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Obstructed defecation

Obstructed defecation syndrome (abbreviated as ODS, with many synonymous terms) is a major cause of functional constipation (primary constipation),[14] of which it is considered a subtype.[15] 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.[15] Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools,[16] and the colonic transit time may be normal (unlike slow transit constipation), but delayed in the rectum and sigmoid colon.[6]

Obstructed defecation syndrome
Other names
  • Functional obstructed defecation syndrome.[1]
  • Obstructed defecation.[2]
  • Obstructive defecation.[3]
  • Outlet obstruction.[4][note 1]
  • Anal outlet dysfunction.[1]
  • Rectal outlet obstruction.[5]
  • Anorectal outlet obstruction.[6]
  • Pelvic outlet obstruction.[7]
  • Outlet obstructive constipation.[8][note 2]
  • Outlet constipation.[9]
  • Pelvic constipation.[1]
  • Difficult evacuation.[1]
  • Obstructed evacuation.[10]
  • Evacuatory dysfunction.[7]
  • Rectal evacuatory dysfunction.[11]
  • Anorectal dysmotility.[6]
  • Dyschezia.[12]
  • Evacuation disorder.[9]
  • Fecal evacuation disorder.[13]
SpecialtyGastroenterology, colorectal surgery / coloproctology

Definitions and terminology edit

Definition and classification of constipation edit

Constipation is usually divided into two groups: primary and secondary.[17] Primary constipation is caused by disrupted regulation of neuromuscular function of in the colon and the rectum, and also disruption of brain–gut neuroenteric function.[17] Secondary constipation is caused by many other different factors such as diet, drugs, behavioral, endocrine, metabolic, neurological, and other disorders.[17] There are main subtypes of primary constipation which are recognized, although overlap exists (see: Co-existence of different constipation subtypes): dyssynergic defecation, slow transit constipation (colonic dysmotility) and irritable bowel syndrome with constipation.[17][6]

Definition and terminology of obstructed defecation syndrome edit

Obstructed defecation is one of the causes of chronic constipation.[18] ODS is a loose term,[16] consisting of a constellation of possible symptoms,[7] caused by multiple, complex[19] and poorly understood[20] disorders which may include both functional and organic disorders.[14] The topic of defecation disorders is very complicated, and there is a lot of confusion regarding terminology and classification in published literature.[9] Occasionally some sources[21] inappropriately treat ODS as a synonym of anismus.[9] Although anismus is a major cause of ODS, there are other possible causes.[15] Other authors use the term ODS to refer to defecatory dysfunction in the absence of any pathological findings (that is, a purely functional disorder).[22] Furthermore, many different terms have been used for ODS, which appear to refer to the same clinical entity. The term ODS does not appear in the ICD-11 and Rome-IV classifications, which both instead refer to "functional defecation disorders". One publication criticized such classifications as being ambiguous and based on symptoms rather than distinct etiopathological entities.[9] The authors suggested that "evacuation disorders" be used as a descriptive term, which would be subclassified to include all possible factors that may be contributory to the symptoms.[9]

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.[23] A revised consensus statement was published by the ASCRS in 2018.[15] Wherever possible, this article generally follows the definitions and terminology of the 2018 consensus statement,[note 3] 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."[15] 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,[16] and the colonic transit time may be normal (unlike slow transit constipation).[6]

Co-existence of different constipation subtypes edit

The ODS may or may not co-exist with other functional bowel disorders, such as slow transit constipation or irritable bowel syndrome.[15] Of all cases of primary constipation, it is reported that 58% are dyssynergic defecation, 47% are slow transit constipation and 58% are irritable bowel syndrome.[17] Significant overlap exists. For example, approximately 60% of patients with dyssynergic defecation also have STC.[17] In a study of 1,411 patients with chronic constipation referred to a tertiary center, 68% had normal transit constipation, 28% had evacuation disorders and less than 1% had slow transit constipation without any evacuation disorder.[17]

ICD-11 edit

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."[24]
  • 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."[25]
  • Incomplete defecation: this entity (ME07.1) exists as a sub-code of fecal incontinence, with no definition.[26]

Rome-IV edit

The term "obstructed defecation syndrome" does not appear in the Rome IV classification. However, diagnostic criteria for functional defecation disorders are listed.[27] According to Rome-IV, this is defined as "features of impaired evacuation" during repeated attempts to defecate.[27] To qualify for this diagnosis, patients must meet the Rome diagnostic criteria for functional constipation or irritable bowel syndrome with constipation (IBS-C).[27] Furthermore, 2 of the following 3 tests must show abnormal results: balloon expulsion test, anorectal manometry or anal surface electromyography, or imaging (e.g. defecography).[27] Two subcategories exist within the functional defecation disorders category: Inadequate defecatory propulsive (F3a) and Dyssynergic defecation (F3b).[27] 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",[27] and "Inappropriate contraction of the pelvic floor as measured with anal surface EMG or manometry with adequate propulsive forces during attempted defecation" respectively.[27] The subcategories F3a and F3b are defined by age- and gender-appropriate normal values for the technique.[27] 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.[27]

Signs and symptoms edit

There is a constellation of possible symptoms.[7]

  • Straining,[19] and attempting to defecate for a long period of time.[28]
  • Inability to voluntarily empty the rectum.[29]
  • Use of, or dependence on, enemas and/or laxatives.[15]
  • Self-digitation.[19]
  • Posturing (the need to assume "unusual" posture).[30]
  • Frequent urge to defecate,[3] and frequent bowel movements/toilet visits,[31] where only fecal pellets may be passed.[16]
  • Conversely, there may reduced number of bowel movements per week.[15][1]
  • Abnormal stool texture, which may be anything from watery/loose (overflow diarrhea),[3] to fragmented,[19] very hard[15] or pellet-shaped.[3]
  • Actual or subjective sensation of incomplete evacuation.[32][19] even with soft stools.[33]
  • Unsuccessful attempts at bowel movements.[1]
  • Painful bowel movements.[1]
  • Tenesmus.[19]
  • Bowel urgency.[19][16]
  • Feeling of occupation or "mass" in the vagina.[33]
  • Pelvic heaviness.[19]
  • Pelvic pain[33] and cramping.[3]
  • Bloating.[1]
  • Fecal incontinence,[33] which may occur after defecation.[16]
  • Urinary incontinence.[33]
  • Poor appetite and early satiety when eating.[3]

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.[7]

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.[16] 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.[16] There are 3 methods: vaginal, perineal and rectal.[11] Gloves are used for hygiene.[16] 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.[19][16] "Milking" pressure can also be applied on the posterior vaginal wall.[16] Perineal digitation (also termed "splinting"),[28] is pushing on the perineum (or buttocks), which acts to stimulate the transverse muscles of the perineum causing a reflex rectal contraction of the rectum which helps to evacuate the feces.[19] Rectal digitation is when patients insert a finger into the anus to "hook" out fecal pellets,[16] 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,[16] such as ulcerations with bleeding and discomfort, and anal fibrosis leading to a stricture.[19]

Pathophysiology edit

Relevant anatomy and physiology edit

In order to understand ODS, it is necessary to understand the normal anatomy and defecation process.[3][6]

The pelvic floor (pelvic diaphragm) can be divided into 4 compartments: Anterior or urinary (bladder, bladder neck, and urethra), Middle or genital (vagina and uterus in women, prostate in men), Posterior (anus, anal canal, sigmoid, and rectum), and Peritoneal (endopelvic fascia and perineal membrane).[34]

Defecation is a complex physiologic process,[3] involving interaction between neural processes, reflexes, colorectal contractility and the biomechanics of straining.[16]

