|Year : 2021 | Volume
| Issue : 1 | Page : 1-6
Update on obstructed defecation syndrome
Reem A Alharbi
Department of Clinical Surgery, College of Medicine, Princess Nourah Bint Abdulrahman University, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
|Date of Submission||07-Nov-2021|
|Date of Decision||16-Nov-2021|
|Date of Acceptance||10-Dec-2021|
|Date of Web Publication||15-Mar-2022|
Reem A Alharbi
Department of Clinical Surgery, College of Medicine, Princess Nourah Bint Abdulrahman University, King Abdullah Bin Abdulaziz University Hospital, Riyadh
Source of Support: None, Conflict of Interest: None
The most common cause leading to primary constipation is obstructed defecation syndrome (ODS). Anatomical disorders in the pelvic floor region (rectocele, enterocoele, rectal intussusception, and rectal prolapse) result in ODS. However, it always occurs in combination with a functional defect of defecation. This review offers an in-depth look at ODS diagnosis and treatment. Conservative or surgical treatment options are available. Conservative treatment includes several approaches to defecation practice and regimen and dietary measures combined with pelvic floor rehabilitation and psychological support. However, some patients require surgical intervention as ODS symptoms might persist despite conservative treatment. Surgical approaches include transvaginal, transabdominal, and transanal procedures. The most widely used are the transanal procedures, which are associated with good short-term results and low complication rates. Nevertheless, the long-term complications are still unknown and being discussed. The underlying cause of ODS is a combination of functional and anatomical abnormalities; therefore, treatment should be focused on pelvic organ systems for several reasons. Accordingly, only a multidisciplinary approach and (multimodal) combination of different approaches can be used to avoid inferior results in this challenging area.
Keywords: Intussusception, obstructed defecation syndrome, pelvic floor disorder, rectocele, stapled transanal rectal resection
|How to cite this article:|
Alharbi RA. Update on obstructed defecation syndrome. Saudi Surg J 2021;9:1-6
| Introduction|| |
Constipation can be systematically divided into primary and secondary. These two types have completely different causes and treatments. Secondary constipation is caused by diseases or causes that are not related to bowel activity or defecation process (bowel tumors, stiffness for various reasons, neurological diseases, drug use, and metabolic disorders). On the other hand, primary constipation is divided into lazy bowel syndrome and terminal constipation. Diagnosis and treatment of lazy bowel syndrome are not the subjects of this review. The main symptoms of terminal constipation are difficulty in bowel movements, feeling of obstruction in the rectum, and the need to exert excessive pressure. Terminal constipation can be divided into two main subgroups: anismus occurs when striated muscles of the pelvic floor (puborectalis and external anal sphincter) fail to relax properly during attempted defecation and obstructive bowel syndrome. Pelvic floor disorders include inaccurate terminology that does not specify these disorders and should not be used in the medical literature.
By definition, obstructed defecation syndrome (ODS) is a byproduct of functional constipation, where patients report incomplete rectal emptying each week with or without a real reduction in bowel movements, stool fragmentation, tenesmus, a desire to urinate, and pelvic pain. According to frequent anamnestic data, it is a need for digital assistance for emptying.,, ODS is a functional disorder resulting in anatomical changes in the rectal region (rectocele, enterocele, and intussusception or prolapse of the rectum). Thus, anatomical changes are a consequence, and not a cause, of this syndrome. ODS mainly affects women. This syndrome is called an “iceberg syndrome” as 90% of ODS patients have rectocele and rectal internal mucosal prolapse as the underlying pathology.
