HAM Syndrome (HTLV-1–Associated Myelopathy / Tropical Spastic Paraparesis)

Hamman’s syndrome—also called Macklin’s syndrome—happens when tiny air sacs in the lungs (alveoli) tear from pressure, letting air track along the bronchial and blood-vessel coverings into the middle of the chest (the mediastinum) and sometimes into the skin. This trapped air causes chest pain, shortness of breath, and crackling under the skin; doctors may hear a crunching sound with the heartbeat called Hamman’s sign. It most often follows a strong strain like heavy coughing, vomiting, labor, intense exercise, or Valsalva-type efforts. Most cases get better with rest, pain control, and observation. The main job is ruling out dangerous look-alikes like esophageal rupture. CMAJ+3Radiopaedia+3PMC+3

HAM/TSP is a long-lasting inflammation of the spinal cord caused by infection with a virus named HTLV-1 (Human T-lymphotropic virus type-1). The inflammation slowly damages the spinal cord, especially the parts that carry movement signals to the legs. Over time, many people develop stiff, weak legs, trouble walking, bladder or bowel problems, back or leg pain, and tingling or numbness. The illness usually moves forward slowly, but it can be faster in some people. There is no single cure yet, but diagnosis and supportive care can help symptoms and safety. World Health Organization+2NINDS+2

Another names

• HTLV-1–associated myelopathy (HAM)

• Tropical spastic paraparesis (TSP)

• HAM/TSP (combined name used in research and clinics)
  These names describe the same condition linked to HTLV-1 infection. World Health Organization

Types

By certainty of diagnosis (based on internationally used criteria):

• Definite HAM/TSP: Typical symptoms/signs plus confirmed HTLV-1 infection and supporting lab results.

• Probable HAM/TSP: Typical picture with strong test support but not all items present.

• Possible HAM/TSP: Some features suggest the illness, but evidence is incomplete; further follow-up and testing are needed. PMC+1

By speed of progression:

• Slowly progressive (most common): Gradual walking stiffness/weakness over years.

• Subacute/rapidly progressive (less common): Symptoms worsen over months, sometimes with earlier pain and bladder issues. PMC+1

By age:

• Adult-onset HAM/TSP (typical).

• Juvenile HAM/TSP (rare; can occur in children and teens, often with a female predominance). Oxford Academic

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Causes

Strictly speaking, HTLV-1 infection is the underlying cause. The items below list causal and risk-enhancing factors that raise the chance of developing HAM/TSP once infected:

1. HTLV-1 infection itself (necessary cause). World Health Organization

2. High HTLV-1 proviral load in blood (strongest known risk factor). PubMed+1

3. Longer time since infection (risk rises with duration). PubMed

4. Certain HLA (immune) genes that increase susceptibility (e.g., DRB101:01, B07:02, C*07:02; findings vary by population). PNAS

5. Lower-risk or protective HLA types lacking (e.g., absence of HLA-A*02 is linked with higher risk in some studies). Oxford Academic

6. Some HLA types can paradoxically raise risk even with lower viral load (e.g., HLA-A*24 in recent work). MDPI

7. Host–virus genetic interactions (specific viral subgroups + a person’s immune genes). PMC+1

8. Female sex shows higher frequency in several cohorts, especially juvenile cases. Oxford Academic

9. Mother-to-child transmission via prolonged breastfeeding (source of infection in many endemic regions). PMC+1

10. Sexual transmission (especially male-to-female) leading to HTLV-1 acquisition. ECDC

11. Transfusion of cellular blood components and organ/tissue transplantation (historically important infection routes). CDC+1

12. Needle sharing / injecting drug use (blood exposure). CDC

13. Immune over-activation to HTLV-1 (chronic inflammation that targets spinal cord). PMC

14. Higher levels of HTLV-1–specific cytotoxic T-cells (strong, persistent responses may drive tissue damage). eLife

15. Co-infections or inflammatory triggers that boost immune stimulation (mechanistic concept under study). Frontiers

16. Older age at infection (suggested in some cohorts to relate to risk; data vary). JAMA Network

17. Family clustering / shared genetic background (reported in some endemic settings). PMC

18. High community prevalence / endemic residence (greater chance of acquiring HTLV-1). ECDC

19. Lack of screening of blood products (where not universal) increases infection risk. CDC

20. Delayed recognition of HTLV-1 status (no preventive counseling; prolonged breastfeeding; unprotected sex). World Health Organization+1