When feces reach the rectum, the rectal walls become naturally distended, stimulating nerve receptors. Brain centres for defecation respond to this sensation and stimulate mass colonic movement in the colon and the rectum.[16] These mass contractions move feces along the colon and into the rectum.[16] Occasionally some straining helps, which normally transmits forces to the upper part of the rectum, and aids defecation.[16] Reflexive relaxation of the external anal sphincter is also triggered.[33] For defecation to occur, rectal pressure must be greater than pressure in the anal canal, which depends on the relaxation of the external anal sphincter, the puborectalis and the intra-abdominal force applied.[33] In normal defecation, the pressure in the rectum increases at the same time as the pressure in the anal canal falls, leading to a propulsive rectoanal pressure gradient (RAG).[22]

According to some experts in ODS, defecation should normally occur once per day.[16] However many sources assert that it is medically "normal" for bowel movements to occur anywhere between three times per week up to three times per day.[35]

Pathophysiology edit

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.[36] Patients with obstructed defecation appear to have impaired pelvic floor function.[18]

Causes edit

Classification edit

ODS can be classified into four groups.[7]

ODS may also be associated with solitary rectal ulcer syndrome.[38]

Discussion of specific causes edit

Dyssynergic defecation (anismus) edit

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".[15] In extreme cases, when defecation is attempted, the muscles may contract instead of relaxing (paradoxical contraction).[15] Dyssynergic defecation may occur in up to 40% of all patients with constipation.[1]

"Celes" edit

The suffix '-cele' is from ancient Greek, and means 'tumor', 'hernia', 'swelling', or 'cavity'. More modern translations are 'cystic cavity' or 'cystic protrusion'.[39] 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.[15][39] An enterocele is a protrusion of peritoneal folds between the rectum and the vagina containing a loop of the small intestine.[15] It is abnormal descent of the small bowel in a deep pouch of Douglas.[16] A sigmoidocele is a protrusion of the peritoneum between the rectum and vagina that contains a loop of the sigmoid colon.[15] An omentocele is a protrusion of the omentum between the rectum and the vagina.[15] 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).[15] If these abnormalities do no reduce spontaneously, the term perineal hernia is used.[39]

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.[39]

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.[16]

Rectal hyposensitivity edit

Also termed "blunted rectum",[12] rectal hyposensitivity is a relatively newly identified entity, defined as "elevation beyond the normal range in the perception of at least one of the sensory threshold volumes [required to elicit rectal sensations] during anorectal manometry."[40][41] There is blunted or reduced perception of distension of the rectum.[40] Conceptually there are two categories of rectal hyposensitivity: primary (dysfunction of the rectal afferent pathway, i.e. a true sensorimotor dysfunction), and hyposensitivity that is secondary to abnormal rectal structure (e.g. megarectum) or rectal biomechanical properties (e.g. rectal hypercompliance).[40] It may be caused by generalized neuropathies such as diabetes mellitus,[12] or by diseases which effect the central nervous system (the spinal cord or brain),[12] such as multiple sclerosis,[12] or Parkinson's disease.[40] Rectal hyposensitivity may also result from pelvic nerve injury (e.g. spinal trauma, pelvic surgery, anal surgery, hysterectomy or disc (L5-S1) surgery).[12][40] People with a history of severe sexual/physical abuse may have rectal hyposensitivity, theorized to reflect altered central processing of rectal sensation in response to painful rectal stimuli.[40] Rectal hyposensitivity is frequently associated with ODS, especially with dyssynergic defecation.[40] It is detected in about 23% of people with constipation overall.[40]

Psychological factors edit

Potential psychological factors which may contribute to ODS are anxiety, depression, post-traumatic stress and sexual abuse.[33] For example, one-third of females with ODS and proctalgia have a history of sexual trauma during childhood or adolescence.[19] Patients with ODS have a higher than normal level of psychiatric conditions, such as obsessive-compulsive disorder, phobia of stool, and eating disorders (such as anorexia nervosa or bulimia).[3] Many patients with ODS will report initiating stressful life events that worsened their constipation.[3] Such life stressors include new job, divorce, financial problems, sexual abuse or assault.[3]

Other neurological causes edit

Other neurological disorders may cause or contribute to ODS, such as dementia,[33] Parkinson's disease,[33] multiple sclerosis,[12] Hirschsprung disease,[12] acute cerebrovascular accident,[33] spinal lesion,[12] or spinal injury.[33] The rectoanal inhibitory reflex is inhibition of the internal anal sphincter. This reflex can be affected by Hirschsprung disease,[12] Chagas disease,[12] and hereditary myopathy of the internal anal sphincter.[12]

Anal stenosis edit

Anal stenosis (also termed anal stricture) is narrowing of the anal canal. According to one report, 88% of cases develop after by hemorrhoidectomy. However, overall it is a rare complication of hemorrhoidectomy (less than 1.5%).[17] Removal of too much anoderm and hemorrhoidal rectal mucosa during this procedure causes scarring and progressive narrowing. Other types of surgical procedure for recurrent anal fissures, abscesses and anal fistulae may cause anal stenosis. Other causes include Crohn's disease, radiotherapy, removal of perianal skin lesions e.g. in Paget disease or Bowen disease, tuberculosis, actinomycosis, lymphogranuloma, anal and rectal cancers and developmental abnormalities of the anus.[17] Some authors describe a "muscular" type of anal stenosis (i.e. a functional disorder). Functional anal stenosis disappears under anesthesia, whereas true anal stenosis does not. The main symptoms of anal stenosis are difficult evacuation of stool, narrow stools, painful defecation, need for self-digitation to achieve defecation, bleeding from anal tears, and constipation.[17]

Diagnosis edit

Diagnosis is very challenging for clinicians, since most patients will simply complain of "constipation".[3] 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.[3] As such, the first step in diagnosis is identification of organic causes of ODS and to identify possible slow transit constipation.[6] Also, patients may be too embarrassed to discuss their exact problems, especially with regards symptoms like digitation.[3]

The two key features of obstructed defecation are:

  1. An inability to voluntarily evacuate rectal contents.[29]
  2. Normal colonic transit time, but delayed transit in the rectum and sigmoid colon.[6]

Scoring systems edit

Scoring system are recommended in ODS to assess the severity of symptoms, to enable measurement of treatment outcomes, and to enable comparison of different treatment modalities in research. The Renzi ODS score is a five-item questionnaire. It has been validated for diagnosis and grading of ODS.[32] The parameters are:

  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

Another validated instrument is the Altomare ODS score.[42] There are 7 parameters, scored from 0-4:

  1. Mean time spent at the toilet
  2. Number of attempts to defaecate per day
  3. Anal/vaginal digitation
  4. Use of laxatives
  5. Use of enemas
  6. Incomplete/fragmented defaecation
  7. Straining at defaecation
  8. Stool consistency

Investigations edit

There are many different investigations which are used in the diagnosis of ODS. Some authors state that multiple different diagnostic tests are required because of the coexistence of multiple causative factors.[33] Extensive anorectal sensory and motor physiological testing may help to identify subgroups of patients in whom surgery may be more successful.[11] However, the financial costs of such testing is significant,[11] and the investigations only change the management in about 23% of cases.[11] Also, performing a full range of physiological tests of defecation function may not distinguish the different subtypes of constipation (of which ODS is only one).[41] Furthermore, such tests give frequent false-positive results in individuals without any symptoms.[3] For example, some have suggested that anismus is an over-diagnosed condition, since the standard investigations or digital rectal examination and anorectal manometry were shown to cause paradoxical sphincter contraction in healthy controls, who did not have constipation or incontinence.[43] Due to the invasive and perhaps uncomfortable nature of these investigations, the pelvic floor musculature is thought to behave differently than under normal circumstances. Therefore, paradoxical pelvic floor contraction is a common finding in healthy people as well as in people with chronic constipation and stool incontinence, and it may represent a non-specific finding or laboratory artifact related to untoward conditions during examination. They concluded that true anismus is actually rare.[43] Many of these tests assess simulated, rather than spontaneous, true defecation function.[9]

Specific investigations which have been used in ODS are:

Diagnostic approach for specific causes edit

Evacuation proctography edit

Evacuation proctography is the most common type of imaging used in the diagnosis of posterior pelvic floor disorders and ODS.[28] It is considered as the reference standard but it does not have perfect accuracy.[28] The technique also uses ionising radiation and is embarrassing and invasive for patients.[28]

