooping, and pain with sex — all classic symptoms of pelvic floor dysfunction stemming directly from the mechanical strain of childbirth.

That's the postpartum version of the straining thread in a single story: prolonged, intense straining during delivery can injure the pelvic floor and set up hemorrhoid and fissure symptoms in the same stretch of time, through related but distinct mechanisms.

The instinct to avoid straining after birth is often overridden by fear of pain. That fear creates its own straining pattern: bracing, holding, and rushing through bowel movements instead of relaxing into them, thus worsening anorectal conditions like hemorrhoids and fissures. 

Hemorrhoids and anal fissures affect a significant share of postpartum patients, often appearing during the third trimester and peaking in the first days to weeks after delivery. 

The good news: this cycle is very treatable. Softening stool, reducing the mechanical pressure of straining, and giving the pelvic floor time and support to recover all work together.

For symptoms that don't resolve with home care alone, postpartum-safe treatment options exist, including prescription creams formulated specifically for breastfeeding recovery, such as Bummed's Long-Acting Hemorrhoid & Fissure Cream, which uses diltiazem to relax the internal anal sphincter, improve blood flow to the area, and support tissue healing.

The Perimenopausal and Menopausal Straining Cycle

The hormonal mechanism here is different from postpartum. The outcome is strikingly similar.

Declining estrogen affects connective tissue strength and vascular tone throughout the body, including the pelvic floor and the venous cushions in the anal canal. At the same time, slower gut motility during perimenopause and menopause makes constipation, and the straining that comes with it, significantly more common.

The result: a pelvic floor with less structural support at exactly the moment straining becomes more frequent. That combination is a major reason hemorrhoid prevalence rises through midlife, often overlapping with other pelvic floor symptoms like prolapse or bladder changes showing up in the same hormonal window.

As with postpartum recovery, the fix isn't just "more fiber" in isolation, though fiber matters. It's addressing stool consistency and bowel mechanics together, so the pelvic floor isn't being asked to compensate for a bowel movement that's fighting it.

When symptoms persist, prescription hemorrhoid and fissure treatment can target the underlying muscle spasm and vascular congestion directly, rather than just calming symptoms temporarily.

Breaking the Straining Cycle: What Actually Helps

Dr. Fong is direct about one of the most common culprits in her book: spending too long on the toilet.

Her rule of thumb: if you've been sitting there more than five minutes, it's too long. The longer you sit without support around the anus while pushing and straining, the more pressure builds on your hemorrhoids.

A few more principles apply across both patient populations:

  • Stool consistency comes first. Neither a well-coordinated pelvic floor nor healthy rectal veins can compensate for consistently hard, dry stool. Fiber and hydration are the foundation, but they aren't always enough on their own, particularly postpartum or during hormonal transitions.
  • Positioning matters. A slightly elevated foot position (think squatty potty) straightens the anorectal angle and reduces the amount of pushing force needed to pass stool.
  • Don't hold your breath. Breath-holding while bearing down spikes intra-abdominal pressure. Slow, steady exhales while bearing down gently put far less pressure on the pelvic floor and rectal veins.
  • Go when you feel the urge, and don't go when you don't. Holding stool in creates the same pelvic floor tension that can lead to fissures; sitting and straining when nothing's ready does the same in the other direction.
  • Address pelvic floor coordination directly. This is where a pelvic floor physical therapist can help: retraining the muscles to relax appropriately during defecation addresses the mechanical root of the straining cycle, not just the downstream symptoms.
  • Treat symptomatic hemorrhoids and fissures alongside the bowel work, not instead of it. A sitz bath in a bathtub of warm water, and topical care, can manage discomfort while the underlying pattern is being retrained, and prescription options are available when home care isn't enough.

When to Seek Treatment

Home care and pelvic floor coordination work resolve a lot of cases. Not all of them.

It's worth reaching out to a provider if:

  • Symptoms persist beyond a few weeks despite consistent home care
  • There's bleeding, a firm or painful lump, or symptoms that keep recurring
  • Straining and anal pain are creating a cycle of avoidance around bowel movements
  • You're postpartum or perimenopausal and dealing with hemorrhoid or fissure symptoms that aren't improving with fiber and hydration alone
  • You're noticing symptoms of pelvic floor dysfunction alongside anorectal symptoms: difficulty fully emptying, a sense of pressure, or bladder changes

Bummed offers discreet telehealth evaluation for hemorrhoids, anal fissures, and related anorectal symptoms, with prescription treatment shipped directly to your door when appropriate.

Options formulated specifically for sensitive life stages include:

Consult with a medical provider before starting any new medications, particularly during pregnancy or while breastfeeding.

A Note for Origin Patients

All new Bummed patients can receive 15% off treatment at Bummed with code PARTNER15.

Bummed content is for general education and should never replace professional medical advice that considers your individual health. If you think you're experiencing a medical emergency, call 911 or head to the nearest emergency department.

Prescription products require an online consultation with a physician who will determine if a prescription is appropriate.