If this syndrome is not properly treated, the patients' quality of life is significantly reduced, both socially and psychologically., The basis of treatment is conservative procedures; however, about 20% of patients require surgical treatment. A significant number of patients with defecating disorders (80%) will respond to conservative treatment alone or with the addition of biofeedback therapy. Currently, because the cause of the disease is a combination of several anatomical abnormalities and functional problems, such as slow transit constipation or IBS, one of the possible surgical procedures is not preferred in the literature.
| Pathophysiology|| |
To understand the causes and development of ODS, we must first summarize the mechanism of physiological defecation. First, as soon as the stool passes through the ampulla of the rectum, it comes in contact with the mechanoreceptors of the proximal part of the anal canal. These receptors provide the central nervous system with information about the quality of rectal contents. At this point, the person can hold the stool in the rectum or push it back into the sigma by tightening the external sphincter and contracting the puborectal muscle. At the right time, after sitting on the toilet and activating the abdominal press, intrarectal pressure rises, causing stool to come out. At the same time, the muscles of the pelvic floor, especially the puborectal muscle and the external sphincter, relax. This softening of the keys allows trouble-free emptying. Relaxation eases the otherwise acute anorectal angle (90°–140°) and opens the distal end of the anus, and stool can be emptied.
The causes of the gradual development of ODS are the weakening of the tissues of the pelvic floor, the gradual descent of the organs with the simultaneous increase in muscle tension of the pelvic floor, and the disturbance of the relaxation of the puborectal muscle. Moreover, the long-term presence of anxiety plays a role. More effort is needed when defecating, resulting in the gradual development of pudendal neuropathy gradually, which affects the sensitivity of the rectal lining. The smaller the stool becomes in volume, the less it affects the rectal mucosa and the weaker the stimulus induces the peristaltic reflex, leading to the inhibition of the internal sphincter contraction. Then, the stool becomes more and more difficult to expel, and a “vicious” circle closes., From this description of the development of ODS, it is clear why the results of surgical treatment, which only addresses the consequences of the disease, are often unsatisfactory.
This disease is characterized by a complex set of functional disorders and the changes in anatomy occur; therefore, the signs and symptoms are very diverse. The basic signs included difficulty in emptying with bowel movements, taking a lot of effort to empty, the feeling of incomplete emptying, and the need for digital assistance in the evacuation of stool (pressure on the perineum through the vagina). It is recommended to use one of the many scoring systems to complete and manage anonymous data; for example, the most commonly used score by Altomare. [Table 1] shows one of these scoring systems which is the ODS score done by Renzi et al. It consists of five items graded from 0 to 5: 0, no symptoms; 20, severe symptoms.
| Diagnostics|| |
Medical history and basic tests, including digital rectal exams, anoscopy, and colonoscopy, should not be ignored. Further examination should be aimed at identifying possible functional causes of ODS and demonstrating anatomical abnormalities. Dynamic X-ray defecography is a test required to identify or rule out organic disorders of the pelvic floor. Moreover, it is used to measure the anorectal angle and perineal descent at rest and during straining. Magnetic resonance defecography is another important tool in which rectocele and intussusception can be identified. It should be considered the first-line diagnostic test to detect structural abnormalities if resources allow.
Intestinal transit time is used to distinguish between other causes of constipation. Then, further examinations focus on the specific anatomical deviations that can cause ODS as follows: rectal-anal sphincter manometry, excretory balloon examination, transanal ultrasound with sphincter imaging, and transvaginal ultrasound. The pudendal motor latency test is used to detect pudendal neuropathy, but this test is not routinely done in our workplace. Psychological testing is very appropriate for many patients, especially because long-term anxiety is often associated with ODS and is one of the causes. A large psychological study has found that up to one-third of patients with ODS or uncomplicated rectal pain experienced sexual trauma in childhood or adolescence.
| Conservative Treatment|| |
Eventually, most surgical treatments fail in the long run because they usually deal only with anatomical outcomes and not with the functional causes of ODS. Therefore, the patient should be chosen carefully for surgical treatment and only after conservative procedures have failed. However, conservative procedures are very lengthy and require a great deal of effort, determination, and regularity from the patient. Conservative treatment often fails, resulting in persistent impatience on the part of the patient and the doctor in general, leading to surgical overtreatment. Surgical procedures can be performed quickly and their short-term results are satisfactory. However, symptoms often recur after surgical treatment, limiting the potential for conservative treatment.