Dyssynergic defecation edit

Dyssynergic defecation may be detected clinically, by digital rectal examination.[1] 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.[1] The diagnosis can be confirmed by anal electromyography, anorectal manometry, and/or defecography.[15]

"Celes" edit

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).[39]

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.[16]

Treatment edit

It is suggested that a multidisciplinary approach is the best way to treat ODS.[19][14] For example, a team composed of a gynecologist or urogynecologist, gastroenterologist and colorectal surgeon.[20] The general goal of treatment is to improve defecation mechanics and stool texture.[3] This will give marked improvement in quality of life for most patients with ODS.[3]

Conservative management versus surgery edit

Treatment may be conservative or surgical.[14] The exact way of managing ODS is controversial, with many authors now taking positions against surgery as a first line treatment for ODS, while others state that surgery should be used as a last resort,[6] not be used at all, or take a more pro-surgery position. Treating ODS can be extremely challenging and time-consuming.[3] It is rare that ODS is "cured" with one intervention or in a single setting.[3]

The underlying, original causes of ODS are typically psychological, muscular and/or neurological.[19] Such causes require complex, long term treatment.[19] Some authors have suggested that surgically correctable anatomical disorders which are detected in ODS patients may actually represent effects, rather than causes of ODS.[19] Furthermore, the complexity of this condition means it takes a lot of time to understand it.[16] However, both patients and surgeons prefer faster solutions like surgical procedures.[16] It has been suggested that this is the reason why most, if not all surgical procedures are unsuccessful in the long term.[19] In other words, the detectable anatomical defects can be restored surgically, but this does not mean that the function is also restored.[19] Others report that the outcomes of non-surgical methods have conflicting results, and their effects are not significant.[30]

Most authors now recommend a combination of different conservative measures.[14] If conservative fail to improve symptoms, management can be supported, where strictly indicated, with surgical procedures as a secondary treatment.[19][14] This approach reflects the multifactorial nature of ODS, where the exact approach to treatment is individualized to each patient. For example, in a patient with isolated dyssynergic defecation and no other anatomical defect, surgery is contraindicated, however where ODS is caused by a neoplastic tumor or external prolapse, surgery is usually strongly indicated.[6] Some stress that it is important for clinicians to set realistic and honest goals with patients.[3]

Overall it is reported that nearly 20% of patients need surgical treatment.[19] Surgery is said to be overused to treat ODS, with more than 50% of patients undergoing the stapled transanal rectal resection (STARR) procedure.[19] There are many different surgical treatments which have been attempted to treat ODS.[30] Some authors state that the vast number of reported surgical treatments that have been used for ODS indicate that surgery is an unsuccessful treatment for ODS.[citation needed]

European consensus guidelines on management edit

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.[44]

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 before attempting surgery.[44]

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.[44]

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.[44]

Conservative (non-surgical) edit

Some authors state that treatment of ODS is mainly conservative.[19] Many such conservative (non surgical / medical) measures have been used to treat ODS:

Diet edit

Dietary measures are frequently used for ODS as the first line treatment.[3] The aim is to improve stool texture.[3] It has been recommended to avoid foods like chocolate, which increase stool viscosity, making it more difficult to pass stools.[19] Bulk-forming laxatives are also frequently used for ODS.[19]

It is recommended to increase dietary fiber intake to 25-30 grams daily. This may be slowly increased up to a level of 50 grams per day. This is usually achieved with high-fiber cereal and fiber powder supplements such as psyllium, methylcellulose, polycarbophil, or wheat dextrin.[3] However, fibre supplementation only fractionally increases gut transit and stool bulk.[11] The effect may take several weeks to become apparent.[11] Other authors report that a high fiber diet rarely helps ODS symptoms, and may make them worse.[6]

Patients with ODS are often advised to drink plenty of water.[19] 1-2 liters of water per day is recommended, especially in warmer climates or warmer weather.[3]

Biofeedback / Pelvic floor rehabilitation edit

Biofeedback is a learning strategy which is based on operant conditioning. The main goal is to improve abdominal and pelvic floor coordination. This is usually done by giving the patient visual or auditory feedback about muscular contraction during attempted defecation maneuvers, as well as verbal feedback about posture and diaphragmatic breathing.[6] Biofeedback can successfully treat abnormal contraction and relaxation of muscles in the anorectum during defecation.[20] This enables normal peristalsis instead of abnormal contraction and retrograde movement of bowel contents.[11]

Biofeedback is now one of the most popular treatments for ODS, particularly because it is safe.[6] It is most beneficial for patients with dyssynergic defecation.[11] It is also used for rectal hyposensation.[19] Rectocele and recto-rectal intussusception can sometimes be treated by pelvic floor rehabilitation alone,[19] as long as they have not been present for a long time.[19] Larger and more significant examples of these organic/anatomical disorders require surgery to correct since they because contributing causes to ODS by themselves.[19] Regardless, this treatment seems to be beneficial both for patients with mild symptoms, and for those with severe symptoms which are unresponsive to other conservative measures and who are being considered for surgery.[11]

Biofeedback has been shown to improve symptoms (improved frequency of bowel movements, reduced straining) and also reduce need for laxatives,[11] and patients stop needing to self-digitate.[20] Researchers demonstrated that patients who had positive results with biofeedback had evidence of improved autonomic innervation of the colon, increased colonic transit time, and had increased quality of life scores.[11] Overall, biofeedback is reported to have about 70% success rate for pelvic floor dyssynergia (dyssynergic defecation).[29] The success of biofeedback for patients with ODS caused by mechanical defects is not well known.[29]

For patients who do not undergo biofeedback, simple pelvic floor and abdominal muscle relaxation exercises may also be useful to make evacuation easier.[19]

Psychotherapy / Psychological counselling edit

Psychological counselling is indicated for people with ODS and depression and/or anxiety.[19] Psychological techniques (guided imagery and relaxation) have been combined with ultrasound-guided biofeedback.[19] This "psycho-echo-biofeedback" approach was reported to be successful for 50% of patients after 2 years.[19]

Irrigation edit

Variously termed hydrocolontherapy,[19] lavage,[19] retrograde large bowel irrigation,[19] 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),[30] administered via a tube inserted into the anus.[19] Some authors report this treatment as effective and safe with no risk of side effects.[19] Self-administered enemas may however be abused, which can cause anorectal fibrosis and stricture, due to repeated microtrauma.[19] 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 edit

Transanal electrostimulation is carried out at home with an anal probe and an electrostimulator.[19] It is a treatment for pudendal nerve neuropathy and rectal hyposensation.[19] Another new treatment combines biofeedback with transanal electrostimulation.[30]

Botox injections edit

Injection of 50-60 units of botulinum toxin A into the puborectalis muscle has been reported for anismus,[19] and ODS.[3] The botulinum toxin is injected under ultrasound guidance into two sites on both sides of the puborectalis muscle.[3] This procedure itself could be considered as minor surgery, although in the studies reporting this technique, patients were not sedated or given local anesthetic.[3] Short term cure rate was approximately 50%.[19] Another study reported 79% of patients had improved symptoms, and had broadening of the anorectal angle demonstrated on defecography.[3] Side effects are transient anal incontinence and hypotension.[19] The effects of Botox only last for about 3 months, meaning the procedure may only be temporary and it may have to be repeated.[3]

Other measures edit

Anismus has been reported to be treated with yoga exercises.[19]

Surgical edit

Surgical procedures can be considered in three groups: transvaginal, transabdominal and transanal; or as either manual techniques or stapling procedures. No surgical procedure has been demonstrated to be the best, and each has advantages and disadvantages.[30] There are no widely accepted selection criteria for these surgical procedures.[30]