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Symptoms

1. Stiff, heavy, or weak legs that make walking hard. This often starts slowly. World Health Organization+1

2. Spastic gait (legs feel tight, steps become scissoring or jerky). World Health Organization

3. Frequent falls or poor balance, especially on uneven ground. NINDS

4. Overactive reflexes (knees/ankles jump briskly) and clonus (ankle beating). World Health Organization

5. Babinski sign (big toe goes up when the sole is stroked). World Health Organization

6. Lower-back pain or aching in the legs (neuritic pain is common). MedLink

7. Tingling, numbness, or burning feelings in the legs. NINDS

8. Bladder urgency, frequency, or leakage, sometimes urinary retention. World Health Organization

9. Constipation or bowel urgency. World Health Organization

10. Muscle spasms or cramps in the legs. NINDS

11. Fatigue—walking takes more effort. NINDS

12. Sexual dysfunction (e.g., erectile or arousal problems). NINDS

13. Slow worsening over time (months to years) in many patients. JAMA Network

14. Occasional faster decline (subacute cases). PMC

15. Anxiety/depression related to disability (common in chronic neurologic disease; clinicians screen for this). NINDS

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Diagnostic tests

A) Physical examination (bedside neurological exam)

1. Strength testing of legs (to document true weakness, side-to-side differences, and progression). Spastic weakness is typical. World Health Organization

2. Tone assessment (feeling for stiffness/spasticity in leg muscles). Increased tone supports spinal cord pathway involvement. World Health Organization

3. Deep tendon reflexes (knee/ankle). Brisk reflexes and clonus are common in HAM/TSP. World Health Organization

4. Babinski sign (plantar response). An up-going big toe supports an “upper motor neuron” problem in the spinal cord. World Health Organization

5. Sensation testing (light touch, pin, vibration). Sensory disturbance helps stage and monitor change. NINDS

6. Gait observation (heel-toe, turning, tandem). A spastic gait—with leg scissoring and short steps—is typical. World Health Organization

7. Bladder and bowel assessment (history + focused exam) because neurogenic bladder and constipation are common. World Health Organization

B) “Manual” or simple functional tests (clinic/bedside tools)

8. Timed walk tests (e.g., 10-meter walk) to track speed and progression in a simple, repeatable way. (Used widely in myelopathies; helpful in HAM/TSP cohorts.) JAMA Network

9. Spasticity scales (e.g., Modified Ashworth Scale) to grade tone and guide therapy. (Standard in spastic disorders; applied in HAM/TSP studies.) JAMA Network

10. Bladder diary and post-void residual check (simple ultrasound) to document neurogenic bladder patterns and retention risk. World Health Organization

11. Falls risk screens (chair-rise, functional reach) to protect safety while walking. (General neuro rehab practice for spastic paraparesis.) NINDS

C) Laboratory & pathological testing

12. HTLV-1 serology (ELISA) with confirmatory Western blot on blood to prove infection. This is the essential first step. SciELO

13. Quantitative HTLV-1 proviral load (PCR) in blood. High values support risk and help research follow-up. Frontiers

14. Lumbar puncture (CSF) for HTLV-1 antibody index to show intrathecal (inside-spinal-fluid) antibody production. This strongly supports definite HAM/TSP. PubMed

15. CSF HTLV-1 DNA by PCR (when available) to further support diagnosis. PubMed

16. CSF inflammatory markers (cells, protein; sometimes cytokines) to document chronic inflammation. (Common in HAM/TSP studies.) PMC

17. Infection-rule-out labs (e.g., HIV, syphilis, Lyme in the right setting) and B12/folate to exclude treatable mimics of myelopathy. Frontiers

D) Electrodiagnostic testing

18. Somatosensory evoked potentials (SSEPs) and/or motor evoked potentials (MEPs) to show slowed or blocked signal conduction in spinal pathways. (Helpful in myelopathies including HAM/TSP.) PMC