Basic nonsurgical procedures include regime measures such as fiber, fluids, and regular laxative intake. Opinions differ on whether laxatives are more appropriate and whether to distinguish them based on the type of effect. Regular use of enemas can be beneficial, and in many cases, ODS is completely resolved and no other treatment is needed. On the other hand, this process can cause recurrent microtrauma in the area of the anal mucosa and, in turn, the formation of fibrosis mucosal and strictures.,
In the cases of anismus or anal sensory disorders, biofeedback treatment has shown to be effective. It is also suitable for treating other diseases; however, it is more effective in managing the above-mentioned abnormalities. A very important part of surgical procedures, especially for muscle imbalance, is the rehabilitation of the pelvic floor. Moreover, yoga has a positive effect. Rehabilitation also yields very good results in the case of pre-established anatomical disorders such as rectoanal and rectal intussusception. Transanal electrical stimulation may yield good results in genital neuropathy and sensory disorders of the rectal mucosa. Psychological treatment should be part of conservative management. Thus, only a combination of different psychological methods with potential psychological support can lead to satisfactory long-term results. In many cases, further surgical treatment is no longer necessary.
| Surgical Treatment|| |
ODS surgical treatment can be divided into several schemes: transvaginal, transabdominal, and transanal procedures being the most natural. The latter can be divided into manual and stapler procedures. Many articles and studies discussed the surgical treatment of rectocele and rectal prolapse. However, studies dealing with complex procedures that cover all disorders and symptoms are lacking, and there is no recommended procedure for when and how patients will indicate the type of individual surgery. On the other hand, it is necessary to realize that the right surgical approach for a given patient is crucial for the whole treatment. Therefore, the evaluation of the results is problematic.
The basic general indication principles of surgical treatment are as follows: first, in the case of internal mucosal prolapse, perform a resection or plication of this prolapse; second, in the case of the clinical manifestation of the rectocele, perform a resection of the redundant mucosa and thus “restore” the strength of the rectovaginal septum; and third, in the case of pelvic floor disorders, focus the surgical procedure on the myotomy of the pelvic floor muscles, especially on the relaxation or partial overstretching of the puborectalis muscle to achieve correction of its hypertonus or hypertrophy.
Posterior colporrhaphy with levator muscle is often the gynecologist's preferred method for rectocellular and rectovaginal septal disorders. It is a relatively simple and safe method with minimal complications. Its results are questionable, and this method does not affect or worsen feelings of incomplete emptying, constipation, or incontinence and sexual dysfunction. This is because this method does not address ODS as a complex of functional disorders and causes but only physiological changes. It is only suitable for small isolated rectoceles without internal rectal prolapse.
Another method is the transvaginal interposition of the biological mesh into the rectovaginal septum to enhance it. This method is still under development, but it is already used in some workplaces.
Transabdominal procedures are indicated in cases of several disorders, most often in combination with a rectocele and large rectal intussusception or even in combination with an enterocele. At present, they are performed almost exclusively using a laparoscopic approach. Laparoscopic rectopexy is a method originally designed to correct external rectal prolapse. First, it releases the rectum by incision only the front of it while preserving the lateral stalks and retracts it cranially. Then, the rectum is fixed with a polypropylene mesh to the solid structures of the pelvis, most often to the periosteum of the sacral promontory. The mesh is fixed to the intestine with sutures in the dorsal part of the rectum or rather on the anterior surface of the rectum (the rectovaginal septum is also strengthened). Concerns about the erosion or infection risks associated with using synthetic mesh in the pelvis have recently led to the use of biological mesh. The method has many variations and is constantly being improved.
The results of laparoscopic abdominal rectopexy for internal rectal prolapse are controversial. Interpretation of these results is hard due to the heterogeneity of patient selection and surgical techniques. Improvement in short term following this procedure is noticed for both incontinence and constipation groups.
In contrast to the above-mentioned method, laparoscopic resection rectopexy is supplemented by resection of the sigmoid in the presence of its excessive elongation. After resection of the sigmoid and rectosigmoid anastomosis, the rectum is fixed again with a mesh. The method has very good results if dolichosigma is one of the factors leading to constipation. Sigmoid colectomy with rectopexy generally had lower recurrence rates but significantly higher morbidity compared to rectal fixation alone.