Partial division of puborectalis muscle edit

This transanal manual procedure aims to relax the tension of a hypertrophic (overdeveloped) puborectalis muscle.[30] The partial division can be done laterally (on one side) or at the posterior midline (in the middle at the back of the muscle).[30] There are some positive reports of this proceudre, which was said to be more effective compared to non surgical treatments such as biofeedback and botulinom toxin A injections.[30] However other reports state that this method is disappointing, failing to improve ODS symptoms for most patients.[30] There is a high risk of fecal incontinence after this surgery and it is generally no longer recommended.[45]

Ventral mesh rectopexy edit

Ventral mesh rectopexy has become popular for rectal prolapse, internal rectal prolapse and ODS, especially in Europe.[46] It is also used for rectoceles,[47] solitary rectal ulcer syndrome,[48] and can be combined with procedures for vaginal prolapse, for example sacrocolpopexy.[47] The predecessor of this procedure was sutured posterior rectopexy, in which the rectum was completely mobilized from the pelvic floor (i.e. including posterior and lateral surgical dissection of the rectum and sigmoid colon).[46] This caused autonomic nerve damage resulting in constipation and obstructed defecation after the surgery.[46] Ventral rectopexy was developed in 2004 as a modification which would not destroy these nerves, since only the ventral/anterior surface (the front surface) is mobilized.[46] A mesh is placed between the anterior wall of the rectum and the vagina.[46] The mesh is then fixed to the sacrum,[49] and the vaginal vault is fixed to the mesh. The mech reinforces the anterior rectal wall, which aims to prevent recurrence of enterocele, intussusception and rectocele.[46] The pouch of Douglas is lost in the process.[46] As such, the aims of the procedure are surgical correction of prolapse of the posterior (rectum + sigmoid colon) and middle (female reproductive organs) pelvic compartments, elevation of the pelvic floor, and reinforcement of the vaginal septum / anterior rectal wall.[47] The procedure is usually performed laparoscopically.[49] The procedure reduces constipation and fecal incontinence in patients with rectal prolapse or rectal intussusception, and has a low rate of complications and recurrence.[49] The procedure is able to correct multiple anatomical defects associated with vaginal and rectal prolapse, as well as improving function in terms of continence and defecation.[47]

Prognosis edit

ODS generally has a benign prognosis, however it is a distressing condition for patients.[44] The condition may severely reduce quality of life,[44] both socially and psychologically,[30] and also reduce sexual well-being.[28] Symptoms persist for some patients despite conservative treatment,[14] and dissatisfactory outcomes are frequently reported after surgery.[44]

Epidemiology edit

Constipation as a general complaint is very common. The ODS subtype is also known to be a common problem,[1] but the exact reported epidemiological figures vary.[12] It is estimated that approximately a third of patients complaining of constipation have the ODS subtype, which is more than slow transit constipation.[12] Some reported or estimated figures include:

  • 7% of adults.[33]
  • 10–20% of adults.[2]
  • 12–19% of North Americans.[1]
  • Up to 30% of the population.[12]

The prevalence is greater in older people of both sexes, especially women. Overall, most patients with ODS are females.[19] Some of the reasons for this female predilection are thought to be related to trauma from childbirth through vaginal delivery, menopausal tissue changes and hysterectomy.[12] However, a not insignificant proportion of patients with ODS are males or nulliparous females (i.e. have never given birth).[2]

Notes edit

  1. ^ "Outlet obstruction" may also refer to disorders of the bladder (bladder outlet obstruction) or the stomach (gastric outlet obstruction).
  2. ^ "Outlet obstructive constipation" (OOC) appears to be the standardized term used in Chinese publications.
  3. ^ With the exception of substitution of the term "anismus", which is used in the ASCRS consensus statement. Many publications instead use the term "dyssynergic defecation", notably ICD-11 and Rome-IV. Some authors have expressed disapproval of the continuned use of the term "anismus".

