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{{Infobox medical condition (new)
{{Infobox medical condition (new)
| name = Obstructed defecation syndrome
| name = Obstructed defecation syndrome
| synonyms = Obstructed defecation, outlet obstruction,<ref name="PMID30228729">{{cite journal |last1=Jani |first1=B |last2=Marsicano |first2=E |title=Constipation: Evaluation and Management. |journal=Missouri medicine |date=May 2018 |volume=115 |issue=3 |pages=236–240 |pmid=30228729}}</ref> anal outlet dysfunction,<ref name="Steele2021">{{cite book |last1=Steele |first1=SR |last2=Hull |first2=TL |last3=Hyman |first3=N |last4=Maykel |first4=JA |last5=Read |first5=TE |last6=Whitlow |first6=CB |title=The ASCRS Textbook of Colon and Rectal Surgery |date=20 November 2021 |publisher=Springer Nature |location=Cham, Switzerland |isbn=978-3-030-66049-9 |edition=4th |language=en}}</ref> rectal outlet obstruction, outlet obstructive constipation, evacuatory dysfunction,<ref name="The Surgical Management of Evacutory Dysfunction" /> outlet constipation, pelvic outlet obstruction<ref name=Coloproctology>{{cite book |last= |first= |title=Coloproctology |publisher=Springer |year=2010 |isbn=978-1-84882-755-4 |editor-last=Zbar |editor-first=Andrew P. |location=New York |editor-last2=Wexner |editor-first2=Andrew P.}}</ref> pelvic constipation,<ref name="Steele2021" /> difficult evacuation,<ref name="Steele2021" /> functional obstructed defecation syndrome,<ref name="Steele2021" />
| synonyms = Obstructed defecation, obstructive defecation,<ref name="Steele2020">{{cite book |last1=Steele |first1=SR |last2=Maykel |first2=JA |last3=Wexner |first3=SD |title=Clinical Decision Making in Colorectal Surgery |date=11 August 2020 |publisher=Springer International Publishing |location=Cham |isbn=978-3-319-65941-1 |edition=2nd |language=en}}</ref> outlet obstruction,<ref name="PMID30228729">{{cite journal |last1=Jani |first1=B |last2=Marsicano |first2=E |title=Constipation: Evaluation and Management. |journal=Missouri medicine |date=May 2018 |volume=115 |issue=3 |pages=236–240 |pmid=30228729}}</ref> anal outlet dysfunction,<ref name="Steele2021">{{cite book |last1=Steele |first1=SR |last2=Hull |first2=TL |last3=Hyman |first3=N |last4=Maykel |first4=JA |last5=Read |first5=TE |last6=Whitlow |first6=CB |title=The ASCRS Textbook of Colon and Rectal Surgery |date=20 November 2021 |publisher=Springer Nature |location=Cham, Switzerland |isbn=978-3-030-66049-9 |edition=4th |language=en}}</ref> rectal outlet obstruction, outlet obstructive constipation, evacuatory dysfunction,<ref name="The Surgical Management of Evacutory Dysfunction" /> outlet constipation, pelvic outlet obstruction<ref name=Coloproctology>{{cite book |last= |first= |title=Coloproctology |publisher=Springer |year=2010 |isbn=978-1-84882-755-4 |editor-last=Zbar |editor-first=Andrew P. |location=New York |editor-last2=Wexner |editor-first2=Andrew P.}}</ref> pelvic constipation,<ref name="Steele2021" /> difficult evacuation,<ref name="Steele2021" /> functional obstructed defecation syndrome,<ref name="Steele2021" />
| image =
| image =
| alt =
| alt =
Line 45: Line 45:
There is a constellation of possible symptoms.<ref name=Coloproctology />
There is a constellation of possible symptoms.<ref name=Coloproctology />


