Obstructed Defecation
Obstructed defecation syndrome is a common, well-defined type of functional constipation. It is characterized by excessive straining at stool, incomplete rectal evacuation, and need for perineal splinting. It is often identified in association with variou
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Key Concepts • Obstructed defecation syndrome is characterized by excessive straining at stool, incomplete rectal evacuation, and perineal splinting. • The primary treatment for patients with obstructed defecation is dietary management and pelvic floor physical therapy. • The primary treatment of patients with overt pelvic prolapse and obstructed defecation is surgical repair of the prolapse. • Symptoms of obstructed defecation are not as reliably relieved as overt prolapse by surgical repair. • Ventral mesh rectopexy or stapled transanal rectal resection are alternative surgical procedures which may more reliably relieve obstructed defecation symptoms. • Sacral nerve stimulation may be an alternative for patients with rectal hyposensitivity and obstructed defecation failing non-operative management
Introduction Pelvic floor disorders are a frequent source of morbidity in the developed world [1]. This is a much more common problem for women and almost one quarter of women in the USA will complain of at least one pelvic floor disorder in their lifetime. The incidence increases with age, parity, and obesity. Demand for pelvic floor services is expected to grow at twice the population rate in the future [2–4]. Suffice it to say that all of the medical specialties will frequently manage patients with pelvic floor complaints however colorectal surgeons will assume a disproportionate share of the diagnosis and management of patients with persistent or refractory symptoms of pelvic floor dysfunction. Pelvic floor disorders typically present with overt pelvic organ prolapse and/or functional disorders of bowel or bladder evacuation. In the USA, 16 % and 9 % of women, respec-
tively, will experience bladder or bowel incontinence. Pelvic organ prolapse affects 3 % of women [2]. Approximately 12–27 % of adults will seek care for constipation related complaints in their lifetime and over $1 billion is spent annually on constipation related goods and services [5]. Typically, constipation in association with pelvic floor disorders is manifested as obstructed defecation. Obstructed defecation syndrome is a well-defined symptom complex consisting of excessive straining at stool, need for perineal splinting, and incomplete rectal evacuation [6–8]. Not uncommonly, different manifestations of constipation co-exist, hence, global hindgut and pelvic evaluation is required for those treating this complicated group of patients [9–12]. This chapter will focus on disordered bowel evacuation in general and specifically on obstructed defecation syndrome. A review will be undertaken of the clinicopathologic features and clinical evaluation of the disorder, its frequent association with other manifestations of pelvic floor dysfunction and the outcomes of medical and surgical therapy for the disorder.
Etiology of Constipation Lower gastrointestinal function involves the formation of stool, its transit through the hindgut and its subsequent expulsion from the body. As anyone involved in the care of the constipated patient knows, this is a complex and coo
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