19. EMG/Nerve conduction studies mainly to exclude peripheral nerve disease and document pyramidal patterns; results can be normal or show upper-motor-neuron patterns rather than peripheral neuropathy. MedLink

E) Imaging

20. MRI of the entire spinal cord (and often brain). Common findings include thoracic cord atrophy and sometimes subtle T2 signal changes; imaging also rules out other causes (disc disease, tumor, compression, MS, NMO). Brain MRI may show related changes. PMC+1

Non-pharmacological treatments (therapies & other measures)

In Hamman’s syndrome, non-drug care is the foundation. These measures ease symptoms, speed re-absorption of air, and prevent worsening while serious causes are excluded.

1. Observation with monitoring. Short hospital or emergency observation to track pain, breathing, and vitals while ruling out dangerous causes; most cases improve within 24–48 hours. ScienceDirect+1

2. Rest and activity restriction. Rest reduces intrathoracic pressure swings and gives the lung time to heal; avoid heavy lifting and straining for 1–2 weeks. PMC

3. High-flow supplemental oxygen. Oxygen speeds “nitrogen wash-out,” helping the body re-absorb free air more quickly; used when symptomatic or hypoxemic. Wiley Online Library

4. Breathing coaching (quiet tidal breathing). Gentle breathing reduces pain and pressure spikes; avoid deep forceful breaths or breath-holding. PMC

5. Cough control strategies (non-drug). Humidified air, honey/tea, and vocal rest reduce coughing fits that can re-injure alveoli. (Medicines may be added if needed; see drug section.) PMC

6. Anti-strain bowel care (dietary fiber, hydration). Prevent constipation to avoid Valsalva-type straining on the toilet. PMC

7. Trigger avoidance education. Pause strenuous exercise; avoid wind-instrument practice, forceful blowing, and weight-lifting until cleared. PMC

8. Asthma self-management plan refresh. Teach spacer use, trigger control, and peak-flow monitoring if asthma contributed. Mediastinum

9. Smoking and vaping cessation counseling. Smoking/vaping (including e-cigarettes) raise coughing and barotrauma risk; quitting helps healing and prevents recurrence. EJCRIM

10. Substance-use counseling (inhalational drugs). Inhaled cocaine and other illicit drugs are reported triggers; counseling reduces recurrence risk. JournalMC

11. Labor & delivery coaching (if postpartum). For future births, guidance on breathing techniques and avoiding prolonged closed-glottis pushing can lower risk. PMC

12. Incentive spirometry (gentle use). Used cautiously to prevent atelectasis; the goal is gentle ventilation—not forceful maneuvers. Cureus

13. Analgesic heat/cold packs. External comfort measures around chest wall muscles may ease pain from strain; use carefully to avoid skin injury. PMC

14. Anxiety calming techniques. Reassurance, paced breathing, and short guided relaxation lower hyperventilation and chest wall tension. PMC

15. Head-of-bed elevation. Upright posture can ease breathing and reduce pain from mediastinal air. PMC

16. Nausea control strategies (non-drug first). Small, bland meals and hydration reduce vomiting strain that can worsen or re-trigger air leaks. PMC

17. Return-precaution coaching. Teach red flags (worsening chest pain, fever, vomiting, severe breathlessness) that require urgent reassessment. PMC

18. Follow-up imaging plan. A clinician may re-image if symptoms persist/worsen; CT is most sensitive but many improve without repeat scans. PMC

19. Safe exertion re-start plan. Gradual return to normal activity over 1–2 weeks once pain and breathlessness resolve. PMC

20. Education on Hamman’s sign and reassurance. Understanding that the condition is usually benign reduces anxiety and improves adherence. PubMed

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Drug treatments (when used)

There is no specific “curative” drug for Hamman’s syndrome. Medicines treat pain, cough, nausea, asthma flares, or associated problems and help prevent complications while the body re-absorbs air. Use is individualized by a clinician.