* Straining.<ref name="Podzemny2015" />
* Straining,<ref name="Podzemny2015" /> and attempting to defecate for a long period of time
* Use of, or dependence on, [[enema]]s and/or [[laxative]]s.<ref name="PMID29521821" />
* Use of, or dependence on, [[enema]]s and/or [[laxative]]s.<ref name="PMID29521821" />
* Self-digitation.<ref name="Podzemny2015" />
* Self-digitation.<ref name="Podzemny2015" />
* Posturing (the need to assume "unusual" posture).<ref name="Liu2016">{{cite journal |last1=Liu |first1=WC |last2=Wan |first2=SL |last3=Yaseen |first3=S |last4=Ren |first4=XH |last5=Tian |first5=CP |last6=Ding |first6=Z |last7=Zheng |first7=KY |last8=Wu |first8=YH |last9=Jiang |first9=CQ |last10=Qian |first10=Q |title=Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience |journal=World Journal of Gastroenterology |date=2016 |volume=22 |issue=35 |pages=7983 |doi=10.3748/wjg.v22.i35.7983 |pmid=27672293}}</ref>
* Posturing (the need to assume "unusual" posture).<ref name="Liu2016">{{cite journal |last1=Liu |first1=WC |last2=Wan |first2=SL |last3=Yaseen |first3=S |last4=Ren |first4=XH |last5=Tian |first5=CP |last6=Ding |first6=Z |last7=Zheng |first7=KY |last8=Wu |first8=YH |last9=Jiang |first9=CQ |last10=Qian |first10=Q |title=Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience |journal=World Journal of Gastroenterology |date=2016 |volume=22 |issue=35 |pages=7983 |doi=10.3748/wjg.v22.i35.7983 |pmid=27672293}}</ref>
* Frequent bowel movements / toilets visits,<ref name="Riss2015">{{cite journal |last1=Riss |first1=S |last2=Stift |first2=A |title=Surgery for obstructed defecation syndrome - is there an ideal technique? |journal=World journal of gastroenterology |date=7 January 2015 |volume=21 |issue=1 |pages=1–5 |doi=10.3748/wjg.v21.i1.1 |pmid=25574075 |pmc=4284324}}</ref> where only fecal pellets may be passed.<ref name="Obstructed Defaecation Web" />
* Frequent urge to defecate,<ref name="Steele2020" /> and frequent bowel movements/toilet visits,<ref name="Riss2015">{{cite journal |last1=Riss |first1=S |last2=Stift |first2=A |title=Surgery for obstructed defecation syndrome - is there an ideal technique? |journal=World journal of gastroenterology |date=7 January 2015 |volume=21 |issue=1 |pages=1–5 |doi=10.3748/wjg.v21.i1.1 |pmid=25574075 |pmc=4284324}}</ref> where only fecal pellets may be passed.<ref name="Obstructed Defaecation Web" />
* Conversely, there may reduced number of bowel movements per week.<ref name="PMID29521821" /><ref name="Steele2021" />
* Conversely, there may reduced number of bowel movements per week.<ref name="PMID29521821" /><ref name="Steele2021" />
* Abnormal stool texture, which may be anything from watery/loose (overflow [[diarrhea]]),<ref name="Steele2020" /> to fragmented,<ref name="Podzemny2015" /> very hard<ref name="PMID29521821" /> or pellet-shaped.<ref name="Steele2020" />
* Fragmented stools.<ref name="Podzemny2015" />
* Very hard stools.<ref name="PMID29521821" />
* Sense of incomplete evacuation.<ref name="Podzemny2015" /> even with soft stools.<ref name="Ciriza2020" />
* Sense of incomplete evacuation.<ref name="Podzemny2015" /> even with soft stools.<ref name="Ciriza2020" />
* Unsuccessful attempts at bowel movements.<ref name="Steele2021" />
* Unsuccessful attempts at bowel movements.<ref name="Steele2021" />
Line 60: Line 59:
* Feeling of occupation or "mass" in the vagina.<ref name="Ciriza2020">{{cite journal |last1=Ciriza de los Ríos |first1=C |last2=Aparicio Cabezudo |first2=M |last3=Zatarain Vallés |first3=A |last4=Rey Díaz-Rubio |first4=E |title=Obstructed defecation syndrome: a diagnostic and therapeutic challenge |journal=Revista Española de Enfermedades Digestivas |date=2020 |volume=112 |doi=10.17235/reed.2020.6921/2020 |pmid=32450707 |url=https://www.reed.es/obstructed-defecation-syndrome-a-diagnostic-and-therapeutic-challenge4824}}</ref>
* Feeling of occupation or "mass" in the vagina.<ref name="Ciriza2020">{{cite journal |last1=Ciriza de los Ríos |first1=C |last2=Aparicio Cabezudo |first2=M |last3=Zatarain Vallés |first3=A |last4=Rey Díaz-Rubio |first4=E |title=Obstructed defecation syndrome: a diagnostic and therapeutic challenge |journal=Revista Española de Enfermedades Digestivas |date=2020 |volume=112 |doi=10.17235/reed.2020.6921/2020 |pmid=32450707 |url=https://www.reed.es/obstructed-defecation-syndrome-a-diagnostic-and-therapeutic-challenge4824}}</ref>
* Pelvic heaviness.<ref name="Podzemny2015" />
* Pelvic heaviness.<ref name="Podzemny2015" />
* [[Pelvic pain]].<ref name="Ciriza2020" />
* [[Pelvic pain]]<ref name="Ciriza2020" /> and cramping.<ref name="Steele2020" />
* [[Bloating]].<ref name="Steele2021" />
* [[Bloating]].<ref name="Steele2021" />
* [[Fecal incontinence]],<ref name="Ciriza2020" /> which may occur after defecation.<ref name="Obstructed Defaecation Web" />
* [[Fecal incontinence]],<ref name="Ciriza2020" /> which may occur after defecation.<ref name="Obstructed Defaecation Web" />
* [[Urinary incontinence]].<ref name="Ciriza2020" />
* [[Urinary incontinence]].<ref name="Ciriza2020" />
* Poor appetite and early satiety when eating.<ref name="Steele2020" />