References edit

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obstructed, defecation, syndrome, abbreviated, with, many, synonymous, terms, major, cause, functional, constipation, primary, constipation, which, considered, subtype, characterized, difficult, incomplete, emptying, rectum, with, without, actual, reduction, n. Obstructed defecation syndrome abbreviated as ODS with many synonymous terms is a major cause of functional constipation primary constipation 14 of which it is considered a subtype 15 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 15 Normal definitions of functional constipation include infrequent bowel movements and hard stools In contrast ODS may occur with frequent bowel movements and even with soft stools 16 and the colonic transit time may be normal unlike slow transit constipation but delayed in the rectum and sigmoid colon 6 Obstructed defecation syndromeOther namesFunctional obstructed defecation syndrome 1 Obstructed defecation 2 Obstructive defecation 3 Outlet obstruction 4 note 1 Anal outlet dysfunction 1 Rectal outlet obstruction 5 Anorectal outlet obstruction 6 Pelvic outlet obstruction 7 Outlet obstructive constipation 8 note 2 Outlet constipation 9 Pelvic constipation 1 Difficult evacuation 1 Obstructed evacuation 10 Evacuatory dysfunction 7 Rectal evacuatory dysfunction 11 Anorectal dysmotility 6 Dyschezia 12 Evacuation disorder 9 Fecal evacuation disorder 13 SpecialtyGastroenterology colorectal surgery coloproctology Contents 1 Definitions and terminology 1 1 Definition and classification of constipation 1 2 Definition and terminology of obstructed defecation syndrome 1 3 Co existence of different constipation subtypes 1 4 ICD 11 1 5 Rome IV 2 Signs and symptoms 3 Pathophysiology 3 1 Relevant anatomy and physiology 3 2 Pathophysiology 4 Causes 4 1 Classification 4 2 Discussion of specific causes 4 2 1 Dyssynergic defecation anismus 4 2 2 Celes 4 2 3 Rectal hyposensitivity 4 2 4 Psychological factors 4 2 5 Other neurological causes 4 2 6 Anal stenosis 5 Diagnosis 5 1 Scoring systems 5 2 Investigations 5 3 Diagnostic approach for specific causes 5 3 1 Evacuation proctography 5 3 2 Dyssynergic defecation 5 3 3 Celes 6 Treatment 6 1 Conservative management versus surgery 6 2 European consensus guidelines on management 6 3 Conservative non surgical 6 3 1 Diet 6 3 2 Biofeedback Pelvic floor rehabilitation 6 3 3 Psychotherapy Psychological counselling 6 3 4 Irrigation 6 3 5 Transanal electrostimulation 6 3 6 Botox injections 6 3 7 Other measures 6 4 Surgical 6 4 1 Partial division of puborectalis muscle 6 4 2 Ventral mesh rectopexy 7 Prognosis 8 Epidemiology 9 Notes 10 ReferencesDefinitions and terminology editDefinition and classification of constipation edit Constipation is usually divided into two groups primary and secondary 17 Primary constipation is caused by disrupted regulation of neuromuscular function of in the colon and the rectum and also disruption of brain gut neuroenteric function 17 Secondary constipation is caused by many other different factors such as diet drugs behavioral endocrine metabolic neurological and other disorders 17 There are main subtypes of primary constipation which are recognized although overlap exists see Co existence of different constipation subtypes dyssynergic defecation slow transit constipation colonic dysmotility and irritable bowel syndrome with constipation 17 6 Definition and terminology of obstructed defecation syndrome edit Obstructed defecation is one of the causes of chronic constipation 18 ODS is a loose term 16 consisting of a constellation of possible symptoms 7 caused by multiple complex 19 and poorly understood 20 disorders which may include both functional and organic disorders 14 The topic of defecation disorders is very complicated and there is a lot of confusion regarding terminology and classification in published literature 9 Occasionally some sources 21 inappropriately treat ODS as a synonym of anismus 9 Although anismus is a major cause of ODS there are other possible causes 15 Other authors use the term ODS to refer to defecatory dysfunction in the absence of any pathological findings that is a purely functional disorder 22 Furthermore many different terms have been used for ODS which appear to refer to the same clinical entity The term ODS does not appear in the ICD 11 and Rome IV classifications which both instead refer to functional defecation disorders One publication criticized such classifications as being ambiguous and based on symptoms rather than distinct etiopathological entities 9 The authors suggested that evacuation disorders be used as a descriptive term which would be subclassified to include all possible factors that may be contributory to the symptoms 9 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 23 A revised consensus statement was published by the ASCRS in 2018 15 Wherever possible this article generally follows the definitions and terminology of the 2018 consensus statement note 3 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 15 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 16 and the colonic transit time may be normal unlike slow transit constipation 6 Co existence of different constipation subtypes edit The ODS may or may not co exist with other functional bowel disorders such as slow transit constipation or irritable bowel syndrome 15 Of all cases of primary constipation it is reported that 58 are dyssynergic defecation 47 are slow transit constipation and 58 are irritable bowel syndrome 17 Significant overlap exists For example approximately 60 of patients with dyssynergic defecation also have STC 17 In a study of 1 411 patients with chronic constipation referred to a tertiary center 68 had normal transit constipation 28 had evacuation disorders and less than 1 had slow transit constipation without any evacuation disorder 17 ICD 11 edit 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 24 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 25 Incomplete defecation this entity ME07 1 exists as a sub code of fecal incontinence with no definition 26 Rome IV edit The term obstructed defecation syndrome does not appear in the Rome IV classification However diagnostic criteria for functional defecation disorders are listed 27 According to Rome IV this is defined as features of impaired evacuation during repeated attempts to defecate 27 To qualify for this diagnosis patients must meet the Rome diagnostic criteria for functional constipation or irritable bowel syndrome with constipation IBS C 27 Furthermore 2 of the following 3 tests must show abnormal results balloon expulsion test anorectal manometry or anal surface electromyography or imaging e g defecography 27 Two subcategories exist within the functional defecation disorders category Inadequate defecatory propulsive F3a and Dyssynergic defecation F3b 27 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 27 and Inappropriate contraction of the pelvic floor as measured with anal surface EMG or manometry with adequate propulsive forces during attempted defecation respectively 27 The subcategories F3a and F3b are defined by age and gender appropriate normal values for the technique 27 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 27 Signs and symptoms editThere is a constellation of possible symptoms 7 Straining 19 and attempting to defecate for a long period of time 28 Inability to voluntarily empty the rectum 29 Use of or dependence on enemas and or laxatives 15 Self digitation 19 Posturing the need to assume unusual posture 30 Frequent urge to defecate 3 and frequent bowel movements toilet visits 31 where only fecal pellets may be passed 16 Conversely there may reduced number of bowel movements per week 15 1 Abnormal stool texture which may be anything from watery loose overflow diarrhea 3 to fragmented 19 very hard 15 or pellet shaped 3 Actual or subjective sensation of incomplete evacuation 32 19 even with soft stools 33 Unsuccessful attempts at bowel movements 1 Painful bowel movements 1 Tenesmus 19 Bowel urgency 19 16 Feeling of occupation or mass in the vagina 33 Pelvic heaviness 19 Pelvic pain 33 and cramping 3 Bloating 1 Fecal incontinence 33 which may occur after defecation 16 Urinary incontinence 33 Poor appetite and early satiety when eating 3 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 7 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 16 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 16 There are 3 methods vaginal perineal and rectal 11 Gloves are used for hygiene 16 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 19 16 Milking pressure can also be applied on the posterior vaginal wall 16 Perineal digitation also termed splinting 28 is pushing on the perineum or buttocks which acts to stimulate the transverse muscles of the perineum causing a reflex rectal contraction of the rectum which helps to evacuate the feces 19 Rectal digitation is when patients insert a finger into the anus to hook out fecal pellets 16 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 16 such as ulcerations with bleeding and discomfort and anal fibrosis leading to a stricture 19 Pathophysiology editRelevant anatomy and physiology edit In order to understand ODS it is necessary to understand the normal anatomy and defecation process 3 6 The pelvic floor pelvic diaphragm can be divided into 4 compartments Anterior or urinary bladder bladder neck and urethra Middle or genital vagina and uterus in women prostate in men Posterior anus anal canal sigmoid and rectum and Peritoneal endopelvic fascia and perineal membrane 34 Defecation is a complex physiologic process 3 involving interaction between neural processes reflexes colorectal contractility and the biomechanics of straining 16 When feces reach the rectum the rectal walls become naturally distended stimulating nerve receptors Brain centres for defecation respond to this sensation and stimulate mass colonic movement in the colon and the rectum 16 These mass contractions move feces along the colon and into the rectum 16 Occasionally some straining helps which normally transmits forces to the upper part of the rectum and aids defecation 16 Reflexive relaxation of the external anal sphincter is also triggered 33 For defecation to occur rectal pressure must be greater than