Obstructed Defecation Syndrome: Diagnosis & Surgical Treatment

ByDr Ashwin Porwal

Consultant Procto-SurgeonApollo Jehangir Hospital

Poona Hospital &Inamdar Hospital

Obstructed Defecation Syndrome (ODS)

Constipation due to difficulty in passing stools once it has reached rectum as a result of Recto rectal Intussusceptions (Internal Rectal Prolapse) or Rectocele

ODS has been shown to be the result of an abnormal function of the muscles involved in defecation or an anatomical abnormality of the pelvic organs

ODS is a complex and multifactorial condition which is often referred to as an Iceberg Syndrome

Prevalence of ConstipationConstipation prevalence in the general population is

estimated at around 5-15% .

reports suggesting significantly higher levels in the elderly, especially above the age of 65.

reports of females being affected more then males, male to female ratio of 1: 2.2.

ODS is estimated to be prevalent in 7% of the adult population and is judged to be the cause of one third of all cases of constipation

1)Failure of conservative treatment for ODS 2)Underlying structural abnormality like Rectocele & Recto-Rectal Intussusceptions on MRI Defecography

NICE guidelines for STARR Surgery for ODS

Efficacy of STARR in ODSIn multiple studies reviewed by NICE , It was observed that there was significant improvement in pre operative constipation symptoms at a mean follow up of 2 years. Post op Defecography also demonstrated correction of Rectocele and intussusceptions in one study. Quality of life following STARR was assessed in few studies , excellent or good outcome was reported by 70-80% of the patients.

Rectocele in females – A Rectovaginal Defect

• A rectocele is an out pouching of the anterior rectal wall and posterior vaginal wall into the lumen of the vagina

Definition

• high rectoceles due to stretching or disruption of the upper third of the vaginal wall and uterosacral ligaments

• mid level rectoceles most common and are associated with loss of pelvic floor support

• low-level rectoceles can be caused by obstetric trauma

Gradation

Rectocele: Prevalence

Prevalence in young nulliparous women : 12%

• Source: Australia & NZ Journal of Obst. & Gynec. 2005 Oct;45(5):391-4

Prevalence in multifarious women with uterus : 18.6 % without uterus : 18.3%

• Source: American Journal of Obst & Gynec Prevalence of Rectocele in male patients who have a history of chronic

constipation and are symptomatic for ODS is as high as 60% in my routine clinical observation

Rectocele & ODS

Symptoms of Rectocele include: – Pain or pressure in the vagina– Pain during sexual intercourse– Pain or pressure in the rectum– Feeling of tissue bulging out of vagina– Constipation: ODS (Obstructed Defecation Syndrome)

• Difficult passage of stool• Needing to apply pressure on vagina to pass stool• Feelings of incomplete stool passage

• Colonoscopy to rule out tumors + IBD• Conservative treatment with laxatives /enemas / diet failed

Before patient sees surgeon

• Patient history• Dr Longo’s Score (ODS Score) assessment• Incontinence / Urogenital assessment to rule out other

complications• Quality of life / Patient motivation assessment

Patient sees the surgeon – Patient

Interview

• Perinea Examination• Proctoscopy resting / straining• Urogenital Examination

Clinical Examination

• Conventional Defecography / MRI Defecography • Anal- manometry and Endo-anal ultrasound – only if

incontinence or suspicion of sphincter damage – otherwise not mandatory

• Colon transit – suspicion of slow bowel movement

Clinical Evaluation

Diagnostic Approach for ODS

Patients of ODS: Symptoms and Signs

• Pain at defecation• Haemorrhoidal prolapse (!) • Extended time at the toilet• Perineal pain / discomfort when standing• Use of laxatives or enemas• Fecal Incontinence• Extreme straining to defecate• Feeling of incomplete evacuation• Fragmented defecation• Vaginal, Perineal or Rectal digitations

History Taking for Constipation

Obstructive• Excessive Straining• Poor response to Laxatives over

a period of time• Either 2-3 visits/day or 2-3 visits

in a week to toilet• Inadequate Defecation• Feeling of stools obstructed in

Rectum• Rectal and or Vaginal Digitations

for Evacuation

Functional / IBS

• Straining + - • No feeling of stools obstructed

in rectum• Usually responds to laxatives• Inadequate Defecation +• Multiple visits to toilet +• Usually no history of digitation

Dr Longo’s ODS Score

Defecography

• Salient phases of Conventional / MRI Defecography Image captured – During rest with filled anal bulb– During maximum contraction of anal sphincter

and pelvic floor muscles– During straining without evacuation – During evacuation – During rest when evacuation is completed

Case: Internal Rectal Prolapse & Rectocele (Conventional Defecography)

Intussusception & Rectocele (1)

Intussusception & Rectocele (2)

Intussusception & Rectocele (3)

Intussusception & Rectocele (4)