[[Fecal incontinence]] to gas, liquid, solid stool, or mucus in the presence of obstructed defecation symptoms may indicate occult [[rectal prolapse]] (i.e., [[rectal intussusception]]), [[internal anal sphincter|internal]]/[[external anal sphincter]] dysfunction, or [[descending perineum syndrome]].<ref name=Coloproctology />
[[Fecal incontinence]] to gas, liquid, solid stool, or mucus in the presence of obstructed defecation symptoms may indicate occult [[rectal prolapse]] (i.e., [[rectal intussusception]]), [[internal anal sphincter|internal]]/[[external anal sphincter]] dysfunction, or [[descending perineum syndrome]].<ref name=Coloproctology />
Line 95: Line 95:


==Diagnosis==
==Diagnosis==
Diagnosis is very challenging for clinicians, since most patients will simply complain of "constipation".<ref name="Steele2020" /> As discussed previously, there are many possible causes of ODS, which often may occur together in the same patient, and ODS may co-exist with other conditions such as slow-transit constipation.<ref name="Steele2020" />

The two key features of obstructed defecation are:
The two key features of obstructed defecation are:
# An inability to voluntarily evacuate rectal contents<ref name="obstructed defecation">{{cite web|last=Welton|first=Mark Lane|title=Obstructed Defecation|url=http://www.health.am/ab/more/obstructed-defecation/|publisher=Armenian Medical Network, Inc|access-date=9 September 2012}}</ref>
# An inability to voluntarily evacuate rectal contents<ref name="obstructed defecation">{{cite web|last=Welton|first=Mark Lane|title=Obstructed Defecation|url=http://www.health.am/ab/more/obstructed-defecation/|publisher=Armenian Medical Network, Inc|access-date=9 September 2012}}</ref>

Revision as of 20:38, 25 December 2022

Obstructed defecation syndrome
Other namesObstructed defecation, obstructive defecation,[1] outlet obstruction,[2] anal outlet dysfunction,[3] rectal outlet obstruction, outlet obstructive constipation, evacuatory dysfunction,[4] outlet constipation, pelvic outlet obstruction[5] pelvic constipation,[3] difficult evacuation,[3] functional obstructed defecation syndrome,[3]
SpecialtyGastroenterology, colorectal surgery / coloproctology

Obstructed defecation syndrome (abbreviated as ODS, with many synonymous terms) is a major cause of functional constipation (primary constipation),[6] of which it is considered a subtype.[7] It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week.[7] Functional constipation is usually defined as infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools,[8] and the colonic transit time may be normal (unlike slow transit constipation).[9]