pressure in the anal canal which depends on the relaxation of the external anal sphincter the puborectalis and the intra abdominal force applied 33 In normal defecation the pressure in the rectum increases at the same time as the pressure in the anal canal falls leading to a propulsive rectoanal pressure gradient RAG 22 According to some experts in ODS defecation should normally occur once per day 16 However many sources assert that it is medically normal for bowel movements to occur anywhere between three times per week up to three times per day 35 Pathophysiology edit 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 36 Patients with obstructed defecation appear to have impaired pelvic floor function 18 Causes editClassification edit ODS can be classified into four groups 7 Functional outlet obstruction Inefficient inhibition of the internal anal sphincterShort segment Hirschsprung s disease Chagas disease Hereditary internal sphincter myopathy Inefficient relaxation of the striated pelvic floor muscles Anismus pelvic floor dyssynergia 36 Multiple sclerosis Spinal cord lesions dd Mechanical outlet obstruction Internal intussusception Enterocele Rectal or anal cancer 37 Anal stenosis 17 dd Dissipation of force vector Rectocele 36 Descending perineum syndrome 37 Rectal prolapse dd Impaired rectal sensitivity Megarectum Rectal hyposensitivity dd ODS may also be associated with solitary rectal ulcer syndrome 38 Discussion of specific causes edit Dyssynergic defecation anismus edit 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 15 In extreme cases when defecation is attempted the muscles may contract instead of relaxing paradoxical contraction 15 Dyssynergic defecation may occur in up to 40 of all patients with constipation 1 Celes edit The suffix cele is from ancient Greek and means tumor hernia swelling or cavity More modern translations are cystic cavity or cystic protrusion 39 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 15 39 An enterocele is a protrusion of peritoneal folds between the rectum and the vagina containing a loop of the small intestine 15 It is abnormal descent of the small bowel in a deep pouch of Douglas 16 A sigmoidocele is a protrusion of the peritoneum between the rectum and vagina that contains a loop of the sigmoid colon 15 An omentocele is a protrusion of the omentum between the rectum and the vagina 15 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 15 If these abnormalities do no reduce spontaneously the term perineal hernia is used 39 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 39 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 16 Rectal hyposensitivity edit Also termed blunted rectum 12 rectal hyposensitivity is a relatively newly identified entity defined as elevation beyond the normal range in the perception of at least one of the sensory threshold volumes required to elicit rectal sensations during anorectal manometry 40 41 There is blunted or reduced perception of distension of the rectum 40 Conceptually there are two categories of rectal hyposensitivity primary dysfunction of the rectal afferent pathway i e a true sensorimotor dysfunction and hyposensitivity that is secondary to abnormal rectal structure e g megarectum or rectal biomechanical properties e g rectal hypercompliance 40 It may be caused by generalized neuropathies such as diabetes mellitus 12 or by diseases which effect the central nervous system the spinal cord or brain 12 such as multiple sclerosis 12 or Parkinson s disease 40 Rectal hyposensitivity may also result from pelvic nerve injury e g spinal trauma pelvic surgery anal surgery hysterectomy or disc L5 S1 surgery 12 40 People with a history of severe sexual physical abuse may have rectal hyposensitivity theorized to reflect altered central processing of rectal sensation in response to painful rectal stimuli 40 Rectal hyposensitivity is frequently associated with ODS especially with dyssynergic defecation 40 It is detected in about 23 of people with constipation overall 40 Psychological factors edit Potential psychological factors which may contribute to ODS are anxiety depression post traumatic stress and sexual abuse 33 For example one third of females with ODS and proctalgia have a history of sexual trauma during childhood or adolescence 19 Patients with ODS have a higher than normal level of psychiatric conditions such as obsessive compulsive disorder phobia of stool and eating disorders such as anorexia nervosa or bulimia 3 Many patients with ODS will report initiating stressful life events that worsened their constipation 3 Such life stressors include new job divorce financial problems sexual abuse or assault 3 Other neurological causes edit Other neurological disorders may cause or contribute to ODS such as dementia 33 Parkinson s disease 33 multiple sclerosis 12 Hirschsprung disease 12 acute cerebrovascular accident 33 spinal lesion 12 or spinal injury 33 The rectoanal inhibitory reflex is inhibition of the internal anal sphincter This reflex can be affected by Hirschsprung disease 12 Chagas disease 12 and hereditary myopathy of the internal anal sphincter 12 Anal stenosis edit Anal stenosis also termed anal stricture is narrowing of the anal canal According to one report 88 of cases develop after by hemorrhoidectomy However overall it is a rare complication of hemorrhoidectomy less than 1 5 17 Removal of too much anoderm and hemorrhoidal rectal mucosa during this procedure causes scarring and progressive narrowing Other types of surgical procedure for recurrent anal fissures abscesses and anal fistulae may cause anal stenosis Other causes include Crohn s disease radiotherapy removal of perianal skin lesions e g in Paget disease or Bowen disease tuberculosis actinomycosis lymphogranuloma anal and rectal cancers and developmental abnormalities of the anus 17 Some authors describe a muscular type of anal stenosis i e a functional disorder Functional anal stenosis disappears under anesthesia whereas true anal stenosis does not The main symptoms of anal stenosis are difficult evacuation of stool narrow stools painful defecation need for self digitation to achieve defecation bleeding from anal tears and constipation 17 Diagnosis editDiagnosis is very challenging for clinicians since most patients will simply complain of constipation 3 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 3 As such the first step in diagnosis is identification of organic causes of ODS and to identify possible slow transit constipation 6 Also patients may be too embarrassed to discuss their exact problems especially with regards symptoms like digitation 3 The two key features of obstructed defecation are An inability to voluntarily evacuate rectal contents 29 Normal colonic transit time but delayed transit in the rectum and sigmoid colon 6 Scoring systems edit Scoring system are recommended in ODS to assess the severity of symptoms to enable measurement of treatment outcomes and to enable comparison of different treatment modalities in research The Renzi ODS score is a five item questionnaire It has been validated for diagnosis and grading of ODS 32 The parameters are Excessive straining Incomplete rectal evacuation Use of enemas and or laxatives Vaginal anal perineal digitations needing to press in the back wall of the vagina or on the perineum to aid defecation Abdominal discomfort and or pain Another validated instrument is the Altomare ODS score 42 There are 7 parameters scored from 0 4 Mean time spent at the toilet Number of attempts to defaecate per day Anal vaginal digitation Use of laxatives Use of enemas Incomplete fragmented defaecation Straining at defaecation Stool consistency Investigations edit There are many different investigations which are used in the diagnosis of ODS Some authors state that multiple different diagnostic tests are required because of the coexistence of multiple causative factors 33 Extensive anorectal sensory and motor physiological testing may help to identify subgroups of patients in whom surgery may be more successful 11 However the financial costs of such testing is significant 11 and the investigations only change the management in about 23 of cases 11 Also performing a full range of physiological tests of defecation function may not distinguish the different subtypes of constipation of which ODS is only one 41 Furthermore such tests give frequent false positive results in individuals without any symptoms 3 For example some have suggested that anismus is an over diagnosed condition since the standard investigations or digital rectal examination and anorectal manometry were shown to cause paradoxical sphincter contraction in healthy controls who did not have constipation or incontinence 43 Due to the invasive and perhaps uncomfortable nature of these investigations the pelvic floor musculature is thought to behave differently than under normal circumstances Therefore paradoxical pelvic floor contraction is a common finding in healthy people as well as in people with chronic constipation and stool incontinence and it may represent a non specific finding or laboratory artifact related to untoward conditions during examination They concluded that true anismus is actually rare 43 Many of these tests assess simulated rather than spontaneous true defecation function 9 Specific investigations which have been used in ODS are Digital rectal exam Anoscopy 3 Colonoscopy 30 Defecography 19 Simultaneous pelvicography and colpocystodefecography PCCD defecography voiding cystography vaginal opacification and pelvicography 30 Entero defecography 19 Magnetic resonance imaging defecography 19 Anorectal manometry 19 Balloon expulsion test 19 Transanal vaginal ultrasound 19 Dynamic perineal ultrasound 19 Pudendal nerve motor latency test 19 Psychological evaluation 19 Gastrointestinal transit time GITT assay 30 Anal surface electromyography 30 Diagnostic approach for specific causes edit Evacuation proctography edit Evacuation proctography is the most common type of imaging used in the diagnosis of posterior pelvic floor disorders and ODS 28 It is considered as the reference standard but it does not have perfect accuracy 28 The technique also uses ionising radiation and is embarrassing and invasive for patients 28 Dyssynergic defecation edit Dyssynergic defecation