Although this concept has been controversial by some, the incidence of postoperative constipation may be reduced by preserving the lateral rectal ligament. Unilateral division and unilateral mesenteric pexy of the lateral pedicle should be considered to reduce the risk of constipation. In contrast, surgeons should avoid sigmoidectomy in patients with preoperative diarrhea. In these cases, only rectopexy using sutures or mesh is more suitable.
Currently, transanal procedures are the most widely used approach in treating anatomical disorders of ODS. Their results in general treatment are still debated and they have many side effects and complications such as bleeding, rectovaginal fistula, incontinence, and pelvic sepsis. These methods have many supporters who have shown good results and low patient stress (short hospitalization and low subjective difficulty after surgery). However, many opponents have suggested that “rectocele resection with ODS is essentially the same as lung resection with asthma.” Transanal procedures can be divided into manual and stapler.
Today, Delorme's internal surgery is practically the only manual transanal surgery for rectocele and rectal intussusception. It involves wrinkling the rectovaginal septal tissue after the transrectal intersection of the mucosa with the possible resection of excess mucosa in the area of the apex of the rectocele. Many authors still support this approach, claiming that there are no statistically significant differences in its results compared to those of the stapling techniques. However, others have reported longer hospital stays and greater complications after this approach.
Stapled transanal rectal resection (STARR) surgery is the most widely used method for rectocele correction and rectal intussusception. Using two circular staplers, originally intended for hemorrhoid surgery, the rectocele sac is resected (anterior and posterior edge of the rectocele, respectively, intussusception). The method can only be used with a small rectocele (depth up to 4 cm), which is determined by the volume of the stapler. The procedure is relatively simple and easy and has a very good postoperative course. Moreover, the short-term results are very good, reported in up to 90% of patients., On the other hand, in terms of long-term outcomes, 55% of the patients reported three or more ODS symptoms 18 months postoperatively and 19% required surgical reintervention. The most common complications immediately after surgery include bleeding from a stapler suture. Other complications include puborectal dyssynergia and painful defecation. Persistent suture rupture with sphincter spasm may also be the cause of persistent pain in the anus. Frequent stool urgency in the 1st week after surgery is due to a reduction in the volume of the rectal ampoule. Nevertheless, more serious complications are rare.
The Contour® Transtar™ operation is a method using one or more curved linear staplers. Thus, it is possible to resect any large bag of rectocele. According to some authors, this method has better results than a simple STARR operation. On the other hand, others have reported statistically the same short-term and long-term results with a higher risk of more serious complications, such as rectovaginal fistulas. In these cases, resecting the rectum wall in its entire width is possible, and thus, there is the possibility of including the wall of the vagina in the suture. Severe retrorectal hematomas have also been described.
The TST-STARR operation is an approach similar to the STARR principle but uses a large-volume stapler that cuts the rectal wall across its entire width. Naldini (who created this method) has reported that the complications are minimal after this approach and it is very effective, especially in treating rectal intussusception. The method has a short learning curve and is safe. In contrast to the STARR method, thanks to the construction of the stapler, it is possible to resect excess mucosa longer than 4 cm, even under direct eye control. The Transanal Repair of Rectocele and Rectal Mucosectomy with one Circular Stapler operation is basically the same as the TST-STARR.
| Conclusion|| |
The mainstay of treatment of ODS is conservative, which bears very good results in many patients at the end. Surgical options are variable and their short-term results are generally good, and, with a correctly preferred procedure, the complications are small. The surgical procedures do not completely resolve the ODS but rather deal with the anatomic abnormality only.
The traditional focus on individual compartments in treating patients with ODS by separate specialties has shifted to specialized multidisciplinary teams including gastroenterologists, colorectal and urogynecological surgeons, specialist radiologists, and specialist practitioners in order to successfully manage this syndrome.
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Conflicts of interest
There are no conflicts of interest.
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