Definitions

ODS is a loose term,[8] consisting of a constellation of possible symptoms,[5] caused by multiple, complex[10] and poorly understood[11] disorders which may include both functional and organic disorders.[6] Furthermore, many different terms have been used, which appear to refer to the same clinical entity. However, the term does not appear in the ICD-11 and Rome-IV classifications, which both instead refer to "functional defecation disorders". Occasionally some sources[12] inappropriately treat ODS as a synonym of anismus. Although anismus is a major cause of ODS, there are other possible causes.[7]

In 2001 the American Society of Colon and Rectal Surgeons (ASCRS), the Colorectal Surgical Society of Australia, and the Association of Coloproctology of Great Britain and Ireland published a consensus statement which covered definitions relevant to this topic.[13] A revised consensus statement was published by the ASCRS in 2018.[7] Wherever possible, this article generally follows the definitions and terminology of the 2018 consensus statement, wherein ODS is defined as "a subset of functional constipation in which patients report symptoms of incomplete rectal emptying with or without an actual reduction in the number of bowel movements per week."[7] ODS may or may not co-exist with other functional bowel disorders, such as slow transit constipation or irritable bowel syndrome.[7] Functional constipation is usually defined as infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools,[8] and the colonic transit time may be normal (unlike slow transit constipation).[9] Other authors use the term ODS to refer to defecatory dysfunction in the absence of any pathological findings (that is, a purely functional disorder).[14]

ICD-11

The term "obstructed defecation syndrome" does not appear in ICD-11. However, the following entries are present, as well as separate codes for most of the individual organic lesions listed in this article:

  • Functional anorectal disorders: "anorectal disorders which principally present anorectal and defecation complaints without apparent morphological changes of anorectal regions." A note is added: "However, the distinction between organic and functional anorectal disorders may be difficult to make in individual patients."[15]
  • Functional defecation disorders: this is listed as a sub-entry of functional anorectal disorders (above). It includes dyssynergic defecation (defined as "paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation"), and inadequate defecatory propulsion (defined as "inadequate propulsive forces during attempted defecation"). A note is added: "The patients must satisfy diagnostic criteria for functional constipation."[16]
  • Incomplete defecation: this entity (ME07.1) exists as a sub-code of fecal incontinence, with no definition.[17]

Rome-IV

The term "obstructed defecation syndrome" does not appear in the Rome IV classification. However diagnostic criteria for functional defecation disorders are listed.[18] According to Rome-IV, this is defined as "features of impaired evacuation" during repeated attempts to defecate.[18] To qualify for this diagnosis, patients must meet the Rome diagnostic criteria for functional constipation or irritable bowel syndrome with constipation (IBS-C).[18] Furthermore, 2 of the following 3 tests must be show abnormal results: balloon expulsion test, anorectal manometry or anal surface electromyography, or imaging (e.g. defecography).[18] Two subcategories exist within the functional defecation disorders category: Inadequate defecatory propulsive (F3a) and Dyssynergic defecation (F3b).[18] These are defined as "Inadequate propulsive forces as measured with manometry with or without inappropriate contraction of the anal sphincter and/or pelvic floor muscles",[18] and "Inappropriate contraction of the pelvic floor as measured with anal surface EMG or manometry with adequate propulsive forces during attempted defecation" respectively.[18] The subcategories F3a and F3b are defined by age- and gender-appropriate normal values for the technique.[18] For all of these Rome-IV diagnoses, diagnostic criteria must have been fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.[18]

Signs and symptoms

There is a constellation of possible symptoms.[5]

  • Straining,[10] and attempting to defecate for a long period of time
  • Use of, or dependence on, enemas and/or laxatives.[7]
  • Self-digitation.[10]
  • Posturing (the need to assume "unusual" posture).[19]
  • Frequent urge to defecate,[1] and frequent bowel movements/toilet visits,[20] where only fecal pellets may be passed.[8]
  • Conversely, there may reduced number of bowel movements per week.[7][3]
  • Abnormal stool texture, which may be anything from watery/loose (overflow diarrhea),[1] to fragmented,[10] very hard[7] or pellet-shaped.[1]
  • Sense of incomplete evacuation.[10] even with soft stools.[21]
  • Unsuccessful attempts at bowel movements.[3]
  • Painful bowel movements.[3]
  • Tenesmus.[10]
  • Bowel urgency.[10][8]
  • Feeling of occupation or "mass" in the vagina.[21]
  • Pelvic heaviness.[10]
  • Pelvic pain[21] and cramping.[1]
  • Bloating.[3]
  • Fecal incontinence,[21] which may occur after defecation.[8]
  • Urinary incontinence.[21]
  • Poor appetite and early satiety when eating.[1]