MR Defecography

MRI Defecography Videos

ODS Cause Substantiated by Defecography Findings

Rectal Intussusception Internal Rectal Prolapse

• closure of the anus by prolapse of the rectum into the anal canal

Rectocele

• accumulation of stool in ventral protrusion of the rectal anterior wall

Patient Inclusion Criteria for STARR Surgery

Symptomatic Dr Longo’s Score more than 15

• Evacuation by prolonged or repeated straining• Frequent calls to defecate prior to or following evacuation• Use of digital means to effect evacuation• Laxative and or Enema use required to defecate• Sense of incomplete evacuation• Excessive time spent on the toilet• Pelvic Pressure, Rectal discomfort, and Perinea pain

Radiological & Clinical Findings

• Recto rectal Intussusceptions• Reconcile

Failure with medical management for 3-6 Months: By Means of Diet & Pelvic floor physiotherapy

Patient Exclusion Criteria for Surgery

General Exclusion Criteria

• Active anorectal infection• Concurrent severe anorectal pathology• Proctitis (Inflammatory Bowel Disease (IBD), Radiation)• Enterocele at rest (low, stable)• Chronic Diarrhea

Relative Exclusion Criteria

• Previous transanal surgery (Rectal anastomosis)• Presence of foreign material adjacent to the rectum (mesh)• Concurrent psychiatric disorder

Surgical Treatment for ODS –Stapled Transanal Rectal Resection(STARR)

Treatment for ODS

STARR (Stapled Transanal Rectal Resection)

• Transanal resection of the lower rectum• Full thickness resection of the anterior rectum wall by stapler after

longitudinal stitches at 10, 12 and 2 o‘clock positions. Similar approach at the posterior wall with stitches at 4, 6 and 8 o‘clock positions.

• Suturing of the overlaping dog ears at 3 and 9 o‘clock positions.

STARR Videos

Complications

rectovaginal fistula (0,3%)

bleeding (needing intervention) (3,7%)

stenosis (1,1%)

constant pain (4,0%)

suture-insufficiency (0,3%)

urgency (9,4%)

Conclusion

STARR is a safe and effective procedure to treat ODS (Obstructd Defecation Syndrome)

The surgery needs only 24hrs of hospitalisation & patient can resume his routine work from 3rd day

The key to success is patient selection

Problem could be the cost involved

Treating ODS - A Patient Case Study!

After Care & Follow upSTARR Surgery DiagnosisHistory Taking

Complain: Chronic Constipation since 3 years

Patient Profile: 26 year old nulliparous female

Patient History: Chronic constipation for over 3 years Symptoms: Need to go to the toilet 3-4 times in a day, Excessive

straining, Extended time in toilet (15 min. minimum), Digitations, Fragmented defecation, Hard stool, Feeling of stool obstructed within the rectum

No relief with diet and pelvic floor physic for 6 months Diagnosis:

P/R examination Anterior Rectocele Dr Longo’s ODS Score 24 MR Defecography findings Moderate anterior Rectocele with severe

descent of the Rectum Advise STARR Surgery

Patient Case Study continued...

Surgery Stapled Transanal Rectal Resection (STARR) 3hrs after surgery the patient complained of mild pain in the anal region,

Was advised to discontinue NBM and take regular Maharashtrian dinner. 12hrs after surgery bearable pain, passed motion with slight discomfort and

observed a few drops of blood during defecation. Discharged 24 hrs after hospitalization and subsequently the patient

resumed work after 4 days.

Follow up 2 Weeks:

Less difficulty to pass motion, No h/o straining, No h/o digitation, Patient was on laxative but it helped her, Satisfactory defecation at least 70% of the time.

1 Month: Motion was fine, evacuation was complete with lesser dose of laxatives.

Follow upSTARR Surgery DiagnosisHistory Taking After Care & Follow upSTARR Surgery DiagnosisHistory Taking

Patient Case Study continued...

Follow up 3 Months:

Patient was not on laxative but motion was sooth and without straining

Findings of MR Defecography repeated after 3 months Normal with absence of Rectocle or any obstruction

Patient was advised to stop all medication and also advised to take a high fiber diet with plenty of water

After Care & Follow upSTARR Surgery DiagnosisHistory Taking

My experience of 1st 100 STARRs…

Patient inclusion criteria • Symptomatic with Dr Longo’s ODS score above 15• Rectocele > 3cm & Recto rectal Intussusceptions

Patient distribution • Male 43 , Female 57• Age 37 < 40 yrs, 63 > 40 yrs• Nulliparous Female 33%• Rectocele Males: 67 % Females: 90%• Recto rectal Intussusceptions Males: 87% Females: 53%Follow up Schedule

• 2 weeks, 1 Month, 3 Months, 6 Months & 1 Year

Findings• Average Dr Longo’s ODS score pre operatively = 26• Average Dr Longo’s ODS score 12 months post operatively =8

ODS Score for 1st 100 STARR Cases

SymptomsMean Pre-op

ScoreMean 12 Months

Post-op Score

Defecation frequency 1 0

Straining Intensity 1 0

Extension of time in defecation 2 1

Sensation of incomplete evacuation 3 1

Recto/perineal pain/discomfort 2 1

Activity reduction per week 4 2

Laxatives 5 3

Enemas 3 0

Digitation 5 0

Mean Dr Longo’s ODS Score 26 8

Thank You!