may be detected clinically by digital rectal examination 1 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 1 The diagnosis can be confirmed by anal electromyography anorectal manometry and or defecography 15 Celes edit 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 39 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 16 Treatment editIt is suggested that a multidisciplinary approach is the best way to treat ODS 19 14 For example a team composed of a gynecologist or urogynecologist gastroenterologist and colorectal surgeon 20 The general goal of treatment is to improve defecation mechanics and stool texture 3 This will give marked improvement in quality of life for most patients with ODS 3 Conservative management versus surgery edit Treatment may be conservative or surgical 14 The exact way of managing ODS is controversial with many authors now taking positions against surgery as a first line treatment for ODS while others state that surgery should be used as a last resort 6 not be used at all or take a more pro surgery position Treating ODS can be extremely challenging and time consuming 3 It is rare that ODS is cured with one intervention or in a single setting 3 The underlying original causes of ODS are typically psychological muscular and or neurological 19 Such causes require complex long term treatment 19 Some authors have suggested that surgically correctable anatomical disorders which are detected in ODS patients may actually represent effects rather than causes of ODS 19 Furthermore the complexity of this condition means it takes a lot of time to understand it 16 However both patients and surgeons prefer faster solutions like surgical procedures 16 It has been suggested that this is the reason why most if not all surgical procedures are unsuccessful in the long term 19 In other words the detectable anatomical defects can be restored surgically but this does not mean that the function is also restored 19 Others report that the outcomes of non surgical methods have conflicting results and their effects are not significant 30 Most authors now recommend a combination of different conservative measures 14 If conservative fail to improve symptoms management can be supported where strictly indicated with surgical procedures as a secondary treatment 19 14 This approach reflects the multifactorial nature of ODS where the exact approach to treatment is individualized to each patient For example in a patient with isolated dyssynergic defecation and no other anatomical defect surgery is contraindicated however where ODS is caused by a neoplastic tumor or external prolapse surgery is usually strongly indicated 6 Some stress that it is important for clinicians to set realistic and honest goals with patients 3 Overall it is reported that nearly 20 of patients need surgical treatment 19 Surgery is said to be overused to treat ODS with more than 50 of patients undergoing the stapled transanal rectal resection STARR procedure 19 There are many different surgical treatments which have been attempted to treat ODS 30 Some authors state that the vast number of reported surgical treatments that have been used for ODS indicate that surgery is an unsuccessful treatment for ODS citation needed European consensus guidelines on management edit 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 44 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 before attempting surgery 44 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 44 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 44 Conservative non surgical edit Some authors state that treatment of ODS is mainly conservative 19 Many such conservative non surgical medical measures have been used to treat ODS Biofeedback 19 also termed Pelvic floor rehabilitation 14 Dietary measures 14 especially high fiber diet 19 30 Bulking laxatives 19 Rectal irrigation 19 Transanal electrostimulation 19 Yoga 19 Psychotherapy 19 14 Placing a stool or box under the feet to raise the legs to simulate squatting posture 3 Diet edit Dietary measures are frequently used for ODS as the first line treatment 3 The aim is to improve stool texture 3 It has been recommended to avoid foods like chocolate which increase stool viscosity making it more difficult to pass stools 19 Bulk forming laxatives are also frequently used for ODS 19 It is recommended to increase dietary fiber intake to 25 30 grams daily This may be slowly increased up to a level of 50 grams per day This is usually achieved with high fiber cereal and fiber powder supplements such as psyllium methylcellulose polycarbophil or wheat dextrin 3 However fibre supplementation only fractionally increases gut transit and stool bulk 11 The effect may take several weeks to become apparent 11 Other authors report that a high fiber diet rarely helps ODS symptoms and may make them worse 6 Patients with ODS are often advised to drink plenty of water 19 1 2 liters of water per day is recommended especially in warmer climates or warmer weather 3 Biofeedback Pelvic floor rehabilitation edit Biofeedback is a learning strategy which is based on operant conditioning The main goal is to improve abdominal and pelvic floor coordination This is usually done by giving the patient visual or auditory feedback about muscular contraction during attempted defecation maneuvers as well as verbal feedback about posture and diaphragmatic breathing 6 Biofeedback can successfully treat abnormal contraction and relaxation of muscles in the anorectum during defecation 20 This enables normal peristalsis instead of abnormal contraction and retrograde movement of bowel contents 11 Biofeedback is now one of the most popular treatments for ODS particularly because it is safe 6 It is most beneficial for patients with dyssynergic defecation 11 It is also used for rectal hyposensation 19 Rectocele and recto rectal intussusception can sometimes be treated by pelvic floor rehabilitation alone 19 as long as they have not been present for a long time 19 Larger and more significant examples of these organic anatomical disorders require surgery to correct since they because contributing causes to ODS by themselves 19 Regardless this treatment seems to be beneficial both for patients with mild symptoms and for those with severe symptoms which are unresponsive to other conservative measures and who are being considered for surgery 11 Biofeedback has been shown to improve symptoms improved frequency of bowel movements reduced straining and also reduce need for laxatives 11 and patients stop needing to self digitate 20 Researchers demonstrated that patients who had positive results with biofeedback had evidence of improved autonomic innervation of the colon increased colonic transit time and had increased quality of life scores 11 Overall biofeedback is reported to have about 70 success rate for pelvic floor dyssynergia dyssynergic defecation 29 The success of biofeedback for patients with ODS caused by mechanical defects is not well known 29 For patients who do not undergo biofeedback simple pelvic floor and abdominal muscle relaxation exercises may also be useful to make evacuation easier 19 Psychotherapy Psychological counselling edit Psychological counselling is indicated for people with ODS and depression and or anxiety 19 Psychological techniques guided imagery and relaxation have been combined with ultrasound guided biofeedback 19 This psycho echo biofeedback approach was reported to be successful for 50 of patients after 2 years 19 Irrigation edit Variously termed hydrocolontherapy 19 lavage 19 retrograde large bowel irrigation 19 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 30 administered via a tube inserted into the anus 19 Some authors report this treatment as effective and safe with no risk of side effects 19 Self administered enemas may however be abused which can cause anorectal fibrosis and stricture due to repeated microtrauma 19 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 edit Transanal electrostimulation is carried out at home with an anal probe and an electrostimulator 19 It is a treatment for pudendal nerve neuropathy and rectal hyposensation 19 Another new treatment combines biofeedback with transanal electrostimulation 30 Botox injections edit Injection of 50 60 units of botulinum toxin A into the puborectalis muscle has been reported for anismus 19 and ODS 3 The botulinum toxin is injected under ultrasound guidance into two sites on both sides of the puborectalis muscle 3 This procedure itself could be considered as minor surgery although in the studies reporting this technique patients were not sedated or given local anesthetic 3 Short term cure rate was approximately 50 19 Another study reported 79 of patients had improved symptoms and had broadening of the anorectal angle demonstrated on defecography 3 Side effects are transient anal incontinence and hypotension 19 The effects of Botox only last for about 3 months meaning the procedure may only be temporary and it may have to be repeated 3 Other measures edit Anismus has been reported to be treated with yoga exercises 19 Surgical edit Surgical procedures can be considered in three groups transvaginal transabdominal and transanal or as either manual techniques or stapling procedures No surgical procedure has been demonstrated to be the best and each has advantages and disadvantages 30 There are no widely accepted selection criteria for these surgical procedures 30 Partial division of puborectalis muscle edit This transanal manual procedure aims to relax the tension of a hypertrophic overdeveloped puborectalis muscle 30 The partial division can be done laterally on one side or at the posterior midline in the middle at the back of the muscle 30 There are some positive reports of this proceudre which was said to be more effective compared to non surgical treatments such as biofeedback and botulinom toxin A injections 30 However other reports state that this method is disappointing failing to improve ODS symptoms for most patients 30 There is a high risk of fecal incontinence after this surgery and it is generally no longer recommended 45 Ventral mesh rectopexy edit Ventral mesh rectopexy has become popular for rectal prolapse internal rectal prolapse and ODS especially in Europe 46 It is also used for rectoceles 47 