Fecal incontinence to gas, liquid, solid stool, or mucus in the presence of obstructed defecation symptoms may indicate occult rectal prolapse (i.e., rectal intussusception), internal/external anal sphincter dysfunction, or descending perineum syndrome.[5]

Self-digitation (digital help) is the use of the digits (fingers) to apply pressure in order to achieve defecation. Most people recognize the need for digitation as a symptom, and not a treatment.[8] Medical professionals generally do not recommend it, since it may lead to complications and is not very effective, only removing feces in the lower part of the rectum.[8] There are 3 methods: vaginal, perineal and rectal.[22] Gloves are used for hygiene.[8] Vaginal digitation is when the patient presses the posterior (back) wall of the vagina to support it, or to push the rectocele pouch from inside the vagina, which makes the anorectum straight and facilitates defecation.[10][8] "Milking" pressure can also be applied on the posterior vaginal wall.[8] Perineal digitation is pushing on the perineum, which acts to stimulate the transverse muscles of the perineum causing a reflex rectal contraction of the rectum which helps to evacuate the feces.[10] Rectal digitation is when patients insert a finger into the anus to "hook" out fecal pellets,[8] or to apply pressure to the walls of the anus and/or the rectum, or to support an obstructing anatomical defects such as a sigmoidocele. Possible complications of rectal digitation are injury of the lining of the rectum,[8] such as ulcerations with bleeding and discomfort, and anal fibrosis leading to a stricture.[10]

ODS may be a cause of incomplete evacuation of stool.[23] Normal emptying of rectal contents is 90-100%. Less than 90% evacuation could be defined as incomplete evacuation.

Causes

One review stated that the most common causes of disruption to the defecation cycle are associated with pregnancy and childbirth, gynaecological descent or neurogenic disturbances of the brain-bowel axis.[24] Patients with obstructed defecation appear to have impaired pelvic floor function.[25]

Specific causes include:

Dyssynergic defecation (anismus)

Dyssynergic defecation (anismus) is defined as "failure of striated muscles of the pelvic floor (the puborectalis muscle and the external anal sphincter) to relax appropriately during attempted defecation".[7] In extreme cases, when defecation is attempted, the muscles may contract instead of relaxing (paradoxical contraction).[7] Dyssynergic defecation may occur in up to 40% of all patients with constipation.[3]

"Celes"

The suffix ‘-cele’ is from ancient Greek, and means ‘tumor,’ ‘hernia,’ ‘swelling,’ or ‘cavity.’ More modern translations are ‘cystic cavity’ or ‘cystic protrusion.’[26] A cul-de-sac hernia (peritoneocele) is a herniation (protrusion) of peritoneal folds into the rectovaginal septum (the tissue between the rectum and the vagina) which does not contain any other abdominal organs.[7][26] An enterocele is a protrusion of peritoneal folds between the rectum and the vagina containing a loop of the small intestine.[7] It is abnormal descent of the small bowel in a deep pouch of Douglas.[8] A sigmoidocele is a protrusion of the peritoneum between the rectum and vagina that contains a loop of the sigmoid colon.[7] An omentocele is a protrusion of the omentum between the rectum and the vagina.[7] These conditions can additionally be described as internal (when visible only on defecography) or as external (when there is a rectocele or rectal prolapse which is visible without imaging).[7] If these abnormalities do no reduce spontaneously, the term perineal hernia is used.[26]

A peritoneocele usually originates in the posterior compartment of the pelvis, or sometimes it can be located anteriorly (in front) or laterally (on the side) to the vagina. In severe cases, during defecation peritoneal contents can protrude through into the vagina or rectum, or displace them. Symptoms are variable, depending on the severity and the location of the herniation, and may include incomplete evacuation of the rectum, heavy sensation in the pelvis, and constipation.[26]