1. Acetaminophen (paracetamol). Class: analgesic/antipyretic. Dose/Time: typical adult 500–1,000 mg every 6–8 h (max per local guidance). Purpose: chest wall pain relief. Mechanism: central COX inhibition for analgesia/antipyresis. Side effects: generally well-tolerated; liver risk in overdose. Medscape

2. NSAIDs (e.g., ibuprofen, naproxen). Class: non-steroidal anti-inflammatory. Dosing: per standard labels. Purpose: pain/inflammation from chest wall strain. Mechanism: COX-1/2 inhibition. Side effects: GI upset, bleeding risk, kidney cautions. Medscape

3. Short-acting antitussives (dextromethorphan). Class: cough suppressant. Purpose: reduce forceful cough that raises intrathoracic pressure. Mechanism: central cough-center modulation. Side effects: drowsiness; avoid overuse. PMC

4. Benzonatate. Class: peripherally acting antitussive. Purpose: blunts cough reflex at airway stretch receptors. Side effects: rare hypersensitivity; keep away from children. PMC

5. Short-acting beta-agonist inhaler (albuterol/salbutamol). Class: bronchodilator. Purpose: relieves asthma-related cough/bronchospasm. Mechanism: β2 stimulation relaxes airway smooth muscle. Side effects: tremor, tachycardia. Mediastinum

6. Inhaled corticosteroids (ICS). Class: anti-inflammatory controller. Purpose: prevent asthma flare triggers that provoke cough. Mechanism: reduces airway inflammation. Side effects: oral thrush; rinse mouth after use. Mediastinum

7. Systemic corticosteroids (short course if strong asthma flare). Class: anti-inflammatory. Purpose: treat acute asthma exacerbation driving cough. Mechanism: broad immunomodulation. Side effects: mood change, glucose rise; short courses typically safe. Mediastinum

8. Antiemetics (ondansetron). Class: 5-HT3 antagonist. Purpose: stop retching/vomiting to reduce pressure spikes. Side effects: constipation, QT caution. PMC

9. Proton pump inhibitors (omeprazole). Class: gastric acid suppression. Purpose: reflux-related cough/vomit reduction. Side effects: headache; long-term risks if overused. PMC

10. Opioid-sparing multimodal analgesia (e.g., acetaminophen + NSAID). Purpose: pain control while minimizing respiratory depression. Note: avoid routine opioids if possible. Medscape

11. Topical lidocaine patches (off-label for localized chest wall pain). Class: local anesthetic. Purpose: focal musculoskeletal pain relief. Side effects: skin irritation. Medscape

12. Mucolytics (e.g., guaifenesin) with hydration. Class: expectorant. Purpose: thin secretions to reduce forceful coughing. Side effects: GI upset. PMC

13. Antibiotics (only if clear secondary infection). Class: antimicrobial. Purpose: treat documented pneumonia/bronchitis when present; not routine for simple Hamman’s. Side effects: vary by agent; avoid unnecessary use. Medscape

14. Anxiolytics (short, targeted use). Class: e.g., hydroxyzine. Purpose: calm anxiety-hyperventilation cycle that worsens pain/breathing. Side effects: sedation. PMC

15. Nebulized bronchodilators if wheezy. Class: β2 agonists ± anticholinergics. Purpose: relieve bronchospasm. Side effects: tremor, dry mouth. Mediastinum

16. Antipyretics for fever from a triggering infection. Class: acetaminophen/NSAIDs. Purpose: comfort; lower metabolic demand. Side effects: as above. Medscape

17. Stool softeners (docusate) and osmotic laxatives (PEG). Purpose: prevent straining. Side effects: cramping/loose stool. PMC

18. Nasal decongestant sprays (short course) if upper-airway cough driver. Purpose: reduce post-nasal drip-cough loop. Side effects: rebound if prolonged. PMC

19. Antihistamines (for cough driven by allergic rhinitis). Class: H1 blockers. Purpose: reduce drip and cough frequency. Side effects: drowsiness (first-gen). PMC

20. Oxygen by nasal cannula (re-emphasized as a “medication” when ordered). Purpose: improve symptoms and speed air re-absorption when needed. Side effects: dryness; monitor in COPD. Wiley Online Library

Important: A 2025 review and clinical guidance emphasize that expectant (watchful) management is safe in uncomplicated spontaneous pneumomediastinum, with medications chosen for comfort and triggers—not to “cure” the air itself. Medscape

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Dietary molecular supplements

Supplements do not treat mediastinal air. At best, they support recovery by reducing cough drivers (e.g., reflux) or supporting lung health. Always clear supplements with a clinician, especially in pregnancy or with other medicines.