solitary rectal ulcer syndrome 48 and can be combined with procedures for vaginal prolapse for example sacrocolpopexy 47 The predecessor of this procedure was sutured posterior rectopexy in which the rectum was completely mobilized from the pelvic floor i e including posterior and lateral surgical dissection of the rectum and sigmoid colon 46 This caused autonomic nerve damage resulting in constipation and obstructed defecation after the surgery 46 Ventral rectopexy was developed in 2004 as a modification which would not destroy these nerves since only the ventral anterior surface the front surface is mobilized 46 A mesh is placed between the anterior wall of the rectum and the vagina 46 The mesh is then fixed to the sacrum 49 and the vaginal vault is fixed to the mesh The mech reinforces the anterior rectal wall which aims to prevent recurrence of enterocele intussusception and rectocele 46 The pouch of Douglas is lost in the process 46 As such the aims of the procedure are surgical correction of prolapse of the posterior rectum sigmoid colon and middle female reproductive organs pelvic compartments elevation of the pelvic floor and reinforcement of the vaginal septum anterior rectal wall 47 The procedure is usually performed laparoscopically 49 The procedure reduces constipation and fecal incontinence in patients with rectal prolapse or rectal intussusception and has a low rate of complications and recurrence 49 The procedure is able to correct multiple anatomical defects associated with vaginal and rectal prolapse as well as improving function in terms of continence and defecation 47 Prognosis editODS generally has a benign prognosis however it is a distressing condition for patients 44 The condition may severely reduce quality of life 44 both socially and psychologically 30 and also reduce sexual well being 28 Symptoms persist for some patients despite conservative treatment 14 and dissatisfactory outcomes are frequently reported after surgery 44 Epidemiology editConstipation as a general complaint is very common The ODS subtype is also known to be a common problem 1 but the exact reported epidemiological figures vary 12 It is estimated that approximately a third of patients complaining of constipation have the ODS subtype which is more than slow transit constipation 12 Some reported or estimated figures include 7 of adults 33 10 20 of adults 2 12 19 of North Americans 1 Up to 30 of the population 12 The prevalence is greater in older people of both sexes especially women Overall most patients with ODS are females 19 Some of the reasons for this female predilection are thought to be related to trauma from childbirth through vaginal delivery menopausal tissue changes and hysterectomy 12 However a not insignificant proportion of patients with ODS are males or nulliparous females i e have never given birth 2 Notes edit Outlet obstruction may also refer to disorders of the bladder bladder outlet obstruction or the stomach gastric outlet obstruction Outlet obstructive constipation OOC appears to be the standardized term used in Chinese publications With the exception of substitution of the term anismus which is used in the ASCRS consensus statement Many publications instead use the term dyssynergic defecation notably ICD 11 and Rome IV Some authors have expressed disapproval of the continuned use of the term anismus References edit a b c d e f g h i j k l m 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 a b c George B Guy R Jones O Vogel J 2 May 2016 Colorectal Surgery Clinical Care and Management Chichester West Sussex UK John Wiley amp Sons ISBN 978 1 118 67478 9 a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae 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 Jani B Marsicano E May 2018 Constipation Evaluation and Management Missouri Medicine 115 3 236 240 PMC 6140151 PMID 30228729 Liberman H Hughes C Dippolito A February 2000 Evaluation and outcome of the delorme procedure in the treatment of rectal outlet obstruction Diseases of the Colon and Rectum 43 2 188 192 doi 10 1007 BF02236980 PMID 10696892 S2CID 38597586 a b c d e f g h i j k l m Andromanakos N Skandalakis P Troupis T Filippou D April 2006 Constipation of anorectal outlet obstruction pathophysiology evaluation and management Journal of Gastroenterology and Hepatology 21 4 638 646 doi 10 1111 j 1440 1746 2006 04333 x PMID 16677147 S2CID 30296908 a b c d e f Zbar AP Nasseri Y Wexner SD 4 May 2012 Coloproctology Springer London ISBN 978 1 4471 2543 3 Anorectal Branch of Chinese Medical Doctor Association Clinical Guidelines Committee Anorectal Branch of Chinese Medical Doctor Association Professional Committee on Anorectal Diseases Chinese Society of Integrated Traditional Chinese and Western Medicine Anorectal Disease Committee of Chinese Medical Women s Association Chinese Constipation Medical Association December 2022 Chinese expert consensus on the diagnosis and treatment of outlet obstructive constipation 2022 edition Zhonghua Wei Chang Wai Ke Za Zhi Chinese Journal of Gastrointestinal Surgery 25 12 1045 1057 doi 10 3760 cma j cn441530 20221009 00404 PMID 36562227 a b c d e f g Lunniss PJ Gladman MA Benninga MA Rao SS December 2009 Pathophysiology of evacuation disorders Neurogastroenterology and Motility 21 Suppl 2 31 40 doi 10 1111 j 1365 2982 2009 01402 x PMID 19824936 S2CID 205372368 Iovino P 2014 Bloating and functional gastro intestinal disorders Where are we and where are we going World Journal of Gastroenterology 20 39 14407 14419 doi 10 3748 wjg v20 i39 14407 PMC 4202369 PMID 25339827 a b c d e f g h i j k l Clark S 22 June 2018 Colorectal Surgery A Companion to Specialist Surgical Practice 6th ed Edinburgh Elsevier ISBN 978 0 7020 7243 7 a b c d e f g h i j k l m n o p Herold A Lehur PA Matzel KE O Connell PR 2017 European Manual of Medicine Coloproctology Second ed Berlin Germany ISBN 978 3 662 53210 2 a href Template Cite book html title Template Cite book cite book a CS1 maint location missing publisher link Ghoshal UC Sachdeva S Pratap N Verma A Karyampudi A Misra A Abraham P Bhatia SJ Bhat N Chandra A Chakravartty K Chaudhuri S Chandrasekar TS Gupta A Goenka M Goyal O Makharia G Mohan Prasad VG Anupama NK Paliwal M Ramakrishna BS Reddy DN Ray G Shukla A 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Journal of Surgery 65 2 87 92 doi 10 1111 j 1445 2197 1995 tb07267 x PMID 7857236 a b Agarwal BB September 2015 Obstructed defecation syndrome Apollo Medicine 12 3 175 180 doi 10 1016 j apme 2015 07 007 Lowry AC Simmang CL Boulos P Farmer KC Finan PJ Hyman N et al July 2001 Consensus statement of definitions for anorectal physiology and rectal cancer report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Rectal Cancer Washington D C May 1 1999 Diseases of the Colon and Rectum 44 7 915 919 doi 10 1007 BF02235475 PMID 11496067 S2CID 19442282 DD92 Functional anorectal disorders ICD 11 for Mortality and Morbidity Statistics icd who int DD92 2 Functional defaecation disorders ICD 11 for Mortality and Morbidity Statistics icd who int ME07 1 Incomplete defaecation ICD 11 for Mortality and Morbidity Statistics icd who int a b c d e f g h i Appendix A Rome IV Diagnostic Criteria for FGIDs Rome Foundation a b c d e f van Gruting IM Stankiewicz A Thakar R 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defecation syndrome Duodecim Laaketieteellinen Aikakauskirja 125 2 221 225 PMID 19341037 a b Welton ML Obstructed Defecation Armenian Medical Network Inc Retrieved 9 September 2012 Garcia Armengol J Moro D Ruiz MD Alos R Solana A Roig Vila JV December 2005 Obstructive defecation Diagnostic methods and treatment Cirugia Espanola 78 Suppl 3 59 65 doi 10 1016 s0009 739x 05 74645 5 PMID 16478617 a b c d e Srisajjakul S Prapaisilp P Bangchokdee S November 2020 Diagnostic clues pitfalls and imaging characteristics of celes that arise in abdominal and pelvic structures Abdominal Radiology 45 11 3638 3652 doi 10 1007 s00261 020 02546 y PMID 32356005 S2CID 217167339 a b c d e f g h Scott SM van den Berg MM Benninga MA February 2011 Rectal sensorimotor dysfunction in constipation Best Practice amp Research Clinical Gastroenterology 25 1 103 118 doi 10 1016 j bpg 2011 01 001 PMID 21382582 a b Ratto C Parrello A Dionisi L Litta F 2014 Coloproctology Colon Rectum and Anus Anatomic Physiologic and Diagnostic Bases for Disease Management Cham Switzerland Springer International Publishing ISBN 978 3 319 10154 5 Altomare DF Spazzafumo L Rinaldi M Dodi G Ghiselli R Piloni V January 2008 Set up and statistical validation of a new scoring system for obstructed defaecation syndrome Colorectal Disease 10 1 84 88 doi 10 1111 j 1463 1318 2007 01262 x PMID 17441968 S2CID 21486903 a b Voderholzer WA Neuhaus DA Klauser AG Tzavella K Muller Lissner SA Schindlbeck NE August 1997 Paradoxical sphincter contraction is rarely indicative of anismus Gut 41 2 258 262 doi 10 1136 gut 41 2 258 PMC 1891465 PMID 9301508 a b c d e f g Picciariello A O Connell PR Hahnloser D Gallo G Munoz Duyos A Schwandner O et al October 2021 Obstructed defaecation syndrome European consensus guidelines on the surgical management The British Journal of Surgery 108 10 1149 1153 doi 10 1093 bjs znab123 hdl 10281 356662 PMID 33864061 Kuckelman J Johnson EK 2019 Solitary Rectal Ulcer Syndrome Chapter in Clinical algorithms in general surgery a practical guide Cham Springer pp 269 274 ISBN 9783319984971 a b c d e f g Lundby L Laurberg S February 2015 Laparoscopic ventral mesh rectopexy for obstructed defaecation syndrome time for a critical appraisal Colorectal Disease 17 2 102 103 doi 10 1111 codi 12830 PMID 25382580 S2CID 34761307 a b c d Gurland B December 2014 Ventral mesh rectopexy is this the new standard for surgical treatment of pelvic organ prolapse Diseases of the Colon and Rectum 57 12 1446 1447 doi 10 1097 DCR 0000000000000248 PMID 25380013 Badrek Amoudi AH Roe T Mabey K Carter H Mills A Dixon AR May 2013 Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome a cause for optimism Colorectal Disease 15 5 575 81 doi 10 1111 codi 12077 PMID 23107777 S2CID 36126910 a b c Samaranayake CB Luo C Plank AW Merrie AE Plank LD Bissett IP June 2010 Systematic review on ventral rectopexy for rectal prolapse and intussusception Colorectal Disease 12 6 504 512 doi 10 1111 j 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