Enterocoele may develop because of weakening pelvic floor, multiple pregnancies, hysterectomy, and long term chronic straining. Sometimes people have a developmental condition where the rectovaginal septum fails to completely fuse, and they have a congenitally deep pouch of Douglas.[8]

Diagnosis

Diagnosis is very challenging for clinicians, since most patients will simply complain of "constipation".[1] As discussed previously, there are many possible causes of ODS, which often may occur together in the same patient, and ODS may co-exist with other conditions such as slow-transit constipation.[1]

The two key features of obstructed defecation are:

  1. An inability to voluntarily evacuate rectal contents[9]
  2. Normal colonic transit time[9]

A five-item questionnaire was validated for diagnosis and grading of obstructed defecation syndrome.[23] The parameters were:

  1. Excessive straining
  2. Incomplete rectal evacuation
  3. Use of enemas and/or laxatives
  4. Vaginal-anal-perineal digitations (needing to press in the back wall of the vagina or on the perineum to aid defecation)
  5. Abdominal discomfort and/or pain

Dyssynergic defecation

Dyssynergic defecation may be detected clinically, by digital rectal examination.[3] Non relaxation or paradoxical contraction of the puborectalis muscle at the anorectal junction can be felt when the patient performs a Valsalva manoeuvre or evacuation.[3] The diagnosis can be confirmed by anal electromyography, anorectal manometry, and/or defecography.[7]

"Celes"

It is difficult to tell peritoneocele, enterocele and sigmoidocele apart from rectocele without imaging. Peritoneocele is the most difficult type of pelvic prolapse to detect by clinical examination. To improve visualization of peritoneocele during MR defecography, the patient should complete normal defecation and the rectal contrast material should be completely evacuated, because then the rectovaginal space widens and pushes the peritoneum and bowel loops inferiorly (lower).[26]

An enterocoele can be easily detected by a clinician during physical examination. Using a bidigital technique (one finger in the anus and another in the vagina), the mass of the enterocele can be felt to "slip upwards" between the fingers when squeezing together. If the patient coughs during this procedure, it is easier to detect.[8]

Classification

Obstructed defecation is one of the causes of chronic constipation.[25]

Outlet obstruction can be classified into four groups.[4]

Treatment

European consensus guidelines on management

In 2021 a consensus regarding approach to treatment of ODS was published. A panel of 31 surgeons from 12 European countries worked on the consensus. The members of the panel were all engaged in research and treatment of ODS, and were considered expert in the field of pelvic floor functional disorders. They came to a consensus on about 50% of controversial issues surrounding management of ODS, which enabled creation of a treatment algorithm. The algorithm was based around the condition of the function of the anal sphincter, the presence of dyssynergia and the presence of other abnormalities like rectocele, intussusception, etc.[27]

They unanimously agreed that surgery should be discouraged for pelvic floor dyssynergia, and instead that biofeedback/pelvic floor retraining was the first line treatment. When dyssynergia is present with major abnormalities like rectocele or rectal intussusception, biofeedback/pelvic floor retraining should be conducted prior to surgery.[27]

For patients with rectal intussusception and a large rectocele or enterocele the experts all preferred laparoscopic (transabdominal) ventral rectopexy with non resorbable mesh, regardless of the function of the sphincter. Especially in the case of poor sphincter function (e.g. some degree of fecal incontinence), they preferred to avoid transanal approach, because there is greater risk of further deterioration in continence function. In the event of failure of previous ventral rectopexy, the consensus was to repeat the same procedure again rather than carry out different procedures.[27]

For patients with large rectocele or enterocele only (i.e. no intussusception), there was no clear consensus about the best treatment. The experts did however agree that mesh should not be used for direct rectocele repair.[27]

Conservative (non-surgical)

Some authors state that treatment of ODS is mainly conservative.[10] Many such conservative (non surgical / medical) measures have been used to treat ODS:

Diet

Dietary measures are frequently used for ODS, including fiber diet, and drinking plenty of water.[10] It has been recommended to avoid foods like chocolate, which increase stool viscosity, making it more difficult to pass stools.[10] Bulk-forming laxatives are also frequently used for ODS.[10]

Pelvic floor rehabilitation / Biofeedback

Rectocele and recto-rectal intussusception can be treated by pelvic floor rehabilitation alone,[10] as long as they have not been present for a long time.[10] Larger and more significant examples of these organic/anatomical disorders require surgery to correct since they because contributing causes to ODS by themselves.[10] Biofeedback is used for anismus and rectal hyposensation.[10] Biofeedback therapy is reported to successfully treat abormal contraction and relaxation of muscles in the anorectum during defecation.[11] This allows some patients to stop straining, and to stop needing to self-digitate.[11] Pelvic floor and abdominal muscle relaxation exercises may also be useful to make evacuation easier.[10]

Psychotherapy / Psychological counselling

Psychological counselling is indicated for people with ODS and depression and/or anxiety.[10] Psychological techniques (guided imagery and relaxation) have been combined with ultrasound-guided biofeedback.[10] This "psycho-echo-biofeedback" approach was reported to be successful for 50% of patients after 2 years.[10]

Irrigation

Variously termed hydrocolontherapy,[10] lavage,[10] retrograde large bowel irrigation,[10] and rectal irrigation. This refers to the use of water to wash out the rectum. Usually this is done with warm water (or normal saline),[19] administered via a tube inserted into the anus.[10] Some authors report this treatment as effective and safe with no risk of side effects.[10] Self-administered enemas may however be abused, which can cause anorectal fibrosis and stricture, due to repeated microtrauma.[10] The disadvantages of this treatment are mainly social stigma and inconvenience. The water and stool may take some time to fully evacuate, especially with patients with obstructed defecation. People with reduced muscular strength of the anal sphincter may encounter problems with later leakage of the water mixed with stool, which may bring similar, socially devastating problems as seen with fecal incontinence. Overall this treatment may be dissatisfying to patients because of difficulty with cohabitation, travel, and work/study or leisure activities.

Transanal electrostimulation

Transanal electrostimulation is carried out at home with an anal probe and an electrostimulator.[10] It is a treatment for pudendal nerve neuropathy and rectal hyposensation.[10] Another new treatment combines biofeedback with transanal electrostimulation.[19]

Botox injections

Injection of 50 units of botulinum toxin A into the puborectalis muscle has been reported for anismus.[10] This procedure itself could be considered as minor surgery. Short term cure rate was approximately 50%.[10] Side effects were transient anal incontinence and hypotension.[10] Botox only lasts for about 3 months, meaning the procedure may only be temporary and it may have to be repeated.[citation needed]

Other measures

Anismus has been reported to be treated with yoga exercises.[10]

Prognosis

ODS generally has a benign prognosis, however it is distressing condition for patients.[27] The condition may severely reduce quality of life,[27] both socially and psychologically.[19] Symptoms persist for some patients despite conservative treatment,[6] and dissatisfactory outcomes are frequently reported after surgery.[27]

Epidemiology

ODS occurs in 7% of the adult population.[21] According to one report "evacuation disorders" are common, affecting 12–19% of North Americans.[3] Most patients with ODS are females.[10]

References

  1. ^ a b c d e f g h Steele, SR; Maykel, JA; Wexner, SD (11 August 2020). Clinical Decision Making in Colorectal Surgery (2nd ed.). Cham: Springer International Publishing. ISBN 978-3-319-65941-1.
  2. ^ Jani, B; Marsicano, E (May 2018). "Constipation: Evaluation and Management". Missouri medicine. 115 (3): 236–240. PMID 30228729.
  3. ^ a b c d e f g h i j k l Steele, SR; Hull, TL; Hyman, N; Maykel, JA; Read, TE; Whitlow, CB (20 November 2021). The ASCRS Textbook of Colon and Rectal Surgery (4th ed.). Cham, Switzerland: Springer Nature. ISBN 978-3-030-66049-9.
  4. ^ a b Zbar, Andrew P.; Wexner, Andrew P., eds. (2010). Coloproctology. New York: Springer. p. 140. ISBN 978-1-84882-755-4.
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