1. Honey (medical-grade). Soothes cough and throat irritation; may reduce nighttime cough frequency. Typical: 1–2 teaspoons as needed. Mechanism: demulcent, antimicrobial properties. PMC

2. Ginger tea. Helps nausea/retching to reduce strain. Typical: 1–2 g dried ginger/day. Mechanism: 5-HT3 modulation; antiemetic. PMC

3. Peppermint tea. May ease GI spasm and gas that provoke reflux-cough cycles. Typical: tea after meals. Mechanism: smooth-muscle relaxation. PMC

4. Throat lozenges (pectin/demethecone). Demulcent coating reduces cough triggers from throat irritation. Use per label. Mechanism: barrier effect. PMC

5. Omega-3 fatty acids. General anti-inflammatory support for airway health. Dose: ~1 g/day EPA+DHA (food-first preferred). Mechanism: eicosanoid modulation. Mediastinum

6. Vitamin D (if deficient). Supports immune and respiratory health; correct deficiency only. Dose: per labs/clinician. Mechanism: immune modulation. Mediastinum

7. Magnesium (dietary). May help bronchial smooth-muscle relaxation (indirect support). Dose: RDA intake unless prescribed. Mechanism: calcium antagonism in smooth muscle. Mediastinum

8. Probiotic foods (yogurt/fermented foods). May help reflux and gut comfort, lowering retching risk. Mechanism: microbiome support. PMC

9. Slippery elm (demulcent, check interactions). Coats throat/esophagus; may reduce cough from irritation or reflux. Use per label; avoid in pregnancy unless cleared. Mechanism: mucilage barrier. PMC

10. Electrolyte fluids (oral rehydration). Hydration thins mucus and reduces cough force. Mechanism: maintains airway hydration. PMC

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Immunity-booster / regenerative / stem-cell” drugs

There is no role for immune “boosters,” regenerative drugs, or stem-cell therapies in straightforward Hamman’s syndrome. The body re-absorbs air naturally. Below clarifies why not—so expectations are realistic.

1. Stem-cell therapies: Not indicated; no evidence they speed air re-absorption or alveolar healing in SPM. Risks and cost outweigh any theoretical benefit. PMC

2. Growth factors (e.g., EGF/FGF drugs): Not used; no clinical data for SPM; potential adverse effects. PMC

3. Immune “boosters” (OTC or IV). SPM is mechanical/barotrauma-related, not an immune-deficiency state; avoid unproven injections/supplements marketed as boosters. PMC

4. Biologics for asthma (e.g., anti-IgE, anti-IL-5)—only if indicated for chronic asthma. They don’t treat SPM, but good asthma control may reduce cough-related triggers long-term. Mediastinum

5. Antifibrotics/regenerative agents: No role in SPM recovery; SPM does not cause fibrotic lung injury. PMC

6. IV magnesium sulfate (acute severe asthma only). This is for life-threatening asthma, not SPM; it can relieve bronchospasm when standard therapy fails. Mediastinum

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Surgeries / procedures

Most Hamman’s cases do not need procedures. These are for complications or different diagnoses discovered during evaluation.

1. Chest tube (tube thoracostomy) for significant pneumothorax with respiratory compromise—if air has also leaked into the pleural space. Medscape

2. Emergency decompression for tension pneumomediastinum (rare) with hemodynamic compromise; surgical or interventional release of mediastinal air. Medscape

3. Esophageal repair when imaging confirms Boerhaave’s syndrome (esophageal rupture), a dangerous mimic that requires surgery. Medscape

4. Tracheobronchial injury repair if trauma/procedure causes airway tear. Family Practice Notebook

5. Mediastinotomy or percutaneous drainage if large, loculated mediastinal air causes persistent symptoms or infection risk (exceptional). Medscape

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Prevention tips

1. Treat and control asthma to reduce cough spikes. Mediastinum

2. Quit smoking/vaping and avoid inhaled illicit drugs. EJCRIM

3. Manage reflux (smaller meals, avoid late eating) to cut vomiting/retching. PMC

4. Avoid forceful Valsalva—don’t hold your breath during lifts; exhale through effort. PMC

5. Use stool-softening strategies if constipated. PMC

6. Taper back to strenuous sports gradually after recovery. PMC

7. Practice cough hygiene (humidifier, hydration). PMC

8. Labor coaching for pregnant patients to avoid prolonged closed-glottis pushing. PMC

9. Seek early care for severe respiratory infections to prevent unchecked coughing fits. Mediastinum

10. Know return precautions (chest pain worse, fever, vomiting, shortness of breath). PMC

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When to see a doctor (or go to ER)

• Immediate/ER: severe or worsening chest pain, shortness of breath, fainting, fever, vomiting/retching with chest pain, or painful swallowing—these raise concern for pneumothorax or esophageal injury. Medscape

• Urgent clinic follow-up (24–48 h): persistent pain, new cough/wheeze, or if you were told to check back after observation. ScienceDirect

• Routine follow-up: asthma optimization, smoking cessation, or postpartum review after an episode during labor. PMC

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What to eat / what to avoid

Eat more of: soft, non-acidic foods; warm liquids (soups/teas); fiber-rich foods and fluids to prevent straining; small frequent meals to reduce reflux. Avoid/limit: very large meals, late-night eating, alcohol, spicy/acidic foods if they worsen reflux, and anything that triggers cough. The aim is comfort and reducing cough/retching that can re-strain the chest. PMC

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Frequently Asked Questions (FAQs)

1) Is Hamman’s syndrome dangerous?
Most cases are benign and get better with rest, oxygen if needed, and pain control. The main concern is ruling out life-threatening mimics (like esophageal rupture) and watching for complications (like pneumothorax). Medscape

2) What exactly causes the air leak?
A sudden pressure spike causes tiny alveoli to rupture; air travels along tissue planes to the mediastinum—this is the Macklin effect. PMC

3) How is it diagnosed?
Doctors use history, exam (may feel crackling under the skin; may hear Hamman’s sign), and imaging. CT chest is most sensitive; a chest X-ray can also show mediastinal air. PMC+1

4) Do I always need a CT scan?
Not always. CT is most sensitive, but if the story is classic and you’re improving, clinicians sometimes avoid repeat imaging. Decisions are individualized. PMC

5) How long does it take to resolve?
Symptoms usually improve within 24–48 hours; the air re-absorbs over days. Return slowly to normal activity once pain and breathlessness settle. ScienceDirect

6) Can it come back?
Recurrence is uncommon if triggers (coughing, straining, inhalational drug use) are controlled—especially with good asthma care and lifestyle changes. Mediastinum

7) Why did it happen during labor?
Prolonged, forceful pushing increases chest pressure and can trigger alveolar rupture; postpartum Hamman’s is rare (about 1 in 100,000 births). PMC

8) What is Hamman’s sign?
A crunching sound heard with each heartbeat over the chest when there’s air in the mediastinum or pericardium—rare but distinctive. Wikipedia

9) Will oxygen help me heal faster?
Supplemental oxygen can speed air re-absorption and ease symptoms; clinicians use it if you are short of breath or uncomfortable. Wiley Online Library

10) Do I need antibiotics?
Not for simple Hamman’s. Antibiotics are only for proven infections; overuse can cause harm. Medscape

11) Do I need surgery?
Very rarely—only for complications like significant pneumothorax, tension physiology, or a different diagnosis (e.g., esophageal rupture). Medscape

12) Can COVID-19 trigger it?
Yes—SPM has been reported in COVID-19, even without ventilation. Management is still supportive, with close monitoring. ScienceDirect+1

13) Is it safe to fly?
Most clinicians advise waiting until symptoms resolve and you’re cleared, because pressure changes may worsen trapped air. (Policy varies—ask your clinician.) Medscape

14) How do I prevent straining on the toilet?
Hydration, fiber, and stool softeners as needed; avoid prolonged breath-holding during bowel movements. PMC

15) Who is at higher risk?
Young males; people with asthma; those who vape/smoke or use inhalational drugs; postpartum individuals after prolonged labor; people with severe coughing illnesses. IJ Case Reports and Images+1

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: September 